New Directions in Child Abuse and Neglect Research (2014)

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Introduction

The 1993 National Research Council (NRC) report Understanding Child Abuse and Neglect 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, regards child abuse and neglect not just as a social problem but as a serious public health issue. Researchers have found that child abuse and neglect affects not only children but also the adults they become. Its effects cascade throughout the life course, with costly consequences for individuals, families, and society. These effects are seen in all aspects of human functioning, including physical and mental health, as well as important areas such as education, work, and social relationships. Furthermore, rigorous examinations of risk and protective factors for child abuse and neglect at the individual, contextual, and macrosystem levels have led to more effective strategies for prevention and treatment.

This public health problem requires swift and effective action. The committee’s deliberations led to recommendations for responding to the problem of child abuse and neglect while remaining realistic about the nature of feasible actions in these challenging political and economic times. The intent is to capitalize on existing opportunities whenever possible while advocating for new actions when they are needed.

The committee also believes that the existing body of research creates enormous opportunities for research going forward; the nation is poised to take full advantage of a developing science of child abuse and neglect. In particular, the results of studies of the consequences of child abuse and ne-

glect, integrating biological with behavioral and social context research, as well as studies and controlled prevention trials that integrate basic findings with services research, now provide a solid base for moving forward with more sophisticated and systematic research designs to address important unanswered questions. New knowledge and better research tools can yield a better understanding of the causes of child abuse and neglect, as well as the most effective ways to prevent and treat it.

At the same time, however, the existing research and service system infrastructures are inadequate for taking full advantage of this new knowledge. The committee hopes that this gap will narrow as researchers in diverse domains collaborate to elucidate the underlying causes and consequences of child abuse and neglect, as those implementing promising interventions learn how best to take evidence-based models to scale with fidelity, and as policies are examined more rigorously for their ability to improve outcomes and create a coordinated and efficient system of care.

THE 1993 REPORT

Two decades ago, the Administration on Children, Youth and Families (ACYF) within the U.S. Department of Health and Human Services asked the National Academy of Sciences to conduct a study of research needs in the area of child abuse and neglect. That study resulted in the 1993 NRC report, which synthesizes the research on child abuse and neglect and, adopting a child-oriented developmental and ecological perspective, outlines 17 research priorities in an agenda that addresses 4 objectives:

1.   clarify the nature and scope of child maltreatment;

2.   provide an understanding of the origins and consequences of child maltreatment to improve the quality of future policy and program efforts;

3.   provide empirical information about the strengths and limitations of existing interventions while guiding the development of more effective interventions; and

4.   develop a science policy for child maltreatment research that recognizes the importance of national leadership, human and financial resources, instrumentation, and appropriate institutional arrangements.

TRENDS SINCE 1993

Since the 1993 report, research on child abuse and neglect has expanded, and understanding of the consequences and other aspects of child abuse and neglect for the children involved, their families, and society has

advanced significantly. During that same period, rates of reported physical and sexual abuse (but not neglect) have declined substantially, for reasons not fully understood. On the other hand, reports of psychological and emotional abuse have risen.

Child abuse and neglect nonetheless remains a pervasive, persistent, and pernicious problem in the United States. Each year more than 3 million referrals for child abuse and neglect are received that involve around 6 million children, although most of these reports are not substantiated. In fiscal year 2011, the latest year for which data are available, state child protective services agencies encountered 676,569 children, or about 9.1 of every 1,000 children, who were found to be victims of child abuse and neglect, including physical abuse, sexual abuse, psychological abuse, and medical and other types of neglect. More than one-quarter had been victimized previously. Of these 676,569 children, 1,545 died as a result of the abuse or neglect they suffered—most younger than 4 years old (ACF, 2012). Yet these figures are underestimates because of underreporting (GAO, 2011). For example, the estimate of the rate of child abuse and neglect by caretakers in 2005-2006 derived from the most recent National Incidence Study of Child Abuse and Neglect, a sample survey, was 17.1 of every 1,000 children (totaling more than 1.25 million children), and many more were determined to be at risk (Sedlak et al., 2010). This uncertainty as to the extent of child abuse and neglect hampers understanding of its causes and consequences, as well as effective prevention and treatment interventions.

Research conducted since 1993 has made clear that child abuse and neglect has much broader and longer-lasting effects than bruises and broken bones or other acute physical and psychological trauma. As noted above, child abuse and neglect can have long-term impacts on its victims, their families, and society. Children’s experiences of these long-term consequences vary significantly, depending on the severity, chronicity, and timing of abuse or neglect, as well as the protective factors present in their lives. Nevertheless, abused and neglected children are more prone to experience mental health conditions such as posttraumatic stress disorder and depression, alcoholism and drug abuse, behavioral problems, criminal behavior and violence, certain chronic diseases, and diminished economic well-being.

Society is also affected. Each year, cases of abuse or neglect may impose a cumulative cost to society of $80.3 billion—$33.3 billion in direct costs (e.g., hospitalization, childhood mental health care costs, child welfare system costs, law enforcement costs) and $46.9 billion in indirect costs (e.g., special education, early intervention, adult homelessness, adult mental and physical health care, juvenile and adult criminal justice costs, lost work productivity) (Gelles and Perlman, 2012). An analysis by the Centers for Disease Control and Prevention found that the average lifetime cost of a case of nonfatal child abuse and neglect is $210,012 in 2010 dollars, most

of this total ($144,360) due to loss of productivity but also encompassing the costs of child and adult health care, child welfare, criminal justice, and special education (Fang et al., 2012). The average lifetime cost of a case of fatal child abuse and neglect is $1.27 million, due mainly to loss of productivity. These costs are comparable to those of other major health problems, such as stroke and type 2 diabetes, issues that garner far more research funding and public attention.

THE CURRENT STUDY

In 2012, ACYF requested that the National Academies update the 1993 NRC report. ACYF asked that the updated report “provide recommendations for allocating existing research funds and also suggest funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.” Box 1-1 contains the complete statement of task for this study.

STUDY APPROACH

The Institute of Medicine of the National Academies appointed a committee with expertise in relevant areas—child development and pediatrics, psychology and psychiatry, social work and implementation science, sociology, and policy and legal studies—to conduct this study. The chair and one committee member had been the chair and a member, respectively, of the 1993 study committee, which provided for continuity. The committee commissioned a number of background papers that reviewed research results and research infrastructure needs in key areas of child abuse and neglect research. It held four face-to-face meetings, including two public sessions, as well as many whole-committee and subcommittee conference calls, to review the literature; discuss current understanding of the extent, causes, and consequences of child abuse and neglect, the effectiveness of intervention programs, and the impact of public policies; and discuss the draft report chapters and reach consensus on findings, conclusions, and recommendations.

Evidence

In constructing the evidence base for this report, the committee looked back nearly 20 years to assess the state of research on child abuse and neglect. Doing so involved a conscious decision to privilege the peer-reviewed literature across a variety of disciplines (e.g., social-cultural science, developmental science, neuroscience, prevention and intervention science, epidemiology) and multiple dimensions of child abuse and neglect, including etiology, consequences, prevention, and intervention, as well as ethics, service delivery, and policy. The committee considered the most rigorous evidence drawn from a variety of study designs and methods, including mixed-methods, experimental, observational, prospective, retrospective, descriptive, longitudinal, epidemiological, meta-analysis, and cost-effectiveness studies.

The committee built on a literature review conducted as part of a workshop exploring major research advances since publication of the 1993 report (IOM and NRC, 2012). That initial literature review yielded a brief updated summary of selected research literature, reports, and grey literature on the topics covered in the original report (NRC, 1993). Relevant studies were selected through a search of several scientific databases and were augmented by additional research conducted by other agencies and organizations (see IOM and NRC, 2012, for more detailed information).

The committee expanded on the 2012 literature review and critically examined publications derived from a literature database search, supplemented by the committee’s knowledge of relevant work in the field. The re-

view strategy began with a keyword search of electronic citation databases, followed by a review of the literature gleaned from published research syntheses, academic books, and peer-reviewed journals (i.e., Child Abuse and Neglect, Child Maltreatment, Children and Youth Services Review, Child Welfare, Protecting Children); websites of research, nonprofit, and policy organizations (including evidence-based clearinghouses); professional conference proceedings; and other grey literature. Literature on child abuse and neglect in the United States was the primary focus; however, the committee also considered key studies from other countries. While the committee’s approach did not represent a systematic review of the evidence, it did provide a body of research well suited to guide an understanding of critical issues and formulation of the recommendations presented in this report.

Definitions

As described in Chapter 2, definitions of child abuse and neglect can vary considerably as legal definitions differ across states, and researchers apply diverse standards in determining whether abuse or neglect has occurred. A basic yet important definition of child abuse and neglect is contained in Section 3 of the Child Abuse Prevention and Treatment Act (CAPTA)¹:

At a minimum, any recent act or set of acts or failure to act on the part of a parent or caretaker, 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.

While this federal definition sets a minimum standard for legal definitions, each state has developed its own definitions of child abuse and neglect. Child abuse and neglect are usually represented by four major categories: physical abuse, neglect, sexual abuse, and emotional (or psychological) abuse. Table 1-1 presents examples of acts that are considered to represent each of these four types of abuse and neglect, as compiled by the Child Welfare Information Gateway.

The examples listed in Table 1-1 are drawn from state definitions of child abuse and neglect; however, they are not representative of any specific state. There is considerable variation across jurisdictions with regard to statutory descriptions of which acts constitute abuse or neglect. In addition, child abuse and neglect are defined in many contexts outside of legal and child protection system venues, research being the most notably germane to this report. Many studies identify cases of abuse and neglect through the use of survey instruments. Across these studies is found much variation

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¹42 U.S.C. § 5101 note.

TABLE 1-1 Examples of Acts of Child Abuse and Neglect

SOURCE: Adapted from CWIG, 2008.

in the types of questions asked of respondents and the types of responses that indicate instances of abuse or neglect. While some standards have been developed, definitions of child abuse and neglect in this context are often tailored to the needs of specific studies.

Given this definitional landscape, which is discussed further in Chapter 2, the committee made two significant determinations with regard to definitions of child abuse and neglect for the purposes of this report. First, the scope of the discussion in this report is limited to actions (or inaction) of parents or caretakers, to the exclusion of extrafamilial abuse. This scope is reflective of the minimum definitional standard prescribed by CAPTA. Although individual jurisdictions may expand their definitions of abuse to include actions by extrafamilial parties, the CAPTA minimum standard is the most universally relevant to legal and child protection systems across the United States, as well as the data drawn from such sources for research purposes. Restricting the scope of this report to parent or caregiver actors also allowed the committee to conduct a more focused evaluation of the causes and consequences of abuse and neglect, as well as the delivery of prevention and treatment services, within the context of family and home. It is important to note that while this scope applies to the organization and content of the report, some of the studies discussed in the following chapters draw samples from jurisdictions that include instances of extrafamilial abuse in their definitions.

Second, the report does not specify a particular set of circumstances that would define whether or not an instance of child abuse or neglect has occurred. In addition to the need to review many studies that incorporate samples based on differing characterizations of acts of child abuse and neglect, there is insufficient evidence with which to determine the single most reliable, effective, and appropriate definitional approach. As studies are presented throughout the report, methodological limitations identified by the committee are described where applicable.

RESEARCH ADVANCES IN CHILD ABUSE AND NEGLECT

As noted above, research conducted in the past 20 years has revealed child abuse and neglect to be a serious public health problem, but it has also revealed that rates of physical and sexual abuse of children (although not neglect) appear to have declined. Credited with the possible declines are some policy and practice reforms that include more aggressive prosecution of offenders, especially in the area of child sexual abuse; more effective treatment programs for victims of child abuse and neglect; and increased investments in prevention programs, especially for new parents. Yet contradictions and inconsistencies in the data demand more analysis.

Publications on child abuse and neglect increased more than threefold over the past two decades. Among the key areas seeing significant advances are (1) research on the consequences of child abuse and neglect, demonstrating that its effects are severe, long-lasting, and cumulative over adulthood; (2) research demonstrating effects on the brain and other biological systems, as well as on behavior and psychosocial outcomes; and (3) rigorous treatment and prevention research demonstrating the effectiveness of interventions.

Despite these advances, however, the research evidence also underscores how much remains unknown. More specific research designs and incorporation of core questions into studies examining factors that impact parental capacity and child development are needed to enable greater understanding and more effective prevention of child abuse and neglect. Also needed is a better understanding of the remarkable declines in reported child abuse, why children have differential sensitivity to abuse of similar severity, and how different types of abuse impact a child’s developmental trajectory.

Needed as well are improved theories and research that can make it possible to disentangle the multiple causes and consequences of child abuse and neglect. The complexity of child abuse and neglect requires a systems approach, employing integrated, cross-disciplinary thinking, and research methods that can support better-specified model testing. Among specific improvements needed are refined theoretical models and research designs representing the relevant disciplines and ecological levels with appropriate specification of effects; multiple measures and methods for tracking core constructs, including neurological and other biological measures such as genetic and epigenetic factors; longitudinal research designs with which to assess the sequences of events that lead to abusive and neglectful behaviors and to identify treatment and prevention interventions that can protect against the intergenerational transfer of abuse and neglect; appropriate statistical analyses that differentiate effects at various ecological levels; appropriate statistical control to create more rigorous experimental opportunities when randomized controlled trials are infeasible for evaluating

interventions; and designs that account for overlapping variance due to children’s being nested within multiple layers of systems. Simpler designs and analyses can still play a role, especially when descriptive studies are needed to generate hypotheses. And essential for any study is clarity of the question being examined, preferably with a hypothesis that can be tested; the appropriate research design and statistical analysis can then be identified.

While some longitudinal studies on child abuse and neglect do exist, including the Longitudinal Studies in Child Abuse (LONGSCAN) and National Survey of Child and Adolescent Well-Being (NSCAW), additional longitudinal, prospective studies are needed. An example of the kind of study required is the Fragile Families and Child Wellbeing Study, which is following a cohort of nearly 5,000 children born in large U.S. cities between 1998 and 2000, with an oversample of 75 percent children born to unmarried parents (for further information, see www.fragilefamilies.princeton.edu). This longitudinal study (now producing the sixth wave of data on children and their families 15 years after the original data collection) has examined many questions related to the nature of the sample, including child abuse and neglect (e.g., Guterman et al., 2009; Lee et al., 2008; Whitaker et al., 2007). The study employs embedded variables, such as children and parents within families, including all the variations that currently occur in families, and many types of data, from neighborhood characteristics to biological measures.

Importantly, this study serves as an example for the rigor of data analysis. A recent working paper by McLanahan and colleagues (2012) carefully reviews the literature on the causal effects of father absence to examine how study design impacts findings. The authors conclude that studies with more rigorous designs have found negative effects of father absence on child well-being, but with smaller effect sizes than have been found with standard cross-sectional designs. These conclusions demonstrate the importance of designing rigorous studies to examine complex questions such as those relating to child abuse and neglect. The Fragile Families study can provide a great deal of information on child abuse and neglect, and a similarly rigorous study designed to examine the many important questions concerning child abuse and neglect could do much more.

Both practice and policy research require similar improvements. Future research efforts need to address the impacts of service integration and the additive effects of conducting multiple interventions that simultaneously address the problem at the individual and community levels. While strengthening the response to child abuse and neglect will require continued rigorous prevention and treatment research on the efficacy of promising interventions, equally important is examining how such efforts can be replicated with quality and consistency. Finally, research is needed to understand the role and impacts of a more integrated, systemic response to child abuse

and neglect with respect to participant outcomes and system performance. A better understanding also is needed of the utility and potential limitations of employing a singular focus on evidence-based decision making to guide policy and practice.

A SYSTEMS FRAMEWORK FOR CHILD ABUSE AND NEGLECT

Research advances in child abuse and neglect make clear that attaining a better understanding of the problem and mounting an effective response will require a systems perspective (e.g., Senge and Sterman, 1992). The public health problem of child abuse and neglect encompasses many embedded systems that are engaged both positively and negatively in creating, sustaining, and responding to the problem. Such systems include individual development, family systems, social relationship systems, and service systems from the local to the national level, among others. All of these systems and factors within them involve complex interdependencies, such that efforts to solve one aspect of the problem may reveal or even create problems at other levels.

Systems thinking has been adopted in the child protection field both in the United States and globally (e.g., Wulczyn et al., 2010). As Wulczyn and colleagues note, the systems approach fits well with the major theoretical model in the field of child development—that of Bronfenbrenner (1979). From any perspective, children can be considered in terms of the nested or embedded and interacting structures (e.g., families, communities) that affect them. Conversely, considering any child-related issue without taking such a perspective will be an incomplete exercise. From the perspective of the child protection system, all of the systems that work with children are highly entangled and must work in concert to achieve effective results (Wulczyn et al., 2010). Figure 1-1 depicts the interplay among the actors, contexts, and components of child protection systems.

Policy and program failures typically are considered to be system failures (Petersen, 2006). They often involve a given system’s establishing unsustainable ends or goals, or the use of approaches that fail to achieve the intended results and may have unintended consequences that may be worse than the initial problem. The common system failures (e.g., Senge and Sterman, 1992; Sterman, 2002) include misspecified ends, unintended consequences, drifting goals, underinvestment in capacity, and delays in delivering results.

An underlying problem that can contribute to all of these types of system failure is incomplete analysis of opportunities and challenges at the initial stage. To be effective, change efforts and the policies designed to sustain them must include a rigorous analysis of system dynamics. For example, the usefulness of systems analysis has been demonstrated in

FIGURE 1-1 Child protection systems: actors, contexts, and components.
SOURCE: Wulczyn et al., 2010 (reprinted with the permission of the paper authors).

multiple successful applications to business challenges (e.g., Ford, 1990; Harris, 1999; Jones and Cooper, 1980), as well as in current efforts to apply systems analysis to the child protection system (e.g., Wulczyn et al., 2010). Systems analysis helps reveal mental models held by participants, including beliefs, assumptions, and presumed knowledge. This allows all participants in a change effort to recognize and take responsibility for their mental models and to account for them in the design of the change effort. In addition, systems analysis includes identification of potential barriers or challenges to implementation so that approaches to overcome them can be anticipated. Finally, the systems analysis approach views all solutions identified by the process as interim, systematically building feedback into the implementation of a change effort. By intentionally seeking, generating, and learning from feedback over time, participants in change efforts will improve their understanding of the system and efforts to improve it, and will see concomitant improvements in the efforts’ results.

The complexity of child abuse and neglect makes the problem difficult to address in the absence of a full understanding of the diverse and multilevel systems that impact its incidence, consequences, and social response. By contrast, sustained and thoughtful systems thinking can lead to rigorous research designs that can advance knowledge and program or service implementation in meaningful ways. Such research can progress from addressing symptoms to focusing increasingly on core causes and solutions that draw more effectively on the strengths of multiple actors and domains.

Prevention of child abuse and neglect is a complex problem that can be

solved only if many societal systems and the people within them cooperate to play positive roles (Wulczyn et al., 2010). As with all complex societal problems, child abuse and neglect has no single cause; therefore, tackling the problem strategically at multiple levels is the only way to make a substantial impact on the problem.

THE UNIQUE ROLE OF SOCIAL AND
ECONOMIC STRATIFICATION

In the 1993 NRC report, issues concerning the influence of sociocultural factors on child abuse and neglect are addressed only marginally and, in truth, somewhat superficially. What is more, that report often implies that the racial and socioeconomic dimensions of abuse and neglect represent “cultural” effects. This misnomer distorts understanding of those social, economic, and cultural factors that influence the prevalence, mechanisms, processes, and outcomes of child abuse and neglect. The present report proposes several new conceptual and empirical directions for addressing these themes in future research on child abuse and neglect. Unfortunately, they are not well covered in existing research in the field, so the review of the literature presented herein generally is missing these perspectives.

The committee emphasizes the importance of adopting a critical stratification lens in considering and writing about the impact of social and economic factors on child abuse and neglect. Stratification involves the rank ordering of people based on their social and economic traits (Keister and Southgate, 2012). Based on this rank ordering, people have unequal access to resources and are differentially exposed to certain behaviors, processes, and circumstances (e.g., discrimination) that influence the nature, power, vulnerability, privilege, and protection of children who are abused, those who abuse them, and those who are charged with preventing and intervening in abuse situations. This lens therefore makes it possible to consider the various domains of stratification—race, skin color, ethnicity, class (social and economic), gender, sexual orientation, immigration status—and how the inequalities that ensue because of rank ordering in these domains impact child abuse and neglect. In addition, this lens enables intersectionality to be infused into the discourse; thus, how the multiple strata occupied by an individual (e.g., a poor dark-skinned Latino female) collectively influence the lived experiences of child abuse and child neglect for all involved can be discussed and differentiated (Burton et al., 2010; Dill and Zambrana, 2009). Finally, attention to stratification issues points to the need to consider how place matters relative to child abuse and neglect. Stratification processes create inequalities in physical and environmental locations that differentially shape certain behaviors and outcomes. Researchers in the field need to consider whether differences in the prevalence and nature of

child abuse and neglect are observed in certain urban, suburban, rural, and regional areas of the United States and how those differences are related to population, institutional, and political inequalities.

Also important is avoiding the error of equating domains of stratification with the attributes and practices of culture. Culture is distinct from stratification. It is not necessarily circumscribed by the same mechanisms and processes as, for example, racial stratification; it encompasses but is larger than stratification issues. In Geertz’s classic work The Interpretation of Culture, culture is defined as “an historically transmitted pattern of meanings embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about and attitudes toward life” (Geertz, 1973, p. 89). And as Swidler notes, “seeing culture as meaning embodied in symbols focuses attention on such phenomena as beliefs, ritual practices, art forms, and ceremonies, and on informal cultural practices such as language gossip, stories, and rituals of daily life” (Swidler, 2001, p. 12). Thus, a fundamental component of culture is the social processes by which these symbols, attitudes, and modes of behavior are shared, reified, and sanctioned within families and communities. A focus on culture then directs attention to different types of questions, such as how certain religions and other collectives (not necessarily defined by race) value children, adopt harsh parenting styles, or execute certain moral codes/beliefs in the contexts in which they reside.

Attention to these issues will contribute to achieving the goal for research on child abuse and neglect of having sufficient specificity so that understanding of the problem’s causes and consequences, as well as programs or services to address it, will be focused rather than overly general. Research conducted to date is informative about risk factors but not about how or why more risk factors lead to worse results, or which risk factors are more important than others and for which types of abuse or neglect. For example, poverty is a risk factor, yet many poor children are not abused or neglected. Which poor children are abused and why? The committee believes attention to these issues of social and economic stratification will yield increased understanding and more effective responses to the problem.

CONCLUSION

Significant progress has been made in efforts to understand child abuse and neglect; to document its devastating and lifelong impacts on both its victims and society; and to develop, test, and replicate evidence-based treatment and prevention strategies. Today, strong evidence demonstrates that child abuse and neglect is a public health issue in terms of both its

immediate impact on child development and well-being and its impact on long-term productivity.

Research advances in child abuse and neglect underscore the importance of viewing the problem as a systemic challenge. The interdependency of myriad factors operating at multiple levels and in multiple domains complicates understanding of the causes and consequences of child abuse and neglect and challenges the ability to design, implement, and sustain effective responses. Building on the gains realized in the past 20 years will require a research paradigm and infrastructure capable of capturing this complexity.

ORGANIZATION OF THE REPORT

This report is organized into nine chapters. Between this introductory chapter and the final chapter, which contains the committee’s recommendations, are seven chapters that review the state of knowledge and contain the committee’s findings and conclusions related to important aspects of child abuse and neglect research. In these chapters, major research findings are summarized at the end of major sections, and each chapter ends with overall conclusions. The aspects of child abuse and neglect addressed are the extent of the problem (Chapter 2); research on its causes (Chapter 3); research on its consequences (Chapter 4); an overview of the child welfare system, which constitutes society’s primary vehicle for identifying and responding to formal reports of child abuse and neglect (Chapter 5); research on the implementation and impacts of prevention and treatment programs (Chapter 6); an overview of the infrastructure for child abuse and neglect research (Chapter 7); and research on relevant public policies (Chapter 8). The recommendations presented in Chapter 9 are based on the findings and conclusions in these chapters, as well as the supporting discussion.

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