9


Recommendations

The 1993 National Research Council (NRC) report notes that “Child maltreatment is a devastating social problem in American society” (NRC, 1993, p. 1). The committee responsible for the present report, armed with research findings gleaned during the past 20 years that document the deleterious impact of child abuse and neglect on the health, well-being, and social constructs of populations across the United States, regards child abuse and neglect not just as a social problem but as a serious public health issue. Child abuse and neglect affects not only children but also the adults they become. Its effects are broad and deep, affecting every aspect of human functioning, and costing American taxpayers considerable federal and state investments in programs and services to address the resulting cascade of problems.

The committee deliberated on recommendations whose implementation can respond to this public health problem while remaining realistic about the nature of actions that can be taken in these challenging political and economic times. The intent of the recommendations presented in this chapter is to capitalize on existing opportunities whenever possible, and at the same time to urge new actions the committee deems essential.

Existing research and service system infrastructures are not sufficient for responding to this public health challenge. The committee’s bold goal is that in the near future, significant and recognizable changes will have been accomplished, changes that will make a difference for children and families and represent measurable, substantive improvement in the many systems that support them.



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9 Recommendations T he 1993 National Research Council (NRC) report notes that “Child maltreatment is a devastating social problem in American society” (NRC, 1993, p. 1). The committee responsible for the present re- port, armed with research findings gleaned during the past 20 years that document the deleterious impact of child abuse and neglect on the health, well-being, and social constructs of populations across the United States, regards child abuse and neglect not just as a social problem but as a serious public health issue. Child abuse and neglect affects not only children but also the adults they become. Its effects are broad and deep, affecting every aspect of human functioning, and costing American taxpayers considerable federal and state investments in programs and services to address the result- ing cascade of problems. The committee deliberated on recommendations whose implementa- tion can respond to this public health problem while remaining realistic about the nature of actions that can be taken in these challenging political and economic times. The intent of the recommendations presented in this chapter is to capitalize on existing opportunities whenever possible, and at the same time to urge new actions the committee deems essential. Existing research and service system infrastructures are not sufficient for responding to this public health challenge. The committee’s bold goal is that in the near future, significant and recognizable changes will have been accomplished, changes that will make a difference for children and families and represent measurable, substantive improvement in the many systems that support them. 385

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386 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH GUIDING PRINCIPLES In developing recommendations to advance child abuse and neglect research, the committee identified several cross-cutting, guiding principles. These are not independent recommendations, but are part of the rationale for the actions recommended by the committee and are important consid- erations for their implementation. The following principles are critical to advancing understanding and knowledge of child abuse and neglect: • disentangle the roles of cultural processes, social stratification influ- ences, ecological variations, and immigrant/acculturation status; • apply multidisciplinary, multimethod, and multisector approaches; and • leverage and build upon the existing knowledge base of child abuse and neglect research and related fields, as well as research defini- tions, designs, and opportunities. Disentangle the Roles of Cultural Processes, Social Stratification Influences, Ecological Variations, and Immigrant/Acculturation Status Efforts to address child abuse and neglect must be informed by an understanding of the complex roles of culture, social stratification, and associated contextual factors in the causes, consequences, prevention, and treatment of the problem, particularly in light of the increasing heteroge- neity of families in the United States. A focus on cultural processes, social stratification influences, ecological variations, and immigrant/acculturation status is pertinent to understanding the causes and consequences of child abuse and neglect and involvement with child protective services or other social service systems. These factors also matter in developing and testing the effectiveness of prevention and intervention strategies and replicating and adapting evidence-based practices for distinct populations or groups so as to ensure cultural fit, reach, efficacy, and adoption (Barrera et al., 2011), as well as social validity and practical application. While an increasing body of research has been dedicated to examining differential experiences based on race, ethnicity, and social context, the level of methodological sensitivity required to parse the roles and interrela- tionships of these factors accurately has not been adequately incorporated across child abuse and neglect research. Further, these factors tend to be omitted from the major considerations driving current research and pro- grammatic development. In designing studies that consider and evaluate the impact of social and economic factors on child abuse and neglect, it is important for research- ers to adopt a critical stratification lens and to avoid the error of equat-

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RECOMMENDATIONS 387 ing domains of stratification with the attributes and practices of culture. Understanding cultural factors related to risk and protective factors or the effectiveness of interventions for child abuse and neglect calls for the complementary use of qualitative and quantitative research methodolo- gies. The use of methods and approaches that are culturally sensitive and responsive to diverse and vulnerable populations is also critical to under- standing the interplay of micro- and macro-level processes and establishing the evidence base. Apply Multidisciplinary, Multimethod, and Multisector Approaches As noted in Chapter 7, child abuse and neglect research domains re- flect the many systems that interact, largely independently, with abused and neglected children and their families. In many jurisdictions, abused and ne- glected children and their families pass through multiple agencies as their cases are processed and they receive services. Each system has its own mis- sion, expertise, agenda, and obligations to fulfill. The various systems are staffed by different disciplines, collect different types of information, and are focused on different outcomes. Definitions of what is considered an act of child abuse and neglect also differ according to systemic priorities and variations in the state legislation that mandates child abuse and neglect reporting. For research purposes, differences in the way child abuse and neglect is identified, documented, and handled create difficulties for ob- taining an accurate picture of its incidence and surrounding circumstances. Further, agencies place different values on research and its relevance to their practice. Thus in many jurisdictions, the integrated, cross-system research necessary to understand causes, consequences, prevention, intervention, and treatment for child abuse and neglect cannot be conducted. There is a pressing need to overcome these barriers and to undertake multidisciplinary research that spans systems. Such efforts would link re- search to the many locations where abused and neglected children receive services and in so doing, bring together the expertise and perspectives of the many interrelated fields that can assist in understanding the multiple, com- plex facets of child abuse and neglect. Steps to overcome these barriers in- clude developing a discrete set of definitions and methodology for question design for use in specific types of research; investing in the capacity to link data across systems; conducting multidisciplinary, multimodal research to capture the different and interrelated impacts of the many services received by abused and neglected children, including a more comprehensive array of intervention outcomes; and applying multimethod research designs, includ- ing those that incorporate qualitative approaches and use methodologies that better reveal the dynamics of the impacts of community and organiza- tional structure on outcomes.

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388 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH Leverage and Build on the Existing Knowledge Base of Child Abuse and Neglect Research and Related Fields, as Well as Research Definitions, Designs, and Opportunities The conclusions and recommendations presented in this report call for dramatic improvements to the knowledge base and the capacity to conduct research in the field of child abuse and neglect. As stakeholders prepare to invest in such research capacity, it is important to note the opportunities offered by notable past and current empirical and services research efforts among the many disciplines associated with child abuse and neglect, as well as related fields. In an era of fiscal constraints, leveraging such existing resources and opportunities is critical to avoid duplication of effort and to support necessary research in an efficient manner. Thus in preparing an agenda for future child abuse and neglect re- search, it is important to draw upon what is currently known so as to identify critical gaps in the collective understanding of the problem. The review of evidence presented in this report, along with the attendant find- ings, should provide guidance in this regard. Opportunities also exist to leverage existing research infrastructures and mechanisms so as to efficiently build the proper supports for large-scale, sustainable child abuse and neglect research efforts. Longitudinal studies present a tremendous opportunity to collect the data necessary to advance understanding of the causes and consequences of child abuse and neglect, as well as the effectiveness of services for its prevention and treatment, but are often costly to initiate and require the sustained commitment of study sponsors. The addition of child abuse and neglect variables to existing population-based, longitudinal studies of children, such as the National Children’s Study, offers a way to leverage existing large-scale data collection efforts and research agendas. In addition, systematic secondary analyses of child abuse and neglect data from existing longitudinal studies, such as the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) and the National Survey of Child and Adolescent Well-Being (NSCAW), would make valuable and efficient contributions to research, policy, and practice discussions. A significant opportunity to supplement current research efforts also lies in the creation of sustainable infrastructure for the conduct of research at the various service locations where abused and neglected children and their families are seen on a daily basis. Linking researchers to service providers would allow for readily available, community-based research samples, and those research efforts could in turn contribute to the improve- ment of services provided by these entities.

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RECOMMENDATIONS 389 RECOMMENDATIONS The following recommendations represent an actionable framework that can guide and support future child abuse and neglect research reflect- ing the needs and knowledge gaps detailed throughout this report. Recom- mendations 1, 2, and 3 urge the development of a national strategic plan to initiate the process of federal coordination and resource allocation that is necessary to support the field of child abuse and neglect research, with a focus on the research priorities set forth in this report. Recommendations 4 through 7 represent critical steps toward the creation of a sustainable in- frastructure for child abuse and neglect research. While these infrastructure recommendations should be considered in the implementation of a national strategic plan, they are actions of considerable importance that merit sepa- rate and specific consideration from the agencies and institutions targeted as key actors. Finally, Recommendations 8 and 9 provide for the evaluation of federal and state policies related to child abuse and neglect. It is important to note that the committee’s charge called for identify- ing child abuse and neglect research priorities. Therefore, the focus of these recommendations is on needed components of future research in the field, to the exclusion of specific actions for providers in the delivery of preven- tion and treatment services. The actions of service providers are obviously of critical importance to the well-being of children impacted by child abuse and neglect, but encompass an area of inquiry that falls outside the purview of this report. It is the committee’s hope that this report’s discussion of re- search needs related to the effective provision of services and the structure of the systems in which they are delivered will lead to improvements in the prevention of child abuse and neglect and the care of those it affects. A National Strategic Plan for Child Abuse and Neglect Research This report has described the current landscape of child abuse and neglect research and presented the body of knowledge that can serve as a foundation for the future growth of the field. Advances in knowledge, technology, and research implementation tools have helped bring about substantial improvements in the collective understanding of the conse- quences of child abuse and neglect, as well as the efficacy of prevention and treatment approaches to mitigating this devastating societal problem. Innovation in linking data across multiple sources has provided access to means of developing more accurate assessments of the community-level prevalence of child abuse and neglect. Dramatic advances in both neural and genomic sciences have offered new insights into the neural and biologi- cal processes associated with abuse and neglect. The development of pre- vention and treatment models has presented service providers with a range

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390 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH of viable program options, and the testing of such models has shown that child abuse and neglect can be both preventable and manageable through informed approaches. The findings presented in this report also identify challenges to be overcome and opportunities to be explored in the field, providing guidance on research areas most in need of further development. Despite the many advances in child abuse and neglect research over the past two decades, significant gaps in knowledge remain. Improved surveillance of child abuse and neglect is needed to identify unexplored risk factors and to better de- pict and examine the significance of national and state incidence trends. Research on the causes of child abuse and neglect needs to move beyond correlational designs and analyses to test causal models. The consequences of child abuse and neglect need to be better understood in terms of the behavioral and neurobiological mechanisms that mediate the association between exposure to abuse and neglect and its behavioral and neurobiologi- cal sequelae. Research on intervention and treatment services needs to move beyond the development of model programs to devise effective strategies for the implementation and replication of programs in varying community settings. Work needs to be initiated on a body of research to examine the effects of changes to the ever-shifting laws and policies related to child abuse and neglect at the federal, state, and local levels. And throughout all domains of child abuse and neglect research, the roles of race, ethnicity, and culture need to be adequately explored, with increased attention to children in underserved and underresearched populations. Chapter 7 of this report highlights the benefits of applying a public health framework to guide empirical research on child abuse and neglect, as well as associated research on interventions, services, and policy. Doing so will require a holistic approach to a problem that spans many spheres of academic and programmatic disciplines and encompasses many systems. New, cross-disciplinary partnerships and support structures are needed to permit advances in the implementation of a coordinated, rigorous, scientific approach and make significant progress in the field. To this end, a shift is needed toward a well-coordinated, properly directed, adequately supported, multidisciplinary scientific enterprise. The field of child abuse and neglect research currently is lacking a core, national-level priority-setting body that can reach all of the many associated disciplines and that has the capacity to allocate the resources necessary to develop a sustainable, accountable research infrastructure. Research sup- port needs to be substantially increased and stable to allow for more com- plete investigations of specific topics and to provide for long-term studies. Mechanisms need to be implemented to facilitate the cohesive interaction of individuals and institutions across varied disciplines and sectors. The committee therefore makes the following three recommendations to sup-

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RECOMMENDATIONS 391 port the development of a national process for coordinating and prioritizing investment in child abuse and neglect research. A Coordinated National Agenda for Child Abuse and Neglect Research A critical component of a national strategic plan will be a comprehen- sive research agenda for child abuse and neglect. This research agenda will examine factors related to both children and adults across physical, mental, and behavioral health domains; include issues that encompass child welfare, economic support, criminal justice, education, and health and behavioral health care systems; and assess the differential needs of a variety of sub- populations. Research needs to be directed at the areas of greatest need, and priority setting will require the input of stakeholders across disciplines and systems. On a national scale, this agenda will necessarily involve co- ordination and collaboration across a variety of federal agencies, as well as partnerships with state agencies, tribes, private entities, and universities that are at the forefront of innovation. Recommendation 1: Federal agencies, in partnership with private foun- dations and academic institutions, should implement a research agenda designed to advance knowledge and understanding of the causes and consequences of child abuse and neglect, as well as the identification and implementation of effective services for its treatment and preven- tion. The research priorities listed in Figure 9-1 should be considered in this agenda. In formulating a national research agenda, it will be critical to identify the most pressing needs and the most significant gaps in knowledge. The findings and conclusions presented throughout this report should be used to guide a national strategy for setting priorities in child abuse and neglect research. To further distill these messages, the committee has identified key research priorities that should be included in a national research agenda and should be considered by all entities concerned with supporting the advancement of the empirical knowledge base on child abuse and neglect, as well as efforts to prevent and ameliorate its deleterious effects. These re- search priorities, summarized in Figure 9-1, fall into three major categories: research on the causes and consequences of child abuse and neglect, services research in complex systems, and child abuse and neglect policy research. In its statement of task, the committee was asked to identify research ar- eas that are no longer a priority for funding. However, the committee could not find support for either scaling back or discontinuing research funding in any specific topic area related to child abuse and neglect. Whereas research in the field of child abuse and neglect has made tremendous progress over

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392 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH Causes and Consequences Services in Complex Systems and Policy  Improve understanding of the separate and synergistic consequences of  Explore highly effective delivery different forms of child abuse and systems. neglect.  Develop and test new programs for  Initiate high-quality longitudinal studies underserved children and families. of child abuse and neglect.  Identify the best means of replicating  Target innovative research on the effective interventions and services causes of child abuse and neglect. with fidelity.  Improve understanding of the  Identify the most effective ways to behavioral and neurobiological implement and sustain evidence- mechanisms that mediate the based programs in real-world settings. association between child abuse and  Investigate the longitudinal impacts of neglect and its sequelae. prevention.  Encourage research designed to provide a better understanding of trends in the incidence of child abuse and neglect.  Evaluate the impact of laws and policies that address prevention and intervention systems and services for child abuse and neglect at the federal, state, and local levels. Disentangle the role of cultural processes, social stratification influences, ecological variations, and immigrant/acculturation status. Apply multidisciplinary, multimethod, and multisector approaches. Leverage and build upon the existing knowledge base of child abuse and neglect research and related fields, as well as research definitions, designs, and opportunities. FIGURE 9-1  Research priorities in child abuse and neglect. the past two decades, more rigorous and coordinated research and evalu- ations, particularly those utilizing cross-disciplinary research designs and high-quality longitudinal data, are needed to establish a complete under- standing of the causes and consequences of child abuse and neglect and the programs, services, and policy mechanisms designed to prevent and treat its effects. As federal agencies, private foundations, and academic institutions work toward the implementation of a national research agenda, it will be important to monitor future progress in research in specific topic areas with an eye toward identifying cases in which additional research will no longer produce tangible benefits for the child abuse and neglect knowledge base.

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RECOMMENDATIONS 393 A National Plan for Implementing and Sustaining Child Abuse and Neglect Research The committee that developed the 1993 NRC report identified as a key priority federal leadership to guide, plan, and coordinate child abuse and neglect research. Based on its review of the current federal infrastructure supports for child abuse and neglect research, the present committee found that high-level, federal coordination of research in this field is still lacking. Notable progress has been made in understanding the problem and efforts to remediate its effects and prevent its occurrence; however, much more could be accomplished if emerging research occurred within a coordinated framework. Support for child abuse and neglect research remains fragmented across a number of federal agencies, private foundations, and academic centers, with little coordination. Further, the small aggregate research budget for this ma- jor public health problem, coupled with the episodic and scattered nature of funding opportunities, discourages scientists from pursuing child abuse and neglect research as a sustainable career path. Also lacking is accountability for progress in the field of child abuse and neglect research as a whole. To create a robust portfolio of child abuse and neglect research opportunities directed at areas of urgent need and to sustain the consistent pursuit of knowledge in this field, a mechanism for high-level, federal coordination, priority setting, and resource allocation should be implemented. Currently, the Federal Interagency Work Group on Child Abuse and Neglect does provide a convening forum at the federal level, with repre- sentation from more than 40 different federal agencies, including nearly all agencies with a major stake in child abuse and neglect research. The group’s stated mission is as follows: • to provide a forum through which staff from relevant federal agen- cies can communicate and exchange ideas concerning child abuse and neglect-related programs and activities, • to collect information about federal child abuse and neglect activi- ties, and • to provide a basis for collective action through which funding and resources can be maximized. The Federal Interagency Work Group on Child Abuse and Neglect is thus in a unique position that allows it to readily assess the needs, capabilities, and available resources of a large number of federal stake- holders. It also presents an opportunity to explore and strengthen inter- agency cooperation on issues that are relevant to the missions of multiple organizations.

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394 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH Recommendation 2: The Federal Interagency Work Group on Child Abuse and Neglect, under the auspices of the assistant secretary of the Administration for Children and Families, should develop a strategic plan that details a business plan, an implementation strategy, and de- partmental accountability for the advancement of a national research agenda on child abuse and neglect. The aim of the strategic plan should be to implement the research agenda formulated in accordance with Recommendation 1 by develop- ing the capability to conduct the research necessary to explore rigorously the areas of greatest need, as well as areas that present an opportunity to achieve significant advances in knowledge in the field. The plan should de- tail specific actions tailored to support research in key areas of need identi- fied in this report. It should also include components of an implementation strategy and a business plan. An implementation strategy will be needed to specify mechanisms required to conduct the necessary research, including but not limited to research grants, cooperative agreements, or contracts; data collection; and staffing requirements. A business plan will be needed to target specific agency resources that will be used to support the imple- mentation strategy. Within the Federal Interagency Work Group on Child Abuse and Ne- glect is a research subcommittee that provides the group with support and guidance for research initiatives. The group also has been involved in col- laboration with the National Institutes of Health’s (NIH’s) Child Abuse and Neglect Working Group, which is tasked with reporting on current NIH efforts, accomplishments, and future plans for research in child abuse and neglect. Both the research subcommittee and the NIH working group should have critical roles in the Federal Interagency Work Group on Child Abuse and Neglect’s shaping of a strategic plan for the implementation of a national research agenda on child abuse and neglect. In the course of its work, the Federal Interagency Work Group on Child Abuse and Neglect should also draw upon the diverse perspectives of its constituents and should engage researchers conducting work throughout the many disciplines associated with child abuse and neglect to ensure the requisite support for the types of research needed to advance knowledge in the field. Opportunities for interagency and interdisciplinary collaboration should be identified so that challenges can be approached with a diversity of perspec- tives, resources can be shared, and duplication of effort can be avoided. In this context, it is important to note that the work of these groups de- pends on the leadership and resources of various research funding agencies. The development of a national strategic plan will depend on the ongoing support of the Administration for Children and Families (ACF), NIH, and

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RECOMMENDATIONS 395 many other member agencies of the Federal Interagency Work Group on Child Abuse and Neglect. Accountability for Implementation of the Strategic Plan To ensure accountability, the strategic plan for child abuse and neglect research should designate specific responsibilities of federal agencies and corresponding program offices, directed according to agency mission and relative availability of resources. Recommendation 3: The assistant secretary of the Administration for Children and Families should convene senior-level leadership of all federal agencies with a stake in child abuse and neglect research to discuss and assign accountability for the implementation of a strategic plan to advance a national research agenda on child abuse and neglect. This convention of high-level federal leadership should take place in several stages and have the specific intent of assigning accountability for implementation of the strategies devised by the Federal Interagency Work Group on Child Abuse and Neglect, as well as generally improving federal coordination for the continuous support of child abuse and neglect research endeavors. As noted, child abuse and neglect research spans a number of academic and professional spheres, and it accordingly has received support from a wide array of federal agencies. Therefore, participants invited to this dis- course should be representative of the multiple agencies whose missions touch upon the many facets of child abuse and neglect research. Representa- tion should include but not be limited to the following agencies and offices: • Office of the Assistant Secretary for Planning and Evaluation; • Institute of Education Sciences of the Department of Education; • Indian Health Service; • Office of Planning, Research and Evaluation; • Office of Minority Health; • NIH (including Office of Behavioral and Social Sciences Research, National Institute on Alcohol Abuse and Alcoholism, National Institute of Child Health and Human Development, National In- stitute of Dental and Craniofacial Research, National Institute on Drug Abuse, National Institute of Mental Health, and National Institute of Neurological Disorders and Stroke); • Substance Abuse and Mental Health Services Administration; • Maternal and Child Health Bureau; • Centers for Disease Control and Prevention;

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396 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH • National Institute of Justice; • Office of Juvenile Justice and Delinquency Prevention; and • Agency for Healthcare Research and Quality. The committee recognizes the importance of on-the-ground experience in assembling the appropriate balance of expertise and authority to foster the success of the convening effort. Therefore, the committee urges the as- sistant secretary of ACF to use his discretion to identify and include the appropriate participants. As a first step, the assistant secretary of ACF should convene the rel- evant federal leadership before the strategic plan assigned to the Federal Interagency Work Group on Child Abuse and Neglect under Recommenda- tion 2 is completed. The focus of this meeting should be to identify specific departments, agencies, program offices, and federal leadership staff that should receive the incipient strategic plan. The assistant secretary should then direct the Federal Interagency Work Group on Child Abuse and Ne- glect to disseminate the strategic plan to the identified designees upon its completion. After the strategic plan has been completed and distributed, the assistant secretary should once again convene the leadership of relevant federal agencies to review its contents and to designate responsibilities and allocate resources according to the plan’s directives. All elements of the strategic plan should be assigned to specific departments, agencies, or program offices. To provide for future monitoring of performance under the strategic plan, the Federal Interagency Work Group on Child Abuse and Neglect should be directed and empowered to provide an annual report to the assistant secretary that contains an assessment of its member agencies’ ac- complishments in achieving the plan’s goals and identifies new issues that may necessitate revisions to the plan. If necessary, the assistant secretary should reconvene relevant federal leadership to ensure that agencies are meeting their objectives under the plan and to assign revisions to the plan. The committee’s recommendations to develop a national strategic plan call for a convening of diverse federal agency leadership resulting in co- ordinated and robust support for child abuse and neglect research across the many associated disciplines. Given that there currently is no federal home for research on child abuse and neglect, however, barriers will likely remain to adequate implementation of a comprehensive and coordinated research agenda. Accordingly, Box 9-1 presents additional suggestions for implementation strategies to ensure interagency commitment to support for child abuse and neglect research.

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RECOMMENDATIONS 397 BOX 9-1 Suggested Implementation Strategies •  rant authority to the Federal Interagency Work Group on Child Abuse G and Neglect for oversight and enforcement of a national strategic plan for child abuse and neglect research. •  reate a Children’s Policy Council through executive order of the White C House Office on Child Abuse and Neglect that includes staffing from the Domestic Policy Council.* • I nclude children and youth among the Domestic Policy Council’s issue area focus on family. •  rescribe an interagency, coordinated approach to child abuse and P n ­ eglect research, practice, and policy through either congressional legis- lation or presidential mandate. A recent model for action of this nature is the U.S. Government Action Plan on Children in Adversity. The impetus for that action plan was the fragmented nature of the activities of the wide array of U.S. government agencies with a stake in protecting vulnerable children globally. Requirements for a comprehensive, coordinated, and effective response on the part of the U.S. government to the world’s most vulnerable children as part of an interagency strategy were codified in P.L. 109-95. That statute also authorized presidential action to monitor and evaluate actions taken under the interagency strategy. The resulting ac- tion plan contains six delineated objectives and outlines specific activities assigned to a set of agency actors for advancement toward corresponding outcomes. *This policy council could be modeled after the White House Rural Council, which was cre- ated by Executive Order and includes representation of all federal agencies with a mission of addressing challenges in rural America, building on the administration’s rural economic strategy, and improving the implementation of that strategy. It is staffed by the Domestic Policy Council and the National Economic Council and is chaired by the secretary of agriculture. The Policy Council has a specific focus on increasing coordination and collaboration to best serve rural communities. A Research Infrastructure to Build and Sustain a Field of Child Abuse and Neglect Research The nature of the research needs identified in this report provides the underlying rationale for the resources and infrastructure that will be needed to support progress. To build a field of research focused on child abuse and neglect, it will be essential to adequately develop the infrastructure compo- nents required to sustain a national, multidisciplinary research enterprise. As discussed in Chapter 7, productive, high-quality scientific research on child abuse and neglect requires a particularly sophisticated infrastructure because of complexities involving diverse independent service systems,

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398 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH multiple professions, ethical issues that are especially complicated, and levels of outcome analysis ranging from the individual child to national statistics. Critical components of such an infrastructure generally include a dedicated and capable cadre of researchers, stable sources of research funding, and sufficient physical capital to conduct research based on so- phisticated designs. Optimism for the attainment of such a goal can be found in the fact that the field does not have to be built from the ground up. The efforts of ACF, NIH, and other federal research funding agencies, as well as the work of private foundations and academic institutions, have all helped lead to dramatic advances in research on this topic. A key catalyst for the develop- ment of a strong, national research infrastructure for the field of child abuse and neglect will be leveraging existing resources, knowledge, and opportu- nities presented by the work conducted within the field thus far. Through national coordination, dedicated funding support, and the commitment of key stakeholders, a foundation can be built from which child abuse and neglect research endeavors will flourish. It is the committee’s hope that the lessons learned presented in this report will provide a framework for the various entities that support child abuse and neglect research to combine their efforts and contribute to the formation of the necessary infrastructure in a stable and sustainable fashion. Through the following recommendations, the committee provides several discrete, actionable steps whose implementation would greatly contribute to the capacity to conduct child abuse and neglect research. However, the research infrastructure necessary to sustain a robust, national child abuse and neglect research enterprise will require a broad array of commitments across all of the various disciplines associated with this field. National Surveillance for Child Abuse and Neglect A high-quality, population-based, epidemiological surveillance system that draws on multiple data sources is critically necessary to the develop- ment of a national strategic approach to child abuse and neglect. Such a system would improve knowledge of the scope of child abuse and neglect to allow for a better understanding of the magnitude of the problem, identifi- cation of populations at greatest risk, and changes in prevalence over time. A more accurate reporting of the incidence of child abuse and neglect could also help in tracking the effectiveness of prevention programs and thus identifying the types of activities that should be replicated. In addition, a comprehensive surveillance system would provide for the collection of data on myriad potential environmental, community, and societal risk factors to guide the direction of effective prevention activities.

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RECOMMENDATIONS 399 Recommendation 4: The Centers for Disease Control and Prevention, in partnership with the Federal Interagency Work Group on Child Abuse and Neglect, should develop and sustain a national surveillance system for child abuse and neglect that links data across multiple sys- tems and sources. Critical steps toward developing an effective national surveillance sys- tem include movement toward more standardized use of child abuse and neglect definitions, further exploration of the context in which child abuse and neglect occurs, and linking of multiple data sources. Standardization of child abuse and neglect definitions The identification of children exposed to child abuse and neglect for research purposes often draws on sources that characterize experiences of abuse and neglect in dissimilar ways. For example, child abuse and neglect is reported to child protective services agencies differently depending on the state in which the agency is located, and surveys designed to elicit recall of abuse and neglect experiences often approach the task with divergent question methodologies. The result can be great variability and inconsistency in reporting on the incidence of child abuse and neglect. One of the first steps toward creating a national surveillance system should be to develop an approach to stan- dardizing definitions of child abuse and neglect across sources from which national data are to be drawn. Based on the committee’s review of definitional work in the field over the past two decades, the use of single, uniform definitions for the differ- ent types of child abuse and neglect throughout the field is neither feasible nor optimal. Given that child abuse and neglect represents a diverse set of behaviors with implications relevant to many research domains, defini- tions must be flexible enough to accommodate a variety of specific research questions. Within the parameters of these constraints, however, the stan- dardization of child abuse and neglect definitions can be improved by the development of a discrete set of definitional elements and a methodology for question design that can be selected for use in specific types of research. This set of definitional elements should be based on items proven to elicit an accurate assessment of the incidence of abuse and neglect and should be designed to best allow for comparison across studies. Linking of data across multiple sources  To provide accurate and effective surveillance of child abuse and neglect, data must be drawn from a variety of sources. Because abused and neglected children come in contact with multiple systems (e.g., mental and physical health care, education, law enforcement, child death reviews), aggregating data across multiple inde- pendent sources can improve identification of cases that were not referred

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400 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH to child welfare agencies. Linking case-based data from multiple sources allows for better identification of the scope of child abuse and neglect, including fatalities (Gibbs et al., 2013; Schnitzer et al., 2008); the devel- opment of profiles of children at risk, such as high-risk infants through a birth match process (Shaw et al., 2013); and planning and implemen- tation of community-level prevention strategies (Putnam-Hornstein and Needell, 2011; Putnam-Hornstein et al., 2011). Multisectoral datasets allow for real-time examination of pressing research, practice, and policy questions at multiple levels of analysis (i.e., individual, familial, agency, and geographic), such as the intersection of drug market activity, chang- ing neighborhood conditions, and substantiated child abuse and neglect (Freisthler et al., 2012). There are many logistical difficulties involved in creating such linkages of data across systems, and agency capacity for the data management and statistical analysis required for the purpose is often lacking. In addition to the inevitable hardware and software incompatibilities, separate systems collect different types of data and code and process the data in different ways, greatly complicating case linkage. Legal restrictions, often com- pounded by confusion about just what is confidential information, inhibit data sharing. Most agencies lack the expertise in data management and statistical analysis to conduct research with their own or combined datasets. Investment in the capacity to link data across the many systems that en- counter abused and neglected children is therefore a priority for advancing knowledge in the field. Research Cadre for Child Abuse and Neglect One of the strengths of the scientific enterprise is the expectation that its members will provide training, mentorship, and support for new inves- tigators. To fulfill this mission, a field must have a supply of funded inves- tigators conducting ongoing studies in which trainees can participate. The field must have access to research training funds to support trainees and new investigators while they learn. Mentors must be competent, involved, and supportive, helping trainees develop new areas of investigation and novel approaches to persistent problems. Strengthening the next generation of child abuse and neglect researchers will require a communication system and learning collaborative that can link these young scholars throughout their careers with those exploring similar and complementary research questions. To bolster the workforce with knowledgeable and dedicated re- searchers, the field also needs support to elevate its institutional relevance as a legitimate and highly important field of academic pursuit.

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RECOMMENDATIONS 401 Recommendation 5: Federal agencies, in partnership with private foun- dations and academic institutions, should invest in developing and sustaining a cadre of researchers who can examine issues of child abuse and neglect across multiple disciplines. To support and develop opportunities to train researchers in this field, a commitment across the various multisectoral entities that support child abuse and neglect research will be necessary. Such training opportunities must be available to develop researchers at all stages of their careers, includ- ing programs targeted toward graduate and undergraduate students as well as early and midcareer research professionals. A specific focus on interdisci- plinary training programs is necessary, to reflect the breadth of fields related to child abuse and neglect research. There are a number of examples and models of successful child abuse and neglect research training initiatives that should be replicated and implemented broadly across disciplines and their affiliated public and private institutions. Various multidisciplinary professional societies have been formed to advance research in child abuse and neglect. In 1977, the International Society for the Prevention of Child Abuse and Neglect was incorporated in Denver to enhance professional education in and recognition of child abuse and neglect around the world (ISPCAN, 2013). Most recently, in 2005, the Academy on Violence and Abuse was founded to support health professionals making violence and abuse core components of health care education (AVA, 2010). Among federal agencies, NIH Career Development Awards provide a mechanism for training and developing researchers at different career stages. These awards are designed to provide support and protected time for an intense career development experience. They could be used to target child abuse and neglect researchers, and similar mechanisms could be devel- oped at other relevant federal agencies to support workforce development in this field. Among private foundations, the Doris Duke Charitable Foundation’s Fellowships for the Promotion of Child Well-Being, implemented through Chapin Hall at the University of Chicago, serve as a model for the type of comprehensive, multidisciplinary training opportunities that need to be developed in the field of child abuse and neglect research. The stated goal of these fellowships is to “identify and develop a new generation of leaders interested in and capable of creating practice and policy initiatives that will enhance child development and improve the nation’s ability to prevent all forms of child maltreatment” (Chapin Hall at the University of Chicago, 2013). The fellowships support grantees’ research efforts at their respective academic institutions and provide academic as well as policy or program mentors to guide the fellows in their work and professional

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402 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH development. Fellows are recruited from a variety of disciplines associated with child abuse and neglect research, and a peer learning network is be- ing developed to encourage communication and collaboration among the multidisciplinary fellows along with their associated mentors. Multidisciplinary Research Centers on Child Abuse and Neglect The call for child abuse and neglect research centers is not new. The 1993 NRC report called for the establishment of such centers, a message that was echoed with regard to family violence in the 2001 Institute of Medicine (IOM) report Confronting Chronic Neglect. To date, however, there has been no movement toward federal support for such centers in the manner envisioned by those earlier committees, and the need for the centers has not diminished. In a field in which research opportunities are often fragmented and inconsistent, these centers would provide a stable home for child abuse and neglect research endeavors, allow the research to be guided by a multidisciplinary perspective, and help train a new genera- tion of child abuse and neglect researchers to ensure a dedicated workforce for the future. A key benefit of the creation of research centers is the ability to bring together partners with a diversity of perspectives and strategic resources. Successful research centers in other fields, including the Alzheimer’s Disease Centers, the Harvard Youth Violence Prevention Center, and the Geriatric Education Centers, have shown how such centers can leverage diversity and resources to advance their areas of inquiry in unique ways (IOM, 2001). These research centers have provided funding for innovative lines of research; strengthened multidisciplinary work by enabling researchers to coordinate their efforts; and established stable, continuous funding streams for major research projects that would not be feasible for individual re- searchers to undertake. Furthermore, research centers have demonstrated their effectiveness in disseminating new knowledge to key professional and lay communities. Recommendation 6: Federal agencies, in partnership with private foun- dations and academic institutions, should provide funding for new multidisciplinary education and research centers on child abuse and neglect in geographically diverse locations across the United States. In the field of child abuse and neglect, the establishment of dedicated research centers would allow entities with the infrastructure capacity to conduct high-quality research, such as academic institutions and private foundations, to access community settings where abused and neglected chil- dren are seen regularly, such as child protective services, the courts, child

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RECOMMENDATIONS 403 advocacy centers, and community health centers. This interdisciplinary col- laboration could lead to the creation of a more robust research portfolio. Specific efforts that could be undertaken by such centers include • conducting child abuse and neglect research in the specific areas of need identified in this report; • developing new lines of investigator-initiated research; • providing an interdisciplinary forum for the exchange of ideas and the formation of partnerships; • supporting professional development in the field of child abuse and neglect research through training programs and mentorship opportunities; and • conducting research on the impact of policies that address child abuse and neglect prevention and intervention systems, as well as services at the federal, state, and local levels. National Institutes of Health Child Maltreatment, Trauma, and Violence Study Section Housed within NIH’s Center for Scientific Review, study sections pro- vide for the review and initiation of investigator-initiated research related to the section’s specified areas of interest. A stable mechanism for evaluating and supporting new areas of investigator-initiated research is critically im- portant for the development and progression of the field of child abuse and neglect research. This mechanism would allow researchers with a concrete understanding of child abuse and neglect research needs to help shape the direction of the field. Recommendation 7: The National Institutes of Health should develop a new child maltreatment, trauma, and violence study section under the Risk, Prevention, and Health Behavior Integrated Review Group. Research developed through a study section on child abuse and neglect, trauma, and violence would fit within areas of interest specific to the Risk, Prevention, and Health Behavior Integrated Review Group. Most notably, child abuse and neglect research would advance knowledge related to the review group’s interest in behavioral and interpersonal interventions; risk and protective processes and models; and social, cognitive, and affective conditions and processes that influence disease and disorder across the life span. The review panel of the proposed study section should comprise a wide range of cross-disciplinary expertise to reflect the spectrum of dis- ciplinary perspectives needed to adequately assess the variety of research needs associated with the field of child abuse and neglect. The panel should

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404 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH represent key fields in research on child abuse and neglect such as psychol- ogy, psychiatry, child and adolescent development, neuroscience, genetics, social work, criminology, criminal justice, pediatrics, family medicine, nurs- ing, and surgery, among others. Evaluation of Child Abuse and Neglect Laws and Policies As discussed in Chapter 8, numerous federal policy changes have been designed to impact the incidence, reporting, and negative health and eco- nomic consequences of child abuse and neglect. However, little work has been done to evaluate the impact of these changes. Such research is needed to determine the effectiveness of policies and in turn to influence future legislative action at both the federal and state levels. Research also is needed to understand the impact of regulatory policies on not only the populations they target but also the systems in which they are implemented. Explicit requirements for the support of policy research should be part of any new legislation related to child abuse and neglect so as to also spur the develop- ment of this body of research and guide the future actions of policy makers. Recommendation 8: To ensure accountability and effectiveness and to encourage evidence-based policy making, Congress should include sup- port in all new legislation related to child abuse and neglect, such as reauthorizations of the Child Abuse Prevention and Treatment Act, for evaluation of the impact of new child abuse and neglect laws and poli- cies and require a review of the findings in reauthorization discussions. While a number of federal statutes, such as the Child Abuse Preven- tion and Treatment Act, dictate minimum federal standards for child abuse and neglect policy, many of the laws and policies affecting how child abuse and neglect is handled in the United States are developed and carried out at the state level. As with federal policies in this area, little research has been conducted on the impact of law and policy changes at the state level. Such research is needed to support future laws and policies that are grounded in sound evidence and to explore the impact of those changes at the individual, community, and system levels. Recommendation 9: To ensure accountability and effectiveness, to sup- port evidence-based policy making, and to allow for exploration of the differential impact of various state laws and policies, state legislatures should include support in all new legislation related to child abuse and neglect for evaluation of the impact of new child abuse and neglect laws and policies and require a review of the findings in reauthoriza- tion discussions.

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RECOMMENDATIONS 405 Also clearly needed is support for policy-relevant research that takes advantage of the variations among states in laws, policies, and programs to enhance knowledge of what works. Opportunities exist to examine, for example, variations in reporting laws, inclusion of children’s exposure to intimate partner violence as reportable, county- versus state-administered child protection systems, differential response, mandated nursery-based prevention education in abusive head trauma, and mandated reporter edu- cation on abuse and neglect. FINAL THOUGHTS The recommendations presented in this chapter represent immediate and groundbreaking actions whose implementation would significantly ad- vance the capacity to conduct research on child abuse and neglect in areas of tremendous value. However, the necessary support for this research will not be attainable without the ongoing commitment of the many stakehold- ers with ties to this work. Furthermore, concerted action of these stakehold- ers based on the findings, conclusions, and recommendations presented in this report needs to be initiated now. The immediate need for such wide- spread action can be distilled into three major points. The benefits are tangible. Various estimates of the societal costs of child abuse and neglect reveal a significant burden across populations within the United States. At the same time, the science of prevention and treatment, along with the testing of associated programs and services, has shown that the incidence of child abuse and neglect can be reduced, and its deleterious effects that cascade throughout the life course can be mitigated. Investments in child abuse and neglect research provide a clear path to improving the nation’s population health, as well as other metrics of well-being. Addi- tionally, one of the frequently overlooked benefits of conducting research on child abuse and neglect issues is that progress can be translated to the many interrelated fields of study. Domains such as child development, child welfare, education, social work, pediatrics, and criminology all stand to benefit from advances in child abuse and neglect research. Opportunities are present. By leveraging existing resources and build- ing upon the knowledge base derived from previous research, the task of building a sustainable child abuse and neglect research infrastructure be- comes less daunting than it may appear. The timing is urgent. In addition to the exigency of the societal burden imposed by child abuse and neglect, immediate action is warranted by the fact that building the proper supports to sustain a national child abuse and neglect research enterprise will take a considerable amount of time. A shift in organizational culture, the creation of a sustainable infrastructure, the development of a new generation of dedicated researchers, the collection of

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406 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH longitudinal data, and effective dissemination and implementation research are examples of necessary endeavors that will require time before the as- sociated benefits can be realized. It is the committee’s hope that the messages of this report will result in swift and effective action at the federal, state, and community levels across the many and varied sectors with a role in child abuse and neglect research. REFERENCES AVA (Academy on Violence and Abuse). 2010. Welcome to the Academy on Violence and Abuse. http://www.avahealth.org (accessed November 27, 2012). Barrera, M., F. G. Castro, and L. K. Steiker. 2011. A critical analysis of approaches to the development of preventive interventions for subcultural groups. American Journal of Community Psychology 48(3-4):439-454. Chapin Hall at the University of Chicago. 2013. Doris Duke fellowships for the promotion of child well-being. http://www.chapinhall.org/fellowships/doris-duke-fellowships (accessed June 25, 2013). Freisthler, B., N. J. Kepple, and M. R. Holmes. 2012. The geography of drug market activities and child maltreatment. Child Maltreatment 17(2):144-152. Gibbs, D. A., L. Rojas-Smith, S. Wetterhall, T. Farris, P. G. Schnitzer, R. T. Leeb, and A. E. Crosby. 2013. Improving identification of child maltreatment fatalities through public health surveillance. Journal of Public Child Welfare 7(1):1-19. IOM (Institute of Medicine). 2001. Confronting chronic neglect: The education and training of health professionals on family violence. Washington, DC: National Academy Press. ISPCAN (International Society for Prevention of Child Abuse and Neglect). 2013. ISPCAN history. http://www.ispcan.org/?page=History (accessed November 27, 2012). NRC (National Research Council). 1993. Understanding child abuse and neglect. Washington, DC: National Academy Press. Putnam-Hornstein, E., and B. Needell. 2011. Predictors of child protective service contact between birth and age five: An examination of California’s 2002 birth cohort. Children and Youth Services Review 33(8):1337-1344. Putnam-Hornstein, E., D. Webster, B. Needell, and J. Magruder. 2011. A public health ap- proach to child maltreatment surveillance: Evidence from a data linkage project in the United States. Child Abuse Review 20(4):256-273. Schnitzer, P. G., T. M. Covington, S. J. Wirtz, W. Verhoek-Oftedahl, and V. J. Palusci. 2008. Public health surveillance of fatal child maltreatment: Analysis of 3 state programs. American Journal of Public Health 98(2):296-303. Shaw, T. V., R. P. Barth, J. Mattingly, D. Ayer, and S. Berry. 2013. Child welfare birth match: Timely use of child welfare administrative data to protect newborns. Journal of Public Child Welfare 7(2):217-234.