HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Partnering to Prevent Child Maltreatment: Lessons and Outcomes

ERIN LYONS: I think it was okay that you went first, Stephanie. I think my goal for today was sort of to provide an overview of the issue. I can actually go to this and tell you. But overview of the issue of child maltreatment, discuss the value and outcomes of broad partnerships at the state level to prevent child maltreatment and to provide examples of state and local partnerships to address this issue. I think the federal perspective first was probably just fine, and then Loretta after me will probably work out pretty well. So hopefully it won't be too confusing to go back a little bit to more of an overview now.

I just wanted to start, we all most likely know what child maltreatment is, but I just wanted to say really briefly to get us going, child maltreatment overall is comprised of three types of abuse. There's physical, sexual and emotional and psychological abuse, and there's also neglect. And neglect cases include those that are defined as medical neglect.

According to the National Child Abuse and Neglect Data System which compiles information from all states that voluntarily submit their Child Protective Services data, the majority of cases of maltreatment are cases of neglect. So in 2003, approximately 63% of maltreatment cases were neglect cases. About 20% were physical abuse and 10% were sexual abuse.

States vary in their definitions of what constitutes abuse and neglect. So it's sometimes difficult to compare rates across states, but in general neglect is considered to be the most common form of maltreatment.

So where are these children? Especially with regards to the child welfare system? I just wanted to give you an overview of this. So at the bottom, well, here it all is. So at the bottom are children who, all children who experience maltreatment. And it's unclear exactly how many children fit into this category. The last data that was really collected at a population level was the national incident study, the third wave of that which was connected in the 1990s. The data suggested that as many as almost three million children experience abuse or neglect in a given year. Efforts are now underway to update this information. So we'll have a better estimate of that bottom chunk of the pyramid.

Next up are children who are believed by the Child Protective Services to have experienced maltreatment. And in 2003 there were just over 900,000 children who had substantiated cases of abuse or neglect. Many more children come to the attention of Child Protective Services. That number in 2003 was close to 5 million. So the number is staggering.

Just above that are children who received services through the child welfare system, either in‑ home or out of home services. They're just under 700,000 children in 2003 who received services. And then finally at the tip of the iceberg are children whose abuse or neglect was substantiated and they became dependents of the court and had their parental rights terminated. These children are eligible for adoption or emancipation, depending how old they are. There were 67,000 children in that category in 2002.

So I just wanted to give you sort of an overview of how many children there are and sort of where they are in this system, child welfare system.

In terms of risk factors, it's best ‑‑ the best way to understand the risk factors is probably according to the ecological model. So starting with the child level factors, risk factors for abuse and neglect include physical disability. There's some evidence that children with physical or other disabilities face higher rates of maltreatment than children without disabilities.

Behavioral and emotional problems, young age. Parent factors include history of abuse or witnessing of abuse in the family when they grew up. Substance abuse and mental illness are also risk factors at the parent level.

Family factors include domestic violence and poverty is also noted as a risk factor. Community factors include neighborhoods characterized by violence and low levels of social support and social norms around discipline and privacy in the home, as well as perceptions that nothing can be done. This is something that the Frameworks Institute and Prevent Child Abuse America have done some work on trying to get a sense of people's feelings in the community about child maltreatment and how to, how they can work to prevent it.

And then policy level factors include CPS legislation or definitions of abuse. This is more of a risk factor for continued abuse. If a child doesn't fit the legal criteria for abuse, it may continue.

And then consequences. Outcomes depend on several factors, including when abuse occurred, how long it occurred, what point the child's developmental status abuse occurred. So there's a lot of factors that come into play here. But outcomes can be both immediate, including physical injuries and sometimes death. And then they can be longer term as well. So they can go into adolescence, including increased risk for aggression, substance abuse, depression, as well as early pregnancy and exposure to STDs in adolescence. And consequences can continue into adulthood. Increased risk for physical violence perpetration and victimization, increased risk for child maltreatment perpetration as the adult. That's the cycle you were talking about, Stephanie.

So I presented the issue to you a little bit. But this is why do MCH professionals address this issue? Child maltreatment obviously exerts a significant impact at populations that MCH professionals serve, including women, infants, children and families. Many states have already recognized this impact and have taken steps to address it and some, including by designating it as a state performance measure in their Title V Block Grants. There's 12 states and one territory that have done that as of the last time I looked, which was the most recent applications.

Not only this, but many of the risk factors and consequences I just talked about are top priorities for MCH agencies and are issues that MCH agencies already address. So child maltreatment is a natural tie‑in into these issues. Some of them include, you may be working on some of these issues, teen pregnancy prevention, maternal depression awareness and prevention, domestic violence and sexual assault prevention, death reviews, both fetal and infant and child and adolescent school health and safety. MCH agencies really don't have, have to start from scratch in addressing child maltreatment. There's a lot of areas for integration of child maltreatment strategies into some of the existing programs they may already have going on.

So one way for MCH to get involved with this issue is by infusing it into their existing programs. Another way, which is sort of the focus of this entire meeting, is by considering it as, you know, their work as part of a larger statewide effort to address child maltreatment overall. So CPS, Child Protective Services, obviously has an important role to play in terms of addressing the issue of child abuse. But other agencies also have an important role to play. Stephanie talked about a lot of the agencies that were involved in the federal work group. And a lot of those same agencies are involved in state level work.

So MCH has an important role to play in statewide efforts. And as MCH is, the role can be broad based to address child abuse, because it's particularly focused on prevention. As part of this focus, MCH can work to reframe the issue of child maltreatment away from the negative to a more positive focus of healthy parenting. MCH can also help to change community norms around prevention by spreading messages that child maltreatment is preventable, and that it's possible to teach positive parenting skills. And finally MCH as a public health agency can work to implement population‑based strategies to prevent child maltreatment. And not only this, but another reason that it makes a lot sense for MCH to be involved in statewide efforts to address child maltreatment is that MCH is connected to the community in a non-punitive way or non-investigative way.

And in particular, women and children and other families served by its existing programs. So MCH has a different ability to interact with women and children in the community, to have a different impact.

So some outcomes of partnerships. We have already talked about integration of child abuse into existing programs. I'm going to skip the second one because that's sort of the overall reason why we partner around this issue. But the last two: Improved collaboration and partnerships can help to improve surveillance of maltreatment at a population level to get a better sense of state specific risk factors and geographic differences and prevalence as opposed to identifying only children that come to attention of CPS authorities. Better surveillance can lead to more tailored interventions and prevention programs that are better able to impact child maltreatment. That's specific to the certain areas in this state.

Broad based partnerships are sometimes better positioned to apply for and receive new sources of funding. That's another reason that partnerships, another outcome of partnerships. And back to the second one, the ability to, partnerships help with the ability to address the needs of children who are not served by CPS. The children's whose cases are not substantiated or face significant risks, partnerships can help to address those needs.

A couple of examples: I've talked a lot in sort of bigger picture, but I wanted to talk a little bit about what some states are doing to partner around this issue already. North Carolina, in North Carolina, the Institute of Medicine and prevent child abuse North Carolina facilitated the development of a task force on child abuse prevention which was chaired by the HHS Secretary in North Carolina as well as a private pediatrician with a lot of experience in this issue.

Task force representatives included juvenile justice, child development, public instructions, state government, Social Services, substance abuse, mental health and community‑based private and nonprofit organizations, including researchers from UNC.

The task force was charged with developing a statewide strategic plan to prevent child abuse and neglect, which included recommendations for enhancing surveillance and creating a permanent position within the health department to lead statewide prevention efforts. And the health department was also given ‑‑ was also recommended that they have the ability to conduct better surveillance.

In Minnesota, the MCH unit in the health department participated in the Home Visitor Training Partnership to develop a training system for home visitors based on the strengths‑based approach. The curriculum was made available to agencies throughout the state to use with their own trainers. And partners included in this effort included Head Start, Minnesota Early Learning Design and Early Childhood Family Education.

Finally, in Virginia, similar to North Carolina, the Center For, it's actually Injury Violence Prevention participated in state planning to prevent child maltreatment.

This planning effort was initiated by Department of Social Services and Prevent Child Abuse Virginia. The Center for Injury and Violence Prevention which is in the Family Health Services unit was included, in a lot of ways because they have already developed a pretty strong reputation around doing sexual violence prevention. So they were included in the mix because of a lot of work they had already been engaging in a related subject. Partners included juvenile justice, domestic violence, education, family, children's trust fund. And the focus of the work was to develop recommendations to build statewide infrastructure for prevention.

So I just wanted to say a couple words about possible you know other areas where these strategies could be focused in terms of addressing issues that are emerging or newer issues. These sort of larger partnerships can, you know, leverage their efforts to address these sorts of things. So one of them is universal parenting education. Another one is response to methamphetamine or promoting safe sleep practices. These are more tailored issues, but ones that partnerships can really work to address.

And that's it for me. I think we're going to be hearing from Loretta now to talk a little bit more about what happened specifically in Hawaii. So I'll pass it over to her.