8


Child Abuse and Neglect Policy

Since the 1993 National Research Council (NRC) report was published, numerous changes have been made to federal and state laws and policies designed to impact the incidence, reporting, and negative health and economic consequences of child abuse and neglect. This chapter reviews the foundations for the development of child abuse and neglect law and policy and describes the current environment of laws and policies related to child abuse and neglect at both the federal and state levels. Also discussed is the evaluation and analysis of these laws and policies. Related research needs are detailed as well.

Policy change in the child protection arena frequently has resulted from a synergistic set of factors: (1) the development of and reporting on evidence that a specific practice reform has had a positive impact, (2) the existence of one or more models or demonstrations of successful implementation of such reforms, and (3) a combination of clinician and advocacy community support for legislation that further promotes the reforms. Thus, for example, it was these factors that led to federal legislative policy reform making voluntary home visiting more widely available through Section 2951 of the Patient Protection and Affordable Care Act. This Maternal, Infant, and Early Childhood Home Visiting Program is designed to strengthen and improve related programs and activities, improve coordination of services for at-risk communities, and identify and provide evidence-based home visiting programs that can improve outcomes for families residing in at-risk communities.

Although the scope of what constitutes “policy” includes both legislation and government agency regulations, protocols, and so on, this chapter



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8 Child Abuse and Neglect Policy S ince the 1993 National Research Council (NRC) report was pub- lished, numerous changes have been made to federal and state laws and policies designed to impact the incidence, reporting, and negative health and economic consequences of child abuse and neglect. This chapter reviews the foundations for the development of child abuse and neglect law and policy and describes the current environment of laws and policies related to child abuse and neglect at both the federal and state levels. Also discussed is the evaluation and analysis of these laws and policies. Related research needs are detailed as well. Policy change in the child protection arena frequently has resulted from a synergistic set of factors: (1) the development of and reporting on evidence that a specific practice reform has had a positive impact, (2) the existence of one or more models or demonstrations of successful implemen- tation of such reforms, and (3) a combination of clinician and advocacy community support for legislation that further promotes the reforms. Thus, for example, it was these factors that led to federal legislative policy reform making voluntary home visiting more widely available through Section 2951 of the Patient Protection and Affordable Care Act. This Maternal, In- fant, and Early Childhood Home Visiting Program is designed to strengthen and improve related programs and activities, improve coordination of services for at-risk communities, and identify and provide evidence-based home visiting programs that can improve outcomes for families residing in at-risk communities. Although the scope of what constitutes “policy” includes both legisla- tion and government agency regulations, protocols, and so on, this chapter 349

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350 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH addresses primarily the evolution of federal and state laws on child abuse and neglect as they affect knowledge and practice. Regulations and proto- cols are typical results of the process of implementing laws at the state and local levels. However, a nonstatutory “policy” reform can also be national in scope. Examples are the recommendations for policy reform issued in the early to mid-1990s by the U.S. Advisory Board on Child Abuse and Neglect. For example, recommendation 13 of the Advisory Board’s first re- port, Child Abuse and Neglect: Critical First Steps in Response to a Na- tional Emergency (U.S. Advisory Board on Child Abuse and Neglect, 1990, p. 138), calls on the Secretary of Health and Human Services (HHS) to “launch a major coordinated initiative involving all relevant components of the Department of Health and Human Services to promote the system- atic conduct of research related to child abuse and neglect.” The Advisory Board’s second report, Creating Caring Communities: Blueprint for an Ef- fective Federal Policy on Child Abuse and Neglect (U.S. Advisory Board on Child Abuse and Neglect, 1991) focuses on the broad federal government response to child abuse and neglect. The report calls for enactment of a “National Child Protection Policy,” one goal of which would be to drive the child protection–related actions of all federal agencies. The report includes a nine-page “Proposed National Child Protection Policy” and a call for an appropriate federal research agency to determine the cost of implementing such a policy, as well as the cost of not doing so. To help prevent child abuse and neglect, the report’s recommendations also include the first call by a blue-ribbon federal panel for national implementation of universal voluntary neonatal home visitation (what the report calls a “dramatic new federal initiative aimed at preventing child maltreatment”). Included as well are four pages of recommendations for improving federally supported research and evaluation related to child abuse and neglect. The Advisory Board’s fourth report, Neighbors Helping Neighbors: A New National Strategy for the Protection of Children (U.S. Advisory Board on Child Abuse and Neglect, 1993), again addresses federal research policy, calling on federal agencies to subject federally supported child protection activities to rigorous evaluation; calling on the National Institute of Mental Health to solicit research aimed at clarifying the relationships among social support, culture, and child abuse and neglect; and urging that federally supported research also assess children’s, parents’, neighbors’, and workers’ own experiences of the context in which child abuse and neglect occurs and their perceptions of systemic responses to the problem. At its core, the debate around the development of laws and policies to help prevent child abuse and neglect involves questions of public value (Pecora et al., 2000). It also involves trade-offs entailed in law making between public benefit and private interests. For example:

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CHILD ABUSE AND NEGLECT POLICY 351 • What is the balance between children’s fundamental right to be safe and parents’ right to raise their children as they see fit? • Should the government’s role be to offer families, on a voluntary basis, services related to the protection of their children, or to force families to accept services they could construe as unwanted govern- ment intrusion into family life? • How can policy promote fairness in child protective interventions, recognizing, for example, that some families come from different cultures whose practices may not coincide with what is covered by child protection laws? • What is the appropriate balance between the due process rights of parents not to have child abuse or neglect case records preserved by child protection agencies in cases that are very old or in which a report of abuse or neglect was not substantiated and the authority of states to maintain appropriate central registries of child abuse and neglect case-related data that might later be used as part of child protection efforts? The development of child abuse and neglect laws and policies should include the application of reason, evidence, and an evaluative framework to such decisions (Pecora et al., 2000). The application of reason refers to pub- lic discourse by practitioners, advocates, researchers, and legislators (Pecora et al., 2000). The evidence for passing laws and changing public policy is derived from a variety of sources, some explicitly guided by research and scientific evidence and others reflecting social consensus about legitimate government activity. For example, even though research evidence suggests that lengthy incarceration for acts of violence is not always necessary for community safety, it is widely supported by citizens because of the societal functions of punishment for wrongdoing and justice for victims. The evaluative framework for child abuse and neglect laws and poli- cies lies with the ability to anticipate and deal with a series of predictable problems that occur as a result of the laws’ and policies’ implementation. Research helps answer questions when those answers are critical to effective implementation. For example: • Is banning the behavior targeted in legislation, such as certain forms of corporal punishment that are most likely to cause seri- ous injury to a child, likely to reduce the rate of child abuse and neglect-related fatalities? • Are safe haven laws (permitting a mother to, without legal con- sequence, abandon a newborn child safely) constructed so as to reduce the number of child abandonments and even deaths of unwanted children that would have occurred in the laws’ absence?

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352 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH • Are there sufficient resources to educate those persons included in a law as mandated reporters of child abuse and neglect, and what is the impact of changing the requirements for who must report or what must be reported? • Is there sufficient public support for changing the definition of what constitutes child abuse and neglect under state law? Given these complexities, the research design needed to evaluate laws and policies is not always the same as the design one would use to evaluate practice interventions. Although some laws and policies can be evaluated by random assignment (e.g., studying the differential response approach of social services in responding to child abuse and neglect reports), random assignment cannot be used if it would differentially affect the legal rights of citizens, if it would subject citizens to unequal treatment under the law, or if it would place children in jeopardy. Furthermore, simply studying the incidence of child abuse and neglect in the aggregate (such as at the state or national level) is unlikely to aid in determining and attributing its potential causes. Another difficulty in evaluating laws and policies related to child abuse and neglect is that adherence to a law, such as a mandatory reporting law, often is predicated on public knowledge, understanding, and support that frequently vary across practitioner disciplines, as well as within and among states. Finally, many of the changes in child abuse and neglect laws and policies over the last few decades have been incremental changes to existing legislation (such as the federal Child Abuse Prevention and Treatment Act [CAPTA]). In those cases, what is needed in terms of law and policy analysis or evaluation is research on the implementation and augmentation of the law or policy, rather than the core law or policy itself. Given these difficulties in conducting analyses of laws and policies and the fact that laws and policies vary by state, the paucity of research in this area is unsurprising. THE POLICY LANDSCAPE Federal and state laws define what constitutes the abuse and neglect of children. They also designate those who must report suspected child abuse and neglect, or make all citizens with reason to suspect abuse and neglect mandated reporters. State laws addressing the abuse and neglect of children were passed in all 50 states following the 1962 amendments to the Social Security Act that required all states to include child protection in their child welfare systems (Myers, 2008). At the same time, the 1962 article “The Battered Child Syndrome” (Kempe et al., 1962, 1985) gave rise to public concern that many voluntary societies for the prevention of cruelty

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CHILD ABUSE AND NEGLECT POLICY 353 to children were disappearing, having been largely replaced by government counterparts known today as child protective services agencies. In 1974, passage of CAPTA1 established state responsibilities for child protection and supported the execution of these responsibilities with new federal money for state programs and national research. CAPTA has been reauthorized multiple times, most recently in 2010 (CWIG, 2011a). As discussed below, CAPTA provided a federal definition of child abuse and neglect and set into motion a series of reforms of state laws, policies, and practices. One direct consequence of CAPTA was the establishment within HHS of a National Center on Child Abuse and Neglect. This center was sub- sequently made an office with, unfortunately, far fewer staff, as a part of reorganization within the department. CAPTA also created authority for the aforementioned U.S. Advisory Board on Child Abuse and Neglect,2 a blue-ribbon expert panel, but after releasing four reports, it was disbanded and never revived. Some support for child abuse and neglect research has continued to be provided by the Office on Child Abuse and Neglect. However, policy- related research continues to be extremely underdeveloped. Important re- search-appropriate policy issues affecting hundreds of thousands of children annually relate to such topics as • mandatory reporting; • child abuse central registries (record-keeping repositories) and re- lated issues of constitutional rights; • education of potential child abuse and neglect reporters, sometimes tied to health professional licensing; • the use of safety and risk assessment instruments by child protec- tive services agency personnel; • training in child abuse and neglect and family violence in medical and other professional schools; • organization of child protection service delivery at the state or county government level; • adoption of new approaches to working with families in which child abuse and neglect is suspected, such as differential response and family group decision making; • in increasing numbers of states, replacing the traditional process of making substantiation decisions in all cases of reported child abuse and neglect that are investigated with an assessment process that does not label parents as having abused or neglected their child; 1  U.S.C. 42 § 62. 2  U.S.C. 42 § 5102.

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354 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH • use of kinship foster care as an alternative to traditional foster care; • emphasis on the safety, permanency, and well-being of children after termination of parental rights; and • the appropriate role for law enforcement and the courts in helping families care for their children and in helping to ensure that chil- dren’s safety, permanency, and well-being needs are addressed. Some policy changes appear never to be questioned, even in the absence of evidence to support their wisdom. These changes include instituting or broadening the scope of mandated reporting of suspected child abuse and neglect. Policy research could and should assess the likely consequences before policy changes are made—for example, when a definition of abuse or neglect is broadened to include children who are witnesses to or otherwise exposed to domestic violence in the home. Since the 1993 NRC report was issued, a variety of controversies have arisen that strongly suggest the need for additional policy-related research. These include, for example, concerns about racial and socioeconomic bias in the making of child abuse and neglect reports (Drake and Zuravin, 1998; Drake et  al., 2011; Lane et al., 2002; Magruder and Shaw, 2008) and wide variation in the interpretation of legal requirements by mandated reporters for reporting reasonable suspicion of child abuse or neglect (Levi and Brown, 2005). It is critical that legislators and program administrators support research designed to carefully examine the federal and state laws that guide responses to child abuse and neglect and build a new knowledge base to guide the implementation of policy changes. FEDERAL LAWS AND POLICIES This section reviews key federal laws and policies designed to address the incidence and consequences of child abuse and neglect that have been enacted over the last several decades and suggests areas in which future research is needed. The Child Abuse Prevention and Treatment Act In 1974, CAPTA3 authorized, among other things, very modest funds for a state grant program focused on initial child protective intervention in cases of suspected abuse or neglect; Congress has since appropriated these funds annually. Despite the limited funding they have received, all states have made significant changes to their child abuse and neglect legislation as mandated by CAPTA’s eligibility requirements. CAPTA has been reau- 3  42 U.S.C. § 5101 et seq.

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CHILD ABUSE AND NEGLECT POLICY 355 thorized every 4-8 years since 1974 (CWIG, 2011a), and reauthorizations have nearly always modified or added new eligibility conditions; as a result, the language of state laws has undergone continual changes to comply with CAPTA. Definitions in CAPTA CAPTA sets 18 as the age up to which states must have laws on re- porting of child abuse and neglect that mandate a child protection system response. The committee knows of no research on how states and counties respond to reports of abuse or neglect involving older teens, or on what child protection agency practices best address youth aged 16 or 17 who are reported as suspected victims for the first time. CAPTA also limits the term “abuse and neglect” to acts or failures to act by parents or caretakers. Some states do not so limit the perpetrators of abuse and neglect, but include reporting of child abuse and neglect allegedly committed by those outside of the child’s home (as a recent example, sports coaches). The CAPTA limitation on who a perpetrator of abuse and neglect may be results in many states having skewed data on child abuse, especially child sexual abuse, because only intrafamilial incidents may be reported in many states. The committee knows of no research that has looked at how a state’s definition of a perpetrator of abuse and neglect affects children’s protection from abuse and neglect overall. In one of its periodic congressional reauthorizations, CAPTA also gave states the option of mandating reporting of only those acts, or failures to act, of alleged abuse and neglect that are recent and that have resulted in physical or emotional harm to the child that is considered serious. Although few states have such limiting language in their definitions of what must be reported, there is no evidence on whether this limiting language results in abused and neglected children falling through the cracks or whether child protective services agencies receive large numbers of reports in which the harm to children is not considered serious. Likewise, the committee has seen no research on how the CAPTA definition of sexual abuse, which was broadened to include acts related to the production of child pornography, statutory rape, and prostitution of children, has affected the protection of those children. Given the wider recognition of and concern about child sexual victimization, research on the impact of states having this broadened language on reportable sex crimes involving children would be most helpful. Still another expanded definition of what is understood to be child abuse and neglect, and again one that has not to the committee’s knowl- edge been studied, is the inclusion of a form of medical neglect, or the “withholding of medically indicated treatment of disabled infants with life-

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356 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH threatening conditions.” These have been referred to as “Baby Doe” cases, and a great deal of attention was originally focused on a few cases of se- verely disabled infants in hospitals who died after allegedly being deprived of treatment (U.S. Advisory Board on Child Abuse and Neglect, 1991). The Baby Doe provision of CAPTA remains in effect, but the committee could find no research on the frequency, outcomes, or cost of handling these cases. This type of case is different from the more general “medical neglect” of a child’s health needs, which sometimes leads to child protec- tive interventions. There are occasionally religious reasons for withholding treatment (e.g., parents who refuse a blood transfusion, transplant, cancer treatment, etc., on religious grounds). CAPTA requires states to have pro- cesses in place whereby a court can order treatment in these circumstances. Another “medical neglect” issue potentially arises in cases where infants are left in neonatal intensive care units for weeks or months at a time, and their parents fail to visit. The committee is unaware of research related to any of these issues. Title I of CAPTA The State Grant Program under CAPTA is for “improving the child protective services system” of each state, specifically by supporting a wide range of comprehensive activities. To obtain CAPTA funding to support their child protective services programs, states must comply with con- gressionally mandated eligibility conditions. Not counting the Baby Doe (protection of severely disabled newborns) response requirement described above, CAPTA currently includes more than 20 requirements for state laws or statewide programs that must be met for a state to receive an annual State Grant. During the years since these provisions were incorporated into federal law, little to no investment has been made in studying how these requirements are best implemented. State legislatures have continually added to these provisions, in differ- ent ways. For example, state legislatures have broadened the scope of who must report suspected child abuse and neglect, penalized the making of false reports of abuse and neglect, extended access to child protective services records to members of multidisciplinary child protection teams, required cross reporting of cases by child protective services to the police (and vice versa), and required that a child’s guardian ad litem be an attorney. Again, little or no investment has been made in research to learn whether these changes better protect children. Few of these changes to CAPTA have ever been examined scientifically with respect to their positive or negative impact. For example, one change to CAPTA mandated hospital referrals to child protective services when infants are born with and identified as being affected by illegal substance

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CHILD ABUSE AND NEGLECT POLICY 357 abuse, even though the birth of a drug-exposed newborn is generally, in and of itself, not legally considered abuse or neglect. The latest 2010 reautho- rization of CAPTA added to this requirement a referral to child protective services for children born with a fetal alcohol spectrum disorder (Children’s Bureau, 2011). Research is similarly lacking on the implementation of other additions to CAPTA’s eligibility requirements. They include (1) a requirement for public disclosure of findings or information in cases of child abuse and neglect-related fatalities or near fatalities, (2) prompt expungement of child protective services records for certain purposes when reports are deter- mined to be unsubstantiated or false, (3) a mechanism for individuals who disagree with an official finding of abuse or neglect to appeal that finding, (4) a requirement for child protective services employees to advise adults accused of abuse or neglect of the allegations made against them at the time of initial contact with child protective services, (5) mandated training of child protective services caseworkers on their legal duties to protect the rights of children and families, and (6) a requirement for every child under age 3 who is substantiated as an abuse or neglect victim to be referred for early intervention services funded under Part C of the federal Individuals with Disabilities Education Act (IDEA). Some other CAPTA eligibility requirements track emerging best prac- tices in the field. Except for the support of the Children’s Bureau in studying the implementation of differential response and some statewide studies of that practice reform, however, the committee is unaware of any investment in research to determine how these CAPTA-promoted best practices are being implemented across the country. One eligibility requirement of CAPTA that has been studied involves important state citizen oversight of child protective services. Every state must establish and maintain “citizen review panels” to examine the policies, procedures, and practices of child protective services. Panel examination is supposed to include a review of handling of specific cases and the extent to which child protective services is effectively discharging its responsibilities. Although research has examined the impact of these panels, further study of how their recommendations have or have not resulted in positive reforms of their states’ child protection systems is needed. Discrepancies/Issues with Reported Child Abuse and Neglect Data CAPTA mandates that states annually provide “to the maximum extent practicable” a data report that now (since the 2010 CAPTA reauthoriza- tion) includes 16 separate types of data (Children’s Bureau, 2011). Some of the required data are straightforward, such as (1) the number of children reported as suspected child abuse and neglect victims; (2) the number of

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358 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH those reports that were substantiated, unsubstantiated, or determined to be false; (3) the number of child abuse and neglect-related deaths, both in the children’s homes and in foster care; and (4) the number of child protec- tive services personnel in different categories (e.g., intake, investigation), their average caseload, and their education and qualifications and training requirements. Compiling accurate data on other data elements is more difficult, and research is needed to determine how states can better collect these data. Examples include (1) the number of substantiated child victims receiving or not receiving services; (2) the number of children removed from their home, organized by disposition of their cases; (3) the number of fami- lies receiving “preventative services”; (4) child protective services response times, from initial investigation to provision of services; (5) the number of children reunited with their family after foster placement; and (6) cases in which a family received “family preservation services,” but within 5 years was the subject of further reports of abuse or neglect or a child fatality. Several additional data elements required by CAPTA are even more dif- ficult to collect. They include data on (1) the number of children provided a court-appointed advocate in their abuse and neglect cases, and those advocates’ average number of out-of-court contacts with their child clients; (2) the number of children under the care of the child welfare system who were transferred into the custody of the juvenile justice system (what are called “crossover youth”); (3) the number of children referred to child pro- tective services for prenatal drug or alcohol exposure; and (4) the number of children eligible for referral to the Part C IDEA program, as well as the number actually referred. Again, a study of best practices for accurately collecting these data would be helpful to the states. Other Components of CAPTA Needing Policy Implementation Research Children’s Justice Act CAPTA includes two additional state grant pro- grams. The first is a program funded through the U.S. Department of Justice but implemented by the Children’s Bureau. Known as the Children’s Justice Act, its formal name is Grants to States for Programs Relating to Inves- tigation and Prosecution of Child Abuse and Neglect Cases. As with the CAPTA State Grants and the State Prevention Grants (in Title II of CAPTA, discussed below), all states have been deemed eligible for, and receive, this funding. Although the legislation requires a comprehensive evaluation of the state’s systems related to child maltreatment, there has been insufficient investment in examining how the goals of this part of CAPTA have or have not been adequately achieved. CAPTA Title II Prevention Grants to states Title II of CAPTA provides grants to states in amounts greater than those provided under the Title I

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CHILD ABUSE AND NEGLECT POLICY 359 State Grant Program. Called Community-Based Grants for the Prevention of Child Abuse or Neglect, the purpose of this funding is “to support community-based efforts to develop, operate, expand, enhance, and co- ordinate initiatives, programs, and activities to prevent child abuse and neglect and to support the coordination of resources and activities, to better strengthen and support families to reduce the likelihood of child abuse and neglect” and “to foster an understanding, appreciation, and knowledge of diverse populations in order to be effective in preventing and treating child abuse and neglect.” In contrast with the Title I State Grants, which lack an evaluation requirement, Title II requires that states “describe the results of evalua- tion, or the outcomes of monitoring, conducted under the State program to demonstrate the effectiveness of activities conducted under this title in meeting the purposes of the program.” Although descriptive summaries of how some states have used these funds are available (Children’s Bureau, 2013; Summers et al., 2011), the committee is unaware of any compre- hensive examination/synthesis of these mandated evaluations or of any overall research on how Title II–funded programs have directly impacted the prevention of child abuse and neglect. Nor is the committee aware of any studies of how a focus on “diverse populations” may have led to improvements in preventing child abuse and neglect among different racial and ethnic groups. CAPTA discretionary funding for demonstration projects Although it is very limited, each year CAPTA discretionary funding is used to support individual grants for state and local child abuse and neglect-related projects. CAPTA requires these discretionary grant projects “to be evaluated for their effectiveness.” Funded projects must provide for such evaluations either as a stated percentage of their demonstration grant funding or as a separate grant or contract entered into by HHS for the purpose of evaluating that project or a group of projects. Because Congress has listed discrete areas for demonstration funding (and will likely add others in the future), it would be helpful to know more about whether the policy reforms suggested by prior congressionally enumerated grant areas have in fact been achieved. Therefore, it would again be helpful to the field if support were provided for a study examining these evaluations and their findings overall. CAPTA research priorities set by Congress Congress has mandated that the Children’s Bureau, “in consultation with other Federal agencies and recognized experts in the field, carry out a continuing interdisciplinary program of research, including longitudinal research, that is designed to provide information needed to better protect children from child abuse or

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374 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH of any research establishing that any particular state statutory scheme for release of records in such cases is more likely to protect children than any other. Safe Haven (Baby Moses) Laws All U.S. states and Washington, DC, have enacted legislation to address infant abandonment and infanticide, in some respects the cruelest form of child abuse and neglect. In exchange for surrendering a baby at a safe location, safe haven laws normally allow one parent, or a representative of that parent, to maintain anonymity and to be protected from prosecution for abandonment or neglect. In most states, the laws apply to very young infants—72 hours old or younger (n = 15), 5 to 14 days old (n = 11), or 1 month old (n = 14)—but some states allow parents to drop infants off within 45 days, 60 days, or up to 1 year (CWIG, 2010). The legislation varies across states by (1) who may leave a baby at a safe haven, (2) what providers are considered safe havens, (3) how old an infant may be to be properly relinquished, (4)���������������������������������������������������  �������������������������������������������������� responsibilities of safe haven providers, (5) pro- tections from liability afforded to providers, (6) protections for the parents in terms of anonymity, (7) protection of the father’s rights, (8) awareness campaigns, and (9) parental liability. Analyses  A number of commentators have written extensively about the purpose or impact of safe haven laws, referencing mainly anecdotal evi- dence or unofficial state data. Some have been critical, as in a white paper by the Evan B. Donaldson Adoption Institute, which suggests that safe haven laws have not been shown to be effective in minimizing unsafe infant abandonment; that the laws are limited by their inability to address the underlying causes of infant abandonment; and that the laws can interfere with aspects of child welfare policy, particularly with adoption statutes (Evan B. Donaldson Adoption Institute, 2003). Others hold a more op- timistic view. In her commentary on the subject, Ayres (2009) suggests that public awareness of safe haven laws is the key to their effectiveness. Through a qualitative review of state-level policy changes in the form of case studies, she argues that increased public awareness of the laws through well-funded media campaigns has contributed to a reduction of unlawful infant abandonment. To the committee’s knowledge, however, there have been no rigorous evaluations of the impact of save haven laws on infant abandonment or death. In fact, the tools needed to conduct an effective evaluation of these laws are not yet in place. States do not systematically collect data on infant abandonment, so it is not possible to make comparisons before and after enactment of the laws. While some notable efforts have been made to col-

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CHILD ABUSE AND NEGLECT POLICY 375 lect statistics on infant abandonment using unofficial state data (see NCSL, 2003) or news reports (Pruitt, 2008), these data have been insufficient to allow an adequate assessment of the impact of safe haven laws. Further, the anonymity provisions of the laws preclude the collection of information necessary for evaluating the laws—whether women who surrender their baby at a safe haven would otherwise have abandoned their child in an unsafe place instead of pursuing a different, legally permissible course of action such as adoption. In her commentary on the topic, Oberman (2009) suggests that without information on the mothers who abandon their chil- dren, evaluating safe haven laws is nearly impossible. Research needs  Given the unavailability of certain data discussed above, the most rigorous study designs are not feasible for addressing this issue. However, time-series analyses (see, e.g., Albert, 2001) comparing rates of abandonment, death, and infanticide before and after implementation of state safe haven laws, combined with cross-state comparison of states with different age requirements, could help shed light on the issue. Factors that should be built into this design include, at a minimum, the amount of in- vestment made in notifying the public about the availability of safe havens through signage and social media, the range of settings that are approved as safe havens, and the availability of other resources to prevent unwanted pregnancies. Other research designs that might be used to examine the im- pact of safe haven laws include instrumental variable approaches (see, e.g., Doyle, 2007) and regression discontinuity designs. Child Abuse and Neglect Central Registries Registries that maintain statewide information on individual child abuse and neglect cases remain a needed policy-related research focus. In addition, Section 633 of the Adam Walsh Child Protection and Safety Act required HHS to establish a national child abuse registry and to conduct a feasibility study regarding implementation issues. The interim report to Congress about the registry addressed the purpose of a national child abuse registry and its availability for employment and background checks. The same issues of accuracy, standard of proof, notification, appeal, expunge- ment, availability to law enforcement or other non-child protection systems, and due process have not been carefully examined at the state level. Representation of Children in Child Abuse and Neglect Proceedings All states have provisions, mandated since 1974 under CAPTA, for appointing a guardian ad litem to represent the interests of a child in a case of child abuse and neglect that results in civil child protective judicial

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376 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH activity. However, these provisions vary among states with respect to who is appointed, with some states appointing a lay individual, others requir- ing that an attorney be appointed, and others allowing volunteer CASAs to take on the role. In some states, a CASA may be appointed in addition to rather than as the guardian ad litem, while in other states, the court appoints legal counsel for the child as required by state law. There is no federally established standardized training for any of these positions, and states vary in their training requirements either through state laws, court rules, or continuing legal education obligations. While a National Qual- ity Improvement Center on Legal Representation of Children is currently examining the impact of two different models of child representation, the committee is unaware of other rigorous comparative evaluations of differ- ent approaches taken across the country. Child Fatalities Due to Abuse and Neglect A number of developments have led to recent bipartisan legislation— the Protect Our Kids Act—designed to address child fatalities due to abuse and neglect. These developments include the rising number of known child abuse and neglect-related deaths even as rates of child abuse fall; a 2011 GAO report stating that such fatalities are undercounted and that states are highly inconsistent in the ways they track, count, and examine these fatalities (GAO, 2011); findings of research on children’s hospital admis- sions (Berger et al., 2011); and the almost daily media reports of the death of children due to abuse and neglect. The Protect Our Kids Act, signed by the President on January 14, 2013, created a national commission to ex- amine child abuse and neglect-related fatalities and to recommend actions that should be taken to evaluate current programs and prevention efforts addressing the problem, as well as a comprehensive national strategy for re- ducing and preventing child abuse and neglect-related fatalities nationwide. The Children’s Bureau responded to concerns about rising rates of child abuse and neglect-related deaths by developing a contract for information gathering with Walter R. McDonald & Associates, as well as convening a 2012 meeting of child welfare directors and child fatality reviewers to examine their processes. The literature in this area includes only three studies, just one of which had a quasiexperimental design. Palusci and colleagues (2010) found that in Michigan, policy changes made after an initial phase of reviews of child fatalities due to abuse and neglect appeared to have positive impacts. De- creases were seen in fatalities among children familiar to child protective services, and specific policy changes appeared to result in improved pro- fessional practice. During this same time, however, child fatalities due to unaddressed mental health needs increased, as did inaccuracies in medical

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CHILD ABUSE AND NEGLECT POLICY 377 examiner findings—both of which are systems-level problems that cannot be addressed solely within the child welfare system. While they hesitate to assign causality, Palusci and colleagues (2010) suggest that it is important to consider whether changes proposed by the review panel could reasonably be expected to affect child abuse and neglect-related fatalities. A number of changes in state law, policy, and procedures during this time impacted child protective services procedures, including training, supervision, and peer review. The authors theorize that the review panel’s recommendations may have had an impact because of the familiarity of the panel members with the child welfare system and the formal process that exists for moving from reviews to recommendations to state action. During its first 5 years of operation, the Arizona Child Fatality Review Program (ACFRP) identified 29 percent of deaths of children under age 18 as preventable, and 56 percent of deaths of children over age 9 (Rimsza et al., 2002). The ACFRP found that 61 percent of the child abuse-related deaths were preventable. Child protective services in Arizona were involved in 21 percent of the child abuse cases prior to the fatal injury or neglect; in two cases, out-of-state child protective services agencies were involved but did not report findings to Arizona. Additionally, the ACFRP identified two instances in which medical personnel were believed to have failed to recognize suspicious injuries. The ACFRP identified five deaths it believed were ruled incorrectly by the medical examiner as natural or accidental that should have been classified as due to child abuse or neglect (Rimsza et al., 2002). Douglas and McCarthy (2011) report that the focus of child fatality review teams varies widely among states, although the focus of most teams includes fatalities due to child abuse and neglect. Additionally, there is little uniformity with regard to content areas in the legislation establishing such teams. The most frequent content areas included in state laws are the com- position of the team (93.4 percent), confidentiality concerns (86.9 percent), review outcomes (86.9 percent), the team’s purpose (95.6 percent), and the team’s selection of cases (58.7 percent) (Douglas and McCarthy, 2011). In most states (89 percent), the stated purpose of the team is to prevent future deaths, but fewer than two-thirds of states require reports from the team to the executive branch of government or the child welfare system, only half of states require public education as a result of the team’s reviews and recommendations, and even fewer states require a public report from the team (although many print them) (Douglas and McCarthy, 2011). States whose establishing legislation for the teams was passed early in the development of such teams were more likely to have an investigative focus for the team. Higher crime rates marginally but significantly predicted that a state’s team would focus on prevention (Douglas and McCarthy, 2011). More rigorous research is required to assess the effectiveness of such

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378 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH teams in preventing deaths due to child abuse and neglect. Given the vary- ing scope of the teams in each state, this research would need to account for several potentially confounding variables, including how the states define deaths due to child abuse and neglect. Research also is needed to better understand what are referred to as “near fatalities” (i.e., children hospitalized for abuse and neglect who are labeled as in serious or critical condition), as well as to look across data systems, as in Putnam-Hornstein’s (2011) examination of abuse and neglect and birth and death records in California. The latter study provided insight in the area of risk factors, noting that previous reports of physical abuse were correlated with child abuse and neglect-related deaths. Finding: State laws differ significantly in defining child abuse and ne- glect. Very little research has examined the impacts of state definitions of child abuse and neglect on child safety, including the effects of in- stituting state definitions; changing state definitions to include educa- tional neglect, medical neglect, parental substance abuse, or exposure to intimate partner violence; and differences among state definitions. Finding: Differences in state definitions of child abuse and neglect- related “near fatalities,” the exclusion of data on fatalities and near fatalities from NDACAN, and limited coordination among jurisdic- tions and state agencies pose challenges to tracking and analyzing the most severe cases of child abuse and neglect. Insufficient research has been conducted to identify best practices for overcoming these barriers. Finding: The guidelines and standards for defining child abuse and neglect vary significantly within states among the various disciplines, agencies, and professional groups involved in preventing, identifying, and responding to the problem. No research addresses the impact of these variations on the safety of children. Finding: Research on state mandatory reporting laws reveals higher rates of substantiation in states with universal mandated reporting laws. Research on professional mandated reporters indicates that many do not report suspected cases of child abuse and neglect because of multiple barriers. Some evidence indicates that additional training of the general mandated reporting workforce could increase reporting. Finding: While no research evaluates the impact of states’ different evidence standards for case substantiation on intervention outcomes, states with more strict evidence requirements for substantiation were

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CHILD ABUSE AND NEGLECT POLICY 379 found to have lower reported rates of child abuse and neglect than states with less strict evidence requirements. Finding: Limited research reveals that complex substantiation decisions are tied to the chronicity of abuse, workers’ concerns about child safety, the availability of quality medical diagnoses, and workforce training. Furthermore, research conclusively finds that children involved in both substantiated and unsubstantiated abuse or neglect cases have very similar case characteristics and outcomes. Finding: Criminal penalties for child physical and sexual abuse vary across states, but research has not examined whether public knowledge of criminal and civil penalties helps prevent child abuse and neglect. Furthermore, analysis of charges and penalties for abusive head trauma has found race to be a stronger predictor of more serious charges than fatality or severity. Finding: Beyond the CAPTA requirement that states preserve the confi- dentiality of child abuse and neglect records to protect the rights of the child and the child’s parents or legal guardians, state statutes vary with respect to the persons or entities allowed access to central registries of child abuse and neglect and other case records. No research establishes that any state’s statutory scheme for releasing records leads to better protection of children. Finding: No rigorous evaluations have examined the impact of safe haven laws on infant abandonment or death. Such evaluations are hampered by the lack of systematic collection of state-level data on infant abandonment and by anonymity provisions in the law that make it impossible to interview women placing their children in safe havens about alternative courses of action. Finding: State CASA provisions vary significantly, but an ongoing study of two different models of child representation by the National Quality Improvement Center on Legal Representation of Children is the only known rigorous comparative evaluation of different approaches. Finding: Recent federal action designed to address child fatalities due to abuse and neglect includes the Protect Our Kids Act, which established a national commission to examine fatalities, recommend actions for program evaluation, and develop a national strategy for prevention, and activities by the Children’s Bureau.

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380 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH Finding: At the state level, the focus of child fatality review teams varies widely. One successful panel review of child fatalities was conducted in Michigan by experts familiar with the child welfare system; they suggested policy changes, which were followed by decreases in child fatalities. More rigorous research is required to assess the effectiveness of such panels in preventing deaths due to child abuse and neglect. Such research would benefit from improved definitions of near fatalities and from linking of data across systems. CONCLUSIONS The heterogeneity of state laws on child abuse and neglect offers an opportunity for a natural experiment that could help illuminate what does and does not work. The impact of policy change could be examined by studying state variations in such areas as mandated reporters, definitions of abuse and neglect, inclusion of the witnessing of intimate partner violence, and other elements included in state laws, as well as the range of penalties. As outlined in this chapter, opportunities also exist to examine variations in reporting laws, county- versus state-administered systems, differential response, mandated nursery-based preventive education in abusive head trauma, and education of mandated reporters about abuse and neglect. New research approaches should be considered, such as propensity scor- ing (D’Agostino, 1998) and difference-within-difference analyses (Shafrin, 2006), which can be powerful tools for examining policy-relevant ques- tions. Explicit requirements for policy research should be part of any newly funded and developed child abuse and neglect research centers. REFERENCES Albert, V. N. 2001. Using time-series analysis to evaluate the impact of policy initiatives in child welfare. Evaluation and Program Planning 24(2):109-117. Alter, J., E. Bennett, V. Bombach, S. Delacueva, J. Hauer, D. Kirchner, D. Meyerhoff, J. Randall, K. J. Starr, J. Trupke-Bastidas, and J. Vos. 2012. Evaluation report: Child pro- tection screening. St. Paul, MN: Office of the Legislative Auditor, State of Minnesota, Program Evaluation Division. Alvarez, K. M., M. C. Kenny, B. Donohue, and K. M. Carpin. 2004. Why are professionals failing to initiate mandated reports of child maltreatment, and are there any empirically based training programs to assist professionals in the reporting process? Aggression and Violent Behavior 9(5):563-578. Ayres, S. 2009. Kairos and safe havens: The timing and calamity of unwanted birth. William and Mary Journal of Women and the Law 15(227):227-289. Berger, R. P., J. B. Fromkin, H. Stutz, K. Makoroff, P. V. Scribano, K. Feldman, L. C. Tu, and A. Fabio. 2011. Abusive head trauma during a time of increased unemployment: A multicenter analysis. Pediatrics 128(4):637-643.

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