Child Maltreatment Research, Policy, and Practice for the Next Decade Workshop Summary (2012) / Chapter Skim
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Appendix D: Background Paper: Major Research Advances Since the Publication of the 1993 NRC Report *Understanding Child Abuse and Neglect*: Highlights from the Literature
Appendix D: Background Paper: Major Research Advances Since the Publication of the 1993 NRC Report *Understanding Child Abuse and Neglect*: Highlights from the Literature
Pages 119-204
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to provide background for the January 30-31 Workshop on Child Maltreatment Research, Policy, and Practice for the Next Generation, hosted by the IOMNRC Board on Children, Youth, and Families. The responsibility for the content of this article rests with the author and does not necessarily represent the views of the IOM, the NRC, or their committees and convening bodies.
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. The statistical figures mask a complex picture of child maltreatment, one that frequently challenges the general public's perception of the nature of the problem of child abuse and neglect.
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. Although a relatively small proportion of reported cases of child abuse and neglect meet legal criteria for substantiation, several studies have suggested that unsubstantiated cases face equal risks (Hussey et al., 2005; Kohl et al., 2009)
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A particular area of interest is research on child maltreatment, which focuses on the characteristics and needs of children and families who experience physical abuse, sexual abuse, emotional maltreatment, and neglect. 1993 Academy Study on Child Abuse and Neglect Nearly two decades ago, the National Research Council (NRC)
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In the intervening years, a national child abuse prevention initiative within the Doris Duke Charitable Foundation has also emerged. In addition, a wave of animal and human research studies focused on stress, trauma, and the regulation of adverse environmental influences (including threats and violence)
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Research studies focused on specific aspects of child welfare, such as the experience with alternative forms of foster care placements or disproportionality in the foster care population, are not addressed. Nor is attention directed toward topics such as the reliability of child testimony, or interventions in judicial settings for victims of child abuse and neglect.
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The initial database review was then supplemented by searches of additional research sources, such as the National Criminal Justice Research Service, the Child Abuse and Neglect Digital Library maintained by Cornell University, and websites maintained by selected HHS agencies, including the Administration for Children and Families (ACF) , Health Resources and Services Administration (HRSA)
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§ 5106g) , as amended by the CAPTA Reauthorization Act of 2010, defines child abuse and neglect as, at minimum: "Any recent act or failure to act on the part of a parent or care taker which results in death, serious physical or emotional harm, sexual abuse or exploitation" or "An act or failure to act which presents an imminent risk of serious harm." This definition of child abuse and neglect refers specifically to parents and other caregivers.
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The 2008 CDC report notes that prior ef forts by the research and legal communities to develop consistent and uniform definitions of child maltreatment were not adequate for use in public health surveillance because many of the data sources used by the research and legal communities are not available to state and local public health officials: Because no public health-based definitions for child mal treatment exist, public health officials continue to use terms related to child maltreatment in different ways and use dif ferent terms to describe the same acts. Not surprising, these inconsistencies have contributed to varied conclusions about the incidence and prevalence of child abuse and neglect.
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In its first Report to Congress on High Priority Evidence Gaps for Clinical Preventive Services, the U.S. Preventive Services Task Force identified "Interventions in Primary Care to Prevent Child Abuse and Neglect" as one of the high-priority areas in "Behavioral Intervention Research Topics That Deserve Further Research." Approximately 1 million abused children are identified in the United States each year.
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The ICD-9 codes for "child maltreatment syndrome" are 995.50, .54, .55, or .59, which include abuse, emotional/psychological abuse, nutritional neglect, sexual abuse, physical abuse, shaken infant syndrome, and other child abuse and neglect. The ICD codes that classify fatalities from child maltreatment are "external cause of death: homicide" (ICD-9 E960-969)
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Even within directly related academic disci plines, such as social work and psychology, specific training or coursework focused on child maltreatment or child welfare may be sparse. Although the governing bodies in some health disciplines have recognized the need for core competencies appropriate to practi tioners in their fields, the call for an overarching set of principles remains unmet.
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This relationship is necessary in cases of physical abuse or neglect (because other forms of assault, e.g., peer or sibling violence or school bullying, do not fall within state-based definitions of child abuse)
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. The National Child Traumatic Stress Network (NCTSN)
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Discrepancies between official reports of child abuse and neglect and other data sources (e.g., health records and household surveys) as well as other methodological challenges have raised basic questions about the scope of the problem, the types of families that are affected, trends over time, and outcomes associated with selected prevention and treatment interventions (Fallon et al., 2010)
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. Per 1,000 children, 9.2 were reported to be "unique victims" of child abuse and neglect in the total population of U.S.
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2) 3 The authors of the Lancet article highlight several concerns in conducting research on the identification, disclosure, and reporting of child abuse and neglect.
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Each of the following sections highlights the key data sources used to develop indicators of child abuse and neglect. These data sources include official reports, health records, and research studies that include periodic household surveys as well as those that follow one population cohort over time.
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DCDC is a compilation of case-level information from child protective services agencies drawn from electronic child abuse and neglect records (all states, with the exception of Oregon, and the District of Columbia and Puerto Rico provided detailed case data in FY 2010; Oregon provided summary data)
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In addition to the data drawn from child protection and child welfare agencies, the U.S. Census Bureau conducts an annual crime victim survey on behalf of the U.S.
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ICD codes for child injury and fatality data As noted in Box 3, the CDC collects data from hospital records that are coded according to ICD-9 and ICD-10. Several research studies have demonstrated difficulties with the data sources that are used to identify child fatalities and injuries that result from maltreatment.
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(2012) also sought to use health records to identify child deaths or serious injuries that resulted from violence by parents or other caregivers (physical abuse)
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Longitudinal Studies Longitudinal Survey of Child Abuse and Neglect (LONGSCAN)
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. Researchers compared interviews with mothers and reports to North Carolina's Registry of Child Abuse and Neglect to examine the reliability of predictive factors of first-year maltreatment reports and potential interventions to reduce the risk of second- and third-year maltreatment reports (Hunter and Knight, 1998; Kotch et al., 1997)
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(2009) , the Dunedin study "provides a rich source of information on child abuse, the causes of antisocial behavior and resulting life course outcomes.
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referred to the Widom survey as "the most famous study of child abuse and neglect" (p.
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NSCAW I involved data from 5,501 children (ages 0 to 14) from 97 child welfare agencies nationwide, who entered the child welfare system within a 15-month period (October 1999-December 2000)
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For example, a recent (December 2011) search of the measures index organized by the National Data Archive on Child Abuse and Neglect (NDACAN)
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The author is not aware of how this analysis of measures used in child maltreatment studies compares with other social or behavioral studies that focus on child development or family processes and relationships. However, the broad and persistent fragmentation of measures across multiple studies inhibits comparative studies and presents a continuing challenge to investigators who wish to pool data across multiple samples in order to increase the power of statistical analyses.
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or behavioral disorders (e.g., substance abuse or domestic violence)
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Such adversities may include poverty, intimate partner violence, substance use, inadequate housing, unemployment, parental illness, mental health disorders, and family dysfunction. Certain psychological, psychiatric, or behavioral factors may precipitate some forms of maltreatment (e.g., the relationship between pedophilia and child sexual abuse or the link between parental depression or substance use and physical abuse)
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His work gives particular attention to neighborhood and residential factors that contribute to victimization, including frequent moves; family loss, conflict, and turmoil (that might be associated with health problems or inadequate housing) ; greater exposure of children to unfamiliar, unrelated, and potentially predatory or aggressive people; and compromises in child supervision that result from these circumstances (Finkelhor, 2008)
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. This work most notably contributed to the initial passage of CAPTA and the creation of a federal program to support state-based child protection and child welfare services.
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. Research on child welfare populations indicates that many of these delays are evident in early childhood and go unserved (Stahmer et al., 2005)
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. Such adaptive "learned" behaviors can be disruptive and contribute to social isolation, and also present risks for future engagement with antisocial peer groups, externalizing behaviors, conduct problems, and substance abuse (Egeland et al., 2002, cited in Gunnar et al., 2006)
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. A third perspective, which has more recently emerged in the research literature, has called attention to the interactions among early experiences, the neurobiology of stress, and brain development.
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(2010) , for example, explored how a prior history of childhood sexual abuse might predict certain physiological responses to stress in late adolescence that also then predicted both higher levels of depression and antisocial behaviors in young adulthood.
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. Young children are at particular risk of adverse consequences, including death -- 87 percent of all child maltreatment fatalities in FY 2009 involved children in this age group, and infants less than a year old comprise 46 percent of all child maltreatment fatalities for this same period (DeVooght et al., 2011)
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. The authors noted, however, that "It is possible that the lower rates at these younger ages reflect some undercoverage of these age groups." PREVENTION EFFORTS The 1993 NRC report Understanding Child Abuse and Neglect observed: In the field of child maltreatment, the goals of preventive interven tions are to reduce risk factors associated with child abuse and ne glect, to improve the outcomes of individuals or families exposed to such risk factors, and to enhance compensatory or protective factors that could mitigate or buffer the child from the effects of victimiza tion.
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focus on populations that exhibit certain risk characteristics generally associated with child maltreatment, such as poverty, first-time pregnancies, or unmarried mothers. Other selective interventions strive to add a prevention element to interventions focused on specific risk characteristics that frequently contribute to child abuse and neglect, such as parents with substance use disorders, mental health problems (usually depression)
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They are designed to prevent the recurrence of abuse and neglect or to mitigate adverse consequences among children who have already experienced maltreatment. These services are often provided to families or children who are in contact with CPS or child welfare agencies.
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. Abusive Head Trauma Prevention Efforts In addition to the community-based prevention programs reviewed by Daro and Dodge, other primary, universal preventive efforts have been initiated in healthcare settings, including prenatal classes, hospitalbased maternity wards, and pediatric offices.
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(2005) examined outcomes associated with abusive head trauma in western New York following an extensive intervention that included multiple parent educational materials (as well as the commitment statement)
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Advisory Board on Child Abuse and Neglect (1990) to recommend a universal system of home visitation for newborns and their parents, especially for first-time, low-income mothers.
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initiative. While most of the models had favorable impacts on primary measures of child development, school readiness, and positive parenting practices, only five models specifically measured the impact of the home visitation program on child maltreatment.
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. Indicated Prevention It is difficult to establish a clear boundary between preventive interventions and treatment services for families already in contact with child protective or child welfare agencies.
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Community-Based Interventions Few efforts have been made to examine the effects of communitybased prevention interventions on child maltreatment outcomes for families that have already come to the attention of CPS. One study that has specifically examined the impact of preventive interventions on recidivism rates of child maltreatment is the Durham Family Initiative (DFI)
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(providing mothers with didactic training in child development, parenting skills, coping strategies for managing stresses in the immediate environment, and assistance in developing social support networks)
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6 TREATMENT INTERVENTIONS A broad array of treatment interventions are available to serve families that are in contact with CPS, child welfare agencies, or health providers as a result of reports of abuse and neglect. Beyond the reporting, investigation, and case assessment services described in a preceding section, these interventions may include medical treatment of initial injuries or health disorders (e.g., head trauma injury in infants or growth retardation in young children)
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Consultation with key subspecialists, child abuse experts, and social services personnel is particularly recommended:
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Pe diatricians often find it helpful to consult a subspecialist in the field of child abuse pediatrics to ensure that the medical evaluation has been complete and the diagnosis is accurate. Subspecialists in radiol ogy, ophthalmology, neurosurgery, neurology, and other fields should also be consulted when necessary to ensure a complete and accurate evaluation.
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. In 2004, two expert panels published reports that documented the extent to which evidence-based treatment interventions for child victims of abuse or neglect as well as the adult offenders were available to CPS and child welfare agencies.
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have identified three treatment models for child victims of abuse and neglect that meet selected standards of evidence (standards include criteria such as soundness of the theory base, extent of general clinical acceptance, and strength of empirical support, among others)
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to the use of the Homebuilders treatment model for families reported for child neglect: The Incredible Years is a parenting and child behavior manage ment skill training program initially designed as a treatment for child behavior disorders as well as a school-based behavior prob lem prevention program for high-risk populations. The program has been adapted for parents from high-risk contexts, such as Head Start, that sometimes have high rates of future child wel fare involvement (Webster-Stratton, 1998; Webster-Stratton and Reid, 2003)
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has reported significantly reduced downstream child maltreatment outcomes among families in child welfare, which may improve the earlier ratings by the OVC and Kauffman reviews. Adult Treatment of Child Sex Molesters In addition to identifying TF-CBT as an evidence-based treatment intervention for victims of physical and sexual abuse, the OVC-convened expert panel gave a high rating to the adult treatment program for child sex molesters (Saunders et al., 2004)
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and low rates of subsequent sexual offenses. Social Service and Other Child Welfare Interventions The treatment interventions described above are generally offered through contract services to state- or county-based human services agencies in responding to families reported for child maltreatment.
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The intake process is the "front end" of the CPS system: It involves the actions associated with the initial receipt of and response to a complaint of child abuse and neglect, also called a "referral." The referrals may involve one or more children, they may involve one or more types of abuse and neglect, they may be a single event or part of a recurring pattern of maltreatment, they may or may not fall within the statutory guidelines of the CPS agency, and the complaint may involve actions that require attention by other social service, health, or law enforcement agencies. Limited knowledge is available about the provision and acceptance of these referrals, in part because the linked data systems needed to track such information are largely nonexistent (Jonson-Reid and Drake, 2008)
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Several research studies have compared the merits of using different models of risk assessment in examining child maltreatment cases. The traditional model is a consensus-based protocol, which relies on a consensus judgment of 8 States that did not provide referral data included Hawaii, Illinois, New Jersey, New York, North Carolina, and Pennsylvania.
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. The report concluded that while most child welfare agencies had adopted some form of risk assessment to guide the resolution of case-specific and system-related practice problems, fundamental problems continued to challenge these efforts.
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The traditional CPS response to child maltreatment cases (sometimes referred to as a forensic response) is appropriate for those circumstances that present desperate situations or immediate threats to safety or injury to a child, such as sexual abuse, imminent harm, or abuse by caregivers in a state or county residential facility.
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As a result, multiple states have developed legislative reforms and flexible service strategies that provide opportunities to offer a "differential response" to CPS investigations of accepted reports of child abuse and neglect allegations (this approach may also be termed an alternative response, family assessment response, dual track, or multiple track)
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105) Recognizing the multiple dimensions of the differential response model, the HHS Children's Bureau has launched a cooperative agreement with the NQIC on Differential Response in Child Protective Services to develop a 5-year project to expand the knowledge base on differential response.
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(2009) provide an overview of the historical practices that have guided judicial oversight in such cases, noting that such lawsuits have successfully challenged the child welfare system in about two thirds of the states, involving "demonstrations or concessions of massive noncompliance with federal requirements -- failure to take action in response to indications of abuse and neglect; arbitrary removal of children without reasonable reunification efforts; and placement of children in inappropriate, often dangerous, settings without substantial consideration or review" (Noonan et al., 2009, p.
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SOCIAL POLICY A detailed review of the key social policy issues associated with the identification, assessment, treatment, and prevention of child abuse and neglect is far beyond the scope of this paper. However, it is useful to highlight some of the major themes that have emerged since the publication of the 1993 NRC report to frame the types of questions that could inform future studies and discussion.
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However, by viewing child abuse as a wicked problem, that is complex and less amenable to being solved, then child welfare professionals can be supported to focus on achiev ing longer term outcomes for children that are more likely to meet their needs. The authors argue for an earlier identification of and in tervention with children who are experiencing multiple adversity, such as those living with parents misusing substances and exposed to intimate partner violence.
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. The report from the Center for Child Welfare Policy captures much of the uncertainty facing administrators and caseworkers in this area: Since large-scale change has historically been so difficult for many organizations, it may ultimately be easier to support ineffective, even potentially harmful, technologies rather than change them, both be cause of the financial investment already made, and because an overburdened workforce cannot sustain another large-scale change.
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The consortium has multiple goals, including identifying evidence-based prevention and treatment interventions (strategies, practices, programs, and policies) that communities can adopt and implement; assisting local communities in implementing measures of well-being and of risk and protective factors in order to assess whether prevention and treatment interventions are achieving their intended benefits; and building a series of communitybased research initiatives that can examine the impact of evidence-based policies, programs, and practices when implemented in high-poverty communities.
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. In other cases, longitudinal research studies of non-U.S.
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More challenging issues are emerging on the horizon, however, with the advent of electronic health systems and efforts to document experience with stress and adversity as part of personal health records. Moving Research into Policy and Practice Researchers in the field of child abuse and neglect are consistently pressed to translate their findings into clinical applications as well as recommendations for policy and practice.
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Examples include efforts by the Translational Research on Child Neglect Consortium (http://trcnconsortium.com/index.htm) and the National Data Archive on Child Abuse and Neglect (http://www.ndacan.cornell.edu/)
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Child Abuse & Neglect 33(11)
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2009. Preventing child abuse and neglect with parent training: Evidence and opportunities.
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W., R Block, and Committee on Child Abuse Neglect.
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Child Abuse & Neglect 31(11-12)
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Child Abuse & Neglect 20(11)
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Child Abuse & Neglect 34(1)
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Child Abuse & Neglect 29(5)
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Child Abuse & Neglect 24(4)
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Child Abuse & Neglect 29(5)
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2009. Legal accountability in the service-based welfare state: Lessons from child welfare reform.
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2010. The efficacy of family support and family preservation services on reducing child abuse and neglect: What the literature reveals.
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Child Abuse & Neglect 35(1)
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2010b. Fourth National Incidence Study of child abuse and neglect (NIS-4)
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2003. Emerging practices in the prevention of child abuse and neglect.
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Child Development 76(5)
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