PREFACE vii

A Coordinated Response to Child Abuse and Neglect: A Basic Manual Diane DePanfilis Marsha K. Salus 1992 U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families National Center on Child Abuse and Neglect DHHS Publication No. (ACF) 92-30362 ADDITIONAL ACKNOWLEDGEMENT This manual, originally published in 1979 as A Community Approach: The Child Protection Coordinating Committee by James L. Jenkins, Robert A. MacDicken, Nancy J. Ormsby, has been revised and expanded by Diane DePanfilis and Marsha K. Salus. This manual was developed and produced by The Circle, Inc., McLean, VA, under Contract No. HHS-10588-1702. TABLE OF CONTENTS Page PREFACE vii ACKNOWLEDGMENTS viii OVERVIEW OF THE MANUAL 1 Purpose of Manual 1 PHILOSOPHICAL TENETS OF CHILD PROTECTION Philosophical Tenets 3 3 DEFINING CHILD MALTREATMENT 5 Definitions in Federal Law 5 Variations in Definitions of Child Abuse and Neglect 5 Operational Definitions 6 Physical Abuse 6 Child Neglect 6 Sexual Abuse 7 Mental Injury (Emotional/Psychological Abuse) 7 Extent of the Problem 8 Incidence by Type of Maltreatment 8 Abuse 8 Neglect 9 UNDERSTANDING CHILD ABUSE AND NEGLECT Causes of Child Abuse and Neglect 11 11 Parent Factors 11 Child Factors 13 Family Factors 13 Environmental Factors 13 Effects of Child Abuse and Neglect 14 iii Page BASIS FOR INTERVENTION AND RESPONSE TO CHILD ABUSE AND NEGLECT 17 The Federal Role in Combating Child Maltreatment 18 Generating Knowledge and Improving Programs 18 Collecting, Analyzing, and Disseminating Information 18 Assisting States and Communities in Implementing Child Abuse Programs 19 Coordination of Federal Efforts 19 The State Role in Combating Child Maltreatment 19 State Reporting Laws 20 Juvenile and Family Court Laws 20 Criminal Laws 21 WORKING TOGETHER 23 Principles Essential for Coordination of Services 23 Agreement on Common Goals 23 Understanding of Professional Roles and Expertise 23 Open Communication 23 Formal 23 Informal 24 Protocols, Policies, and Procedures 24 Reporting Policies 24 Protocols 24 Procedures for Feedback 25 ROLES AND RESPONSIBILITIES OF COMMUNITY PROFESSIONALS 25 Child Protective Services 25 Law Enforcement 25 Educators 26 Health Care Providers 27 Mental Health Professionals 27 Legal and Judicial System Professionals 27 Support Services Providers 28 iv Page Problems Encountered 28 CHILD PROTECTION SYSTEM 31 Identification 31 Reporting 31 Reporting Procedures 32 How and When To Report 32 Who Receives Reports 32 Contents of the Report 33 Immunity to Reporters 33 Penalties for Failure To Report 33 Problems in Reporting 34 Intake 34 Initial Assessment/Investigation 35 Family Assessment 37 Case Planning 37 Treatment 38 Evaluation of Family Progress 38 Case Closure 39 PREVENTING CHILD ABUSE AND NEGLECT 41 Types of Prevention Efforts 41 Prevention Initiatives in Health Care 42 Community-Based Prevention 42 Role of the Workplace in Strengthening Families 43 Targeting Social Services on Prevention 43 Prevention in the Schools 44 SUMMARY 45 GLOSSARY OF TERMS 47 NOTES 51 SELECTED BIBLIOGRAPHY 57 OTHER RESOURCES 63 v PREFACE The Child Abuse Prevention and Treatment Act was signed into law in 1974. Since that time, the Federal Government has served as a catalyst to mobilize society's social service, mental health, medical, educational, legal, and law enforcement systems to address the challenges in the prevention and treatment of child abuse and neglect. In 1977, in one of its early efforts, the National Center on Child Abuse and Neglect (NCCAN) developed 21 manuals (the User Manual Series) designed to provide guidance to professionals involved in the child protection system and to enhance community collaboration and the quality of services provided to children and families. Some manuals described professional roles and responsibilities in the prevention, identification, and treatment of child maltreatment. Other manuals in the series addressed special topics, for example, adolescent abuse and neglect. Our understanding of the complex problems of child abuse and neglect has increased dramatically since the user manuals were first developed. This increased knowledge has improved our ability to intervene effectively in the lives of "at risk" children and their families. For example, it was not until the early 1980's that sexual abuse became a major focus in child maltreatment research and treatment. Likewise, we have a better grasp of what we can do to prevent child abuse and neglect from occurring. Further, our knowledge of the unique roles key professionals can play in child protection has been more clearly defined, and a great deal has been learned about how to enhance coordination and collaboration of community agencies and professionals. Finally, we are facing today new and more serious problems in families who maltreat their children. For example, there is a significant percentage of families known to Child Protective Services (CPS) who are experiencing substance abuse problems; the first reference to drug-addicted infants appeared in the literature in 1985. Because our knowledge base has increased significantly and the state of the art of practice has improved considerably, NCCAN has updated the User Manual Series by revising many of the existing manuals and creating new manuals which address current innovations, concerns, and issues in the prevention and treatment of child maltreatment. This manual, A Coordinated Response to Child Abuse and Neglect: A Basic Manual, provides the foundation for the series and addresses community prevention, identification, and treatment efforts. As a companion to updated manuals for each profession, this manual is intended to be used by all professionals involved in child protection: CPS, law enforcement, education, mental health, legal services, health care, and early childhood professionals. The manual also will provide general information to anyone who is concerned about the problem of child maltreatment. vii ACKNOWLEDGMENTS Diane DePanfilis, M.S.W., is currently a doctoral student at the University of Maryland School of Social Work and consults nationally in activities such as analyzing child protection policy, writing and editing publications and curricula, providing professional training, conducting research and evaluation of child welfare services, and developing practice- and administrative-related instruments and planning documents. She began her career as a child welfare caseworker in 1973 and also has had experience at the local level providing direct services, supervising casework staff, coordinating a multidisciplinary team, and managing a countywide child protective services program. Marsha K. Salus, A.C.S.W., is a social work consultant who has worked in the field of child abuse and neglect for over 15 years. She began her career as a child protective services caseworker and supervisor. She has developed numerous national curricula for professionals involved in the identification, prevention, and treatment of child abuse and neglect. She has delivered training in all aspects of child protection to professionals around the world and has written numerous manuals and pamphlets on child welfare topics. Ms. Salus served as the Chair of the Advisory Panel for this contract. The following were members of the Advisory Panel for Contract No. HHS-105-88-1702: Thomas Berg Private Practice Washington, DC Kathleen Furukawa Military Family Resource Center Arlington, VA Richard Cage Montgomery County Department of Police Rockville, MD Judy Howard University of California Los Angeles, CA Peter Correia National Resource Center for Youth Services Tulsa, OK Molly Laird League Against Child Abuse Westerville, OH Howard Davidson ABA Center on Children and the Law Washington, DC Michael Nunno Family Life Development Center Ithaca, NY Helen Donovan National Committee for Prevention of Child Abuse Chicago, IL Marsha K. Salus Chair, Advisory Panel Alexandria, VA Judee Filip American Association for Protecting Children Englewood, CO viii OVERVIEW OF THE MANUAL Child abuse and neglect is a community concern. No one agency or profession alone can prevent or treat the problem. The community has a legal, moral, and ethical responsibility to assume an active role in responding to physical, sexual, and emotional abuse and neglect of children. At the State and local levels, community professionals assume various responsibilities, ranging from prevention activities and identification and reporting of child maltreatment to intervention and treatment. In each community, reports of child abuse and neglect are investigated by CPS and/or the police. Prevention and treatment are provided by both public and private agencies and professionals. Volunteer organizations and self-help groups provide assistance and support to families. Additionally, each military installation has a child abuse and neglect program called the Family Advocacy Program. The Federal Government furthers these State and local efforts in many different ways. The National Center on Child Abuse and Neglect (NCCAN), created by the Child Abuse Prevention and Treatment Act of 1974 (P.L. 93-247), is the agency responsible for providing grants for programs mandated by the P.L. 101-126 and coordinating the Federal Government's child abuse and neglect activities.* Since child maltreatment is such a complex problem, it requires many diverse efforts on the national, State, and local levels to prevent and treat it. To protect children from harm and to strengthen families so that they can meet their children's developmental needs, all concerned citizens must be able to identify and report suspected cases of child maltreatment. In addition, all relevant community professionals need to be involved in their community's identification, prevention, and treatment efforts. PURPOSE OF MANUAL This manual provides the basic information professionals and concerned citizens need in order to become involved in and enhance their community's intervention efforts. The manual: ? provides an overview of the philosophical tenets on which child protection is based; ? defines child abuse and neglect in legal and operational terms; ? provides an overview of the nature, extent, causes, and effects of child maltreatment; ? describes the Federal, State, and local responsibilities in child protection; ? describes the importance of and strategies for enhancing community collaboration and coordination; ? provides an overview of the child protection system; and ? describes the roles of the court, community agencies, and professionals in the prevention, identification, and treatment of child abuse and neglect. *The Act that dictates the current functions of NCCAN is P.L. 101-126, Child Abuse Prevention and Treatment Act, as amended, October 25, 1989. ii A Coordinated Response to Child Abuse and Neglect: A Basic Manual is one in a series of manuals which addresses the roles of key professionals involved in child protection and special issues in child maltreatment, for example, Preventing and Treating Child Sexual Abuse. Because the manual provides an overview of the problem of child abuse and neglect and how to prevent and treat it, the manual can be used by anyone interested in knowing more about child maltreatment. In addition, since the manual provides the foundation necessary for professional involvement in child protection, it accompanies each profession-specific manual, for example, Child Protective Services: A Guide for Caseworkers. iii PHILOSOPHICAL TENETS OF CHILD PROTECTION The role of the family in American society is important in our Nation's history and tradition. Society presumes that parents want to and do act in their children's best interest. Based on that assumption, parents have a right to rear their children if they are willing and able to protect them. However, the Supreme Court provided that this presumption can be overcome and cited "the incidence of child abuse and neglect as grounds for rebutting parents rights." Therefore, when parents cannot meet their children's needs and protect their children from harm, society has a responsibility to intervene to protect the health and welfare of children. Any intervention into family life on behalf of children must be guided by the legal base for action, strong philosophical underpinnings, and sound professional standards for practice. This chapter describes the philosophical tenets on which the community's responsibility for child protection is based. PHILOSOPHICAL TENETS Communities should develop and implement programs to strengthen families and prevent the likelihood of child abuse and neglect. Raising children today is a challenging proposition. A number of societal factors make it difficult for many to be effective parents, for example, the use of drugs; the lack of support from extended families for those living in rural as well as urban communities; the number of teenage parents; the increasing number of families without homes; and the rate of joblessness for many unskilled adults. These factors affect the level of risk of maltreatment for many children. There is a need for communities to implement prevention programs aimed at identifying high-risk families and to provide supportive intervention to reduce occurrence of maltreatment. Child maltreatment is a community problem; no single agency, individual, or discipline has the necessary knowledge, skills, resources, or societal mandate to provide the assistance needed by abused and neglected children and their families. Child abuse and neglect is complex and multidimensional. No one service or intervention has been shown to prevent or treat child maltreatment effectively. Therefore, the expertise and resources of all agencies and professionals who work with children and families are needed if the community's prevention and treatment efforts are to be successful. To optimize the effectiveness of the multidisciplinary response to child maltreatment, it is important that all participants respect and preserve the distinct roles of each involved professional group while forging a functional team to address this complex problem. Intervention must be sensitive to culture, values, and religion and other individual differences. It is important for professionals to be aware of the essential uniqueness of each individual. Since there is no single cause of child maltreatment, the community response should be individualized to examine the particular circumstances of each child and family. Since many abusive and neglectful adults have similar problems, it is easy to categorize or pigeonhole them and then offer packaged solutions. While people may have similar problems, there are elements of individual situations which will invariably be unique. Therefore, intervention must consider the unique background, strengths, and resources of each family.1 Consequently, professionals must develop cultural competencies in working with individuals and families different from themselves. Professionals must recognize that most parents do not intend to harm their children; rather, abuse and neglect is the result of a combination of factors: psychological, social, situational, and societal. Parents may be more likely to maltreat their children if they were emotionally deprived, abused, or neglected as children; iv are isolated without family or friends to depend on; feel worthless and have never been loved or cared about; are emotionally immature or needy; abuse drugs or alcohol; or are in poor health. Parents who harm their children through abusive and neglectful behavior often feel remorse about their maltreating behavior; however, their problems often prevent them from stopping their harmful behavior. In order to be helpful to families, service providers need to believe that many maltreating adults have the capacity to change their abusive/neglectful behavior, given sufficient help and resources to do so. All forms of helping are based on the belief that people have the strength and potential to make changes in their lives. While some children and families need help only briefly, others need assistance, in one form or another, for long periods of time. If our goal is to help families protect their children and meet their basic needs, then the community's response must be nonpunitive, noncritical, and conducted in the least intrusive manner possible. One of the essential ingredients in developing a therapeutic relationship is demonstrating respect for the client. To show respect, professionals must believe in the inherent dignity and worth of all human beings. Thus, people do not have to earn respect, they are automatically worthy of respect by virtue of their being human. This does not mean that we approve of a caretaker's abusive or neglectful behavior. It does mean that we must show respect for the person, while disapproving of his/her actions.2 Growing up in their family is optimal for children, as long as children's safety can be assured. Maintaining the family as a unit preserves the bonding and loving relationship with the parents and siblings and allows the children to grow and develop within the culture and environment most familiar to them. Therefore, if safety for children can be assured, our first goal is to maintain children in their own homes by strengthening families so that they can meet their children's developmental needs and protect them from harm. Regardless of the physical and emotional trauma children may suffer at the hands of their parents, they develop attachment to their parents, even though the attachment may be dysfunctional. Our efforts must first be to empower families to meet the needs of their children and to resolve the problems that led to maltreatment. If families cannot or will not meet their children's needs or protect their children from harm, and children have to be removed from their families to ensure their safety, all efforts must focus on a permanent plan for the child. In most cases, the preferred permanency plan is to return children to their families. Removing a child from his/her family should be a measure of last resort; it should be used only to ensure the child's safety. This is because removal of children from their parents alters children's developmental needs; children experience loss of the family, identity confusion, and negative effects on their self-concept. Prolonged psychological vulnerability lessens the likelihood of successful life experiences as an adult. Children in foster care live day-to-day with an uncertainty of knowing that they can be moved at any minute. Children who live with their families rarely suspect that their families would expel them or that they could be taken away, even if these ideas are verbalized by parents in anger. However, once separated, the reality of this becomes compelling in the child's life experience. Each day and hour lived without the reassurance of permanence detracts from a child's capacity to form trusting relationships, something needed by all human beings to survive in the larger society.3 v DEFINING CHILD MALTREATMENT Child abuse and neglect is a widespread problem in American society. A child of any age, sex, race, religion, and socioeconomic background can fall victim to child abuse and neglect. To prevent and treat child abuse and neglect effectively, we must have a common understanding of the definition and the extent of the problem. DEFINITIONS IN FEDERAL LAW The Child Abuse Prevention and Treatment Act defines child abuse and neglect as "the physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment ? of a child under the age of 18, or except in the case of sexual abuse, the age specified by the child protection law of the State ? by a person (including any employee of a residential facility or any staff person providing out-of-home care) who is responsible for the child's welfare ? under circumstances which indicate that the child's health or welfare is harmed or threatened thereby..." The Act defines sexual abuse as "the use, persuasion, or coercion of any child to engage in any sexually explicit conduct (or any simulation of such conduct) for the purpose of ? producing any visual depiction of such conduct, or ? rape, molestation, prostitution, or ? incest with children." The Act also defines child abuse as the withholding of medically indicated treatment for disabled infants with life-threatening conditions. The Act defines this provision as "...the failure to respond to the infant's life-threatening conditions by providing treatment (including appropriate nutrition, hydration, and medication) which in the treating physician's or physicians reasonable medical judgement, will most likely be effective in ameliorating or correcting all such conditions." VARIATIONS IN DEFINITIONS OF CHILD ABUSE AND NEGLECT Within any given State and community, there are different types of definitions of child maltreatment. Some definitions are found in laws, some are found in procedures, and some are found in the informal practices of those agencies assigned to implement laws concerning child abuse and neglect. State laws are a major source for definitions of child abuse and neglect: ? Reporting law describes the circumstances and conditions, if known or suspected by a mandated reporter, which would obligate them to report and if known or suspected by any person would permit them to report. These reports activate the child protection process. vi ? Juvenile or family court acts provide definitions which are necessary for the court to have jurisdiction over a child alleged to have been abused or neglected. This allows the court to take custody of a child. When the child's safety cannot be ensured in the home, it allows the court to order specific treatment for the parents and child, etc. Often juvenile/family court and reporting law definitions are the same. ? Criminal law defines those forms of child abuse and neglect which are criminally punishable, for example, sexual abuse, severe physical abuse, or child endangerment. OPERATIONAL DEFINITIONS It is also important to understand how the definitions of physical abuse, child neglect, sexual abuse, and mental injury (also referred to as emotional/psychological abuse) are operationalized in practice. Physical Abuse Physical abuse is characterized by physical injury (for example, bruises and fractures) resulting from punching, beating, kicking, biting, burning, or otherwise harming a child. Although the injury is not an accident, the parent or caretaker may not have intended to hurt the child. The injury may have resulted from overdiscipline or physical punishment that is inappropriate to the child's age or condition. The injury may be the result of a single episode or of repeated episodes and can range in severity from minor bruising to death. Any injury resulting from physical punishment that requires medical treatment is considered outside the realm of normal disciplinary measures. A single bruise may be inflicted inadvertently; however, old and new bruises in combination, bruises on several areas of the face, or bruising in an infant suggest abuse. In addition, any punishment that involves hitting with a closed fist or an instrument, kicking, inflicting burns, or throwing the child is considered child abuse regardless of the severity of the injury sustained. Child Neglect Child neglect is characterized by failure to provide for the child's basic needs. Neglect can be physical, educational, or emotional. The latest national incidence study defines three types of neglect: ? Physical neglect includes refusal of or delay in seeking health care, abandonment, inadequate supervision, and expulsion from home or refusing to allow a runaway to return home. ? Educational neglect includes permission of chronic truancy, failure to enroll a child of mandatory school age, and inattention to a special educational need. ? Emotional neglect includes such actions as chronic or extreme spouse abuse in the child's presence, permission of drug or alcohol use by the child, and refusal or failure to provide needed psychological care. It is very important to distinguish between neglect and a parent's or caretaker's failure to provide necessities of life because of poverty or cultural norms. vii Sexual Abuse Sexual abuse includes a wide range of behavior: fondling a child's genitals, intercourse, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials. Most State laws distinguish between sexual abuse and sexual assault. To be considered sexual abuse, these acts have to be committed by a person responsible for the care of the child (for example, a parent, babysitter, day care provider, or other person responsible for a child.) Sexual assault is usually defined as sexual acts committed by a person who is not responsible for the care of the child. Sexual abuse can involve varying degrees of violence and emotional trauma. The most commonly reported cases involve incest (sexual abuse occurring among nuclear family members), which most often occurs between father or stepfather and daughter. However, mother-son, father-son, mother-daughter, and brother-sister incest also occurs. Sexual abuse may also be committed by other relatives such as aunts, uncles, grandfathers, grandmothers, and cousins. Mental Injury (Emotional/Psychological Abuse) Emotional abuse includes acts or omissions by the parents or other persons responsible for the child's care that have caused, or could cause, serious behavioral, cognitive, emotional, or mental disorders. In some cases of emotional/psychological abuse, the parental acts alone, without any harm evident in the child's behavior or condition, are sufficient to warrant CPS intervention; for example, the parents/caretakers use extreme or bizarre forms of punishment, such as torture or confinement of a child in a dark closet. For less severe acts, such as habitual scapegoating, belittling, or rejecting treatment, demonstrable harm to the child is often required for CPS (the public agency providing services to abused and neglected children and their families) to intervene. Emotional abuse is the most difficult form of child maltreatment to identify. First, the effects of emotional maltreatment, such as lags in physical development, learning problems, and speech disorders, are often evident in children who have not experienced emotional maltreatment. Second, the effects of emotional maltreatment may only become evident in later developmental stages of the child's life. Third, the behaviors of emotionally abused and emotionally disturbed children are often similar. There are some guidelines that can help distinguish between emotional disturbance and emotional abuse. The parents of an emotionally disturbed child generally recognize the existence of a problem, whereas the parents of an emotionally abused child often blame the child for the problems or ignore the existence of a problem. The parents of an emotionally disturbed child show concern about the child's welfare and actively seek help, whereas the parents of an emotionally abused child often refuse offers of help and appear punitive and unconcerned about the child's welfare. Although any of the forms of child maltreatment may be found alone, they often occur in combination. And, emotional abuse is almost always present when other forms are identified. viii EXTENT OF THE PROBLEM The most recent National Incidence Study estimates that nearly 1 million children nationwide experienced demonstrable harm as a result of maltreatment in 1986.4 According to the same study, almost 1.5 million children nationwide experienced abuse or neglect if children "at risk of or threatened with harm" are included in the estimate. In addition, 1,100 children are known to have died as a result of abuse or neglect in 1986. In comparing the 1986 overall incidence rate with the 1980 rate, the number of children who experienced demonstrable harm from abuse or neglect increased 51 percent. The National Incidence Study concludes that this increase may be more reflective of increased recognition and reporting of child maltreatment than of an actual increase in incidence. While the National Incidence Study estimates are based on interviews with a range of professionals in sample counties across the country, not all cases known to professionals are eventually reported as mandated by law. Even so, the number of children reported to CPS increased nearly 57 percent since 1980. Of those cases accepted for investigation in 1986, CPS officially "substantiated" (determined credible evidence of maltreatment existed) 53 percent of the cases. This reflected an increase of 10 percent in the number of substantiated cases since 1980. Comparing "incidence" with "reported cases," data indicate that many abused and neglected children recognized by educational, medical, and mental health professionals are not known to the local CPS. This finding emphasizes the importance of reporting cases of suspected child maltreatment to child protection authorities. Incidence by Type of Maltreatment The 1986 National Incidence Study found that the majority of child maltreatment cases (64 percent) involved neglect (917,200 children or 14.6 per 1,000) and less than half (43 percent) involved abuse (590,800 children or 9.4 per 1,000). Abuse The following findings present the number of cases by type of abuse: ? Physical Abuse. A total of 311,500 children, or 4.9 per 1,000, were physically abused in this country in 1986. ? Emotional Abuse. The next most frequently occurring type of abuse is emotional abuse, involving 188,100 children, or 3.0 per 1,000. ? Sexual Abuse. While sexual abuse remains the least frequent type of abuse, its incidence is not far behind that of emotional abuse. The National Incidence Study found that 133,600 children nationwide, or 2.1 per 1,000, experienced sexual abuse in 1986. It is important to note that the incidence of sexual abuse tripled since 1980. Many experts believe that sexual abuse is the most underreported form of child maltreatment because of the "conspiracy of silence" which so often characterizes these cases. *The statistics reflect the revised definition of child abuse and neglect, which includes combined totals of children who were demonstrably harmed and threatened with harm. ix Neglect There are a number of different types of neglect, each with differing incidence rates: ? Physical neglect is the most frequently occurring type of neglect, involving 507,700 children, or 8.1 per 1,000. ? Educational neglect is the second most frequent type of neglect, with 285,900 children, or 4.5 per 1,000. ? Emotional neglect is the least frequent type, involving 203,000 children, or 3.2 per 1,000. x UNDERSTANDING CHILD ABUSE AND NEGLECT Understanding the nature and causes of child abuse and neglect has challenged American society since the 19th century. If there is one fact we have learned during this time, it is that there is no single cause of child maltreatment. In addition, child abuse and neglect can occur across all socioeconomic, religious, and ethnic groups. CAUSES OF CHILD ABUSE AND NEGLECT There are a variety of manifestations and causes of child abuse and neglect. While there may be less consensus about specific causes, most will agree that child maltreatment occurs as a result of multiple forces that impact the family, interact and reinforce each other, and eventually result in child abuse and neglect.5 Children are at risk of maltreatment then as a result of the pattern of interaction between themselves and their families and environments.6 It must be emphasized that while certain factors may often be present among families where maltreatment occurs, this does not mean that the presence of these factors will always result in child abuse and neglect. Professionals who have a responsibility for intervening in cases of child maltreatment must recognize the multiple and interactional causes of the problem and must individualize their assessment and treatment of children and families. What might be the cause in one family may not be the cause in another family, and the factors that may cause maltreatment in one family may not result in child abuse and neglect in another family. Some professionals believe that different factors account for different forms of child abuse or neglect occurring, that is, physical, sexual, neglect, and emotional maltreatment. Here again, while particular factors may often be identified in certain types of cases, this does not mean that these factors will always be present or that their presence will always lead to maltreatment. We will consider some of the factors thought to be associated with child maltreatment by categorizing them according to factors related to parents, children, families, and the environment. Parent Factors The most consistent finding in the child abuse literature is that maltreating parents often report having been physically, sexually, or emotionally abused or neglected as children.7 An incorrect conclusion from this finding, however, is that maltreated children will grow up to become maltreating parents. There are individuals who have not been abused as children who become abusive, as well as individuals who have been abused as children and do not subsequently abuse their own children. There is limited understanding of why some parents who were maltreated as children abuse or neglect their own children and why other parents with a similar history do not. A parent's overall history as a child plays a large part in how prepared he/she may be to be a parent. Individuals who have not had their own developmental needs met may find it very difficult to meet the needs of their children.8 Although many abusive parents experience behavioral and emotional difficulties, mental illness plays a very small overall role in child maltreatment.9 No consistent set of personality traits or clusters of personality traits have xii been identified as characterizing abusive parents. Characteristics identified in some maltreating parents are low self-esteem, low intelligence, ego deficiency, impulsivity, hostility, isolation and loneliness, anxiety, depression and apathy, rigidity, fear of rejection, low frustration tolerance, narcissism, fearfulness, immaturity and dependency, distrustfulness, neuroticism, drug or alcohol abuse, and criminal behavior.10 In particular, substance abuse has become an increasing problem. The devastating nature of drugs, predominantly crack/cocaine, is far reaching. Respondents to a recent national survey estimate that as much as 20 to 90 percent of CPS cases involve substance abuse (depending on the area of the country). State CPS agencies report that polydrug use (use of multiple drugs), combined with the parents' history of abuse or deprivation as children, is resulting in caseloads comprised of seriously dysfunctional families.11 Alcohol abuse continues to be a common problem of parents who maltreat their children. While in the past alcoholism represented a family's only substance abuse problem, today alcohol has become a gateway drug used prior to or in conjunction with more highly addictive substances.12 Another recent phenomenon is the number of women abusing drugs. In contrast to the predominance of men among the addictive population when heroin was the drug of choice, today women abuse crack at a rate at least equal to men. The end result of such abuse is the growing number of infants being born exposed to illegal substances.13 Treatment providers describe drug abusing mothers as women who have experienced cycles of victimization and have few job skills, poor self-esteem, and often, many children. Drugs provide them with an opportunity to feel better but often interfere with their ability to parent.14 A variety of problems resulting from a lack of skills and knowledge have also been suggested as characteristic of some maltreating parents.15 These include a lack of parenting skills, (including overuse of physical punishment), problems with coping and self-control, marital difficulties, and a general lack of interpersonal skills. Parents' lack of knowledge of child development may result in inappropriate expectations. Inappropriate attitudes can contribute to maltreating behavior, for example, acceptance of violence as a way to solve problems or belief that children are property.16 These attitudes can also result in punishment when parents expect behaviors that the child is not developmentally capable of, for example, spanking a 1-year-old for soiling his/her pants. Specific situations, such as untimely childbearing, physical illness, and poor ability to empathize with their children, can substantially increase the likelihood of child maltreatment, particularly when social stress and social isolation characterize the family.17 In some situations, single parents may be at higher risk of maltreating their children due to higher stress and low income. 18 As mentioned earlier, identifying these characteristics should not be confused with direct causation. In other words, just because someone is a single parent does not mean he/she will have a tendency to be a maltreating parent. Researchers suggest, however, that being alone as a parent can produce stress (for some parents), which in combination with other factors may result in a risk of maltreatment. xiii Child Factors Certain children are more physically and emotionally vulnerable than others to maltreating behavior. The child's age and physical, mental, emotional, and social development can greatly increase or decrease the likelihood of maltreatment, depending on the interactions of these characteristics with parental factors previously discussed. Younger children, due to their physical size and development status, are particularly vulnerable to certain forms of maltreatment, such as the "battered child syndrome,"19 the whiplash shaken infant syndrome, 20 and nonorganic failure to thrive. 21 Also, infants with low birth weight may be at increased risk for maltreatment. The child's behavior, for example, aversive crying and unresponsiveness, can increase the likelihood of maltreatment,22 particularly if a parent has a poor ability to empathize with the child and difficulty controlling his/her emotions. Some children may inadvertently contribute to their victimization by possessing characteristics that make it difficult for caregivers to relate to them.23 For example, infants who are constantly ill are less capable of eliciting nurturing responses from mothers who lack emotional support, are working through the grief process, or have few nurturing skills.24 In general, children who are perceived as "different,"25 such as disabled children, are at greater risk for abuse and neglect.26 Children who are socially isolated are often felt to be at higher risk for all types of maltreatment.27 For example, a child who does not have a close relationship with his/her mother and has few or no friends may be more susceptible to offers of attention and affection in exchange for sexual activities.28 Family Factors Specific life situations of some families can increase the likelihood of maltreatment, such as marital conflict, conflictual relationships with extended family, domestic violence, employment and financial stress, and social isolation.29 While these factors in themselves may not cause maltreatment, they may exacerbate other negative interactional patterns. Families involved in child maltreatment tend to exhibit a pattern of day-to-day interaction characterized by a low level of social exchange, low responsiveness to positive behavior, and high responsiveness to negative behavior.30 Other research suggests that maltreating parents display fewer appropriate caregiving behaviors than nonmaltreating parents31 and that they tend to use ineffective and inconsistent punishment and discipline. 32 Child abuse can therefore be seen as a problem in parent-child interaction with parental, social, and psychological factors playing contributory but not causal roles.33 Research on attachment and bonding (the development of love between parent and child) has demonstrated the importance of early parent-child interactions within the first days of life, particularly with premature and ill newborns.34 Specifically related to child maltreatment, studies have found that less parent-infant contact during early hospitalization was more likely to lead to abuse. 35 Environmental Factors Environmental factors are often found in combination with child, parent, and family factors, as has been highlighted in previous sections of this chapter. The incidence of child maltreatment (as defined by State statute) is higher in some cultures, societies, and communities than others. And what one culture defines as child abuse and neglect may be socially acceptable interaction in another culture. Economic pressure, values concerning the role of the child in the family, attitudes about the use of physical punishment, and the degree of social support for parents seem to account for these differences.36 xiv Stress caused by such factors as poverty is associated with higher rates of reported child maltreatment, as evidenced at times of increased unemployment and recession.37 Also, the stress created by "racism" in American society can contribute to the incidence of child abuse and neglect. In addition to isolation within the family, maltreating families are also often isolated from neighbors and the broader community. As a result, maltreating families tend to participate less in community organizations and make less use of available economic, health, and social resources.38 There is a continuing debate, however, regarding whether the lack of social support actually causes child maltreatment or is just one of many characteristics of some maltreating families, a manifestation of the problem rather than a causal factor.39 For example, it is unclear whether the high rate of maltreatment among single parents is the result of social isolation or the result of a combination of factors which may also include economic stress, the burden of child care for one person, or difficulty with interpersonal relationships.40 EFFECTS OF CHILD ABUSE AND NEGLECT There are several problems with clearly articulating the effects of child maltreatment. First, some studies have focused on discovering child maltreatment in the background of prison populations, mental health patients, and other clinical populations who often have had many other problems. Further, other studies examining the effects among maltreated children have not always used control groups of nonmaltreated children to compare findings. In addition, since the nature and extent of maltreatment are different for each child and family, it is inappropriate to draw conclusions that certain effects will always occur. Despite these difficulties, it is possible to identify effects which occur for some children. Research on the effects of maltreatment on children has cited neurological, intellectual and cognitive, behavioral, emotional, and personality consequences.41 More specifically, research on neurological consequences has identified neurological disorders present in children who have suffered physical abuse resulting in head injuries as well as other forms of abuse. 42 Results of studies examining potential intellectual and cognitive effects of maltreatment have been less consistent. While some control group studies with infants and toddlers are highly supportive of the conclusion that abuse is related to intellectual and cognitive deficits,43 other studies have seen similar consequences in control groups of accidentally injured and/or low income children.44 While there is no single behavioral set that is characteristic of abused children, the presence of socioemotional problems in many maltreated children is well documented. The consequences of the abuse will vary with the developmental level of the child, the duration and intensity of abuse, and the quality of the subsequent home environment and community support.45 Studies report behavior that is either passive and withdrawn or very active and aggressive. 46 Further consequences may include psychiatric symptoms (such as bedwetting, tantrums, hyperactivity, and bizarre behavior), low self-esteem, school learning problems, social withdrawal, oppositional behavior, hypervigilance to adult cues, compulsivity, and pseudoadult behavior.47 Physically abused children were also found to be significantly more self-destructive, evidencing more suicide attempts and self-mutilation.48 In one study of maltreated adolescents, six different patterns of consequences were identified: acting out, depression, generalized anxiety, extreme adolescent adjustment, emotional-thought disturbance, and helplessness-dependency.49 More specifically, 70 percent had academic performance difficulties. Sleeping problems were evident in over half of the subjects, with 31 percent admitting drug abuse and 35 percent reporting aggressive behaviors. Many of the adolescents had homicidal thoughts (41 percent) and 23 percent had engaged in self-destructive or reckless behaviors. Another study, which compared abused, neglected, and rejected boys with boys who experienced love and nurturing over a 40-year time period, found that all but the loved group had significantly higher rates of juvenile delinquency; about half of the abused and neglected group were convicted of serious crimes, became alcoholics, or suffered from mental illness; and a disproportion of the maltreated group died at an unusually young age. 50 In addition, the University of Southern Maine studied 4,000 violent youth and determined that 59 percent were reported by agency personnel as having been neglected and xv unsupervised as children.51 Further, a study of 6,815 delinquent youth determined that adolescents who had been neglected generally committed nonviolent crimes, such as possession of drugs.52 In their review of studies focused on the impact of child sexual abuse, Browne and Finkelhor report that the empirical literature confirms the existence, in a percentage of the victim population, of almost all of the initial effects of sexual abuse reported in the clinical literature, including fear, anxiety, depression, self-destructive behavior, anger, aggression, guilt and shame, impaired ability to trust, revictimization, sexually inappropriate behavior, school problems, truancy, running away, and delinquency. However, no effect was found to be universal. 53 Their review further suggests that empirical studies with adults confirm the presence of many of the hypothesized long-term effects of sexual abuse mentioned in the clinical literature: suic idal tendencies, fears, isolation and stigma, lowered self-esteem, distrust, revictimization, substance abuse, sexual dysfunction, and promiscuity.54 An important research finding for clinicians is that the seriousness of negative effects experienced by victims can be directly influenced by the availability of support from parents, siblings, relatives, and professionals.55 This will be the subject of further discussion in later sections of this manual. xvi BASIS FOR INTERVENTION AND RESPONSE TO CHILD ABUSE AND NEGLECT For most Americans, the values of privacy and freedom from government intrusion are cherished principles. Throughout the Bill of Rights, this country's founders demonstrated their intent to limit governmental invasion of matters deemed private. This tradition has continued and is firmly established as part of our cultural heritage. However, the right of family or personal privacy is not an absolute right, for our constitutional guarantees do not exist without limitation. Certain factors, both internal and external to a family and its individual members, affect these rights and needs. When the basic needs a society recognizes are not met or when rights are violated, such as in cases of child maltreatment, society believes it has an obligation to intervene to assist the affected individuals. In 1874, Henry Burg, founder and president of the Society for the Prevention of Cruelty to Animals, after being denied assistance by the New York Department of Charities, brought before the New York City Court a child named Mary Ellen who had been beaten severely by her parents. The court exercised "protective" supervision over the child, ruling that she was a member of the animal kingdom and therefore entitled to legal protection. The following year, the first Society for the Prevention of Cruelty to Children was formed in the United States. About a quarter century later, the Illinois Juvenile Court Act established the first separate court for children in the Nation.56 Within our constitutional scheme, each State has the power and responsibility to enact laws that protect the health, safety, and welfare of its residents. The power to enforce such legislation, termed "law enforcement," gives the States some control over the relationship between the child and its community. Thus, States all have enacted legislation concerning child labor, child custody, education, and most importantly for this discussion, child abuse and neglect. Federal law recognizes that certain basic protections must exist to ensure a degree of equal treatment and basic services for all children regardless of State of residence. The Child Abuse Prevention and Treatment Act, discussed in the overview of this manual, serves as a Federal resource to support the States' duty and power to act on behalf of a child when parents are unable or unwilling to do so. This duty and power arise from the parens patriae doctrine, which vests in the State a right of guardianship of minors. This doctrine originated in feudal England, where justification for the assumption of control of estates inherited by minors was needed by the ruling lords. The early English colonists carried this doctrine with the body of English law which has become the foundation of the American system. The doctrine of parens patriae has gradually evolved into the principle that the community, in addition to the parent, has a strong interest in the care and nurturing of children, who represent the future of the community. A wide range of institutions have arisen which are direct responses to the recognition of this interest. Our schools, juvenile courts, and social service agencies all derive their authority from the State's power to ensure the protection and rights of children as a unique class of citizens. xviii THE FEDERAL ROLE IN COMBATING CHILD MALTREATMENT Federal programs designed specifically to stimulate child welfare services and direct Federal aid to families date from 1935 with the passage of the Social Security Act. Since that time, this Act has been amended as additional social problems have been identified. Still, this Act is the bedrock upon which many of our social service systems are built. The key programs under this legislation relevant to services for families in which child abuse and neglect have occurred are Aid to Families with Dependent Children (AFDC); AFDC-Foster Care; Child Welfare Services; Emergency Assistance; Title XX Social Services; Title XIX Medicaid; Early Periodic Screening, Diagnosis and Treatment (EPSDT); Supplemental Security Income (SSI); SSI Disabled Children's Program; and Title V Crippled Children's Services. In 1974, Congress enacted the Child Abuse Prevention and Treatment Act (P.L. 93-247), establishing NCCAN as a focal point for Federal efforts to address the problem of child abuse and neglect. From the outset, NCCAN has provided leadership in establishing child abuse as a national concern and a Federal priority. Other sources of Federal money supporting broad child welfare services were combined with State and local resources and private efforts to begin to provide the comprehensive services needed to prevent child abuse and neglect and to protect and treat maltreated children. Since 1975, NCCAN has fulfilled four major functions: ? generating knowledge and improving service programs; ? collecting, analyzing, and disseminating information; ? assisting States and communities in implementing child abuse programs; and ? coordinating Federal efforts. Generating Knowledge and Improving Service Programs Since 1975, NCCAN has funded approximately 700 research and demonstration projects nationwide to improve knowledge about identification and treatment of child abuse and neglect. These projects involve multidisciplinary, multiservice delivery systems and address every aspect of child maltreatment. Collecting, Analyzing, and Disseminating Information NCCAN's primary efforts in the area of collecting and analyzing information relate to incidence and reporting data. NCCAN has funded two national incidence studies and has conducted periodic analyses of child neglect and abuse reports. Currently, NCCAN is exploring options for improved collection and analysis of State child abuse and neglect reports. A major strength of NCCAN's activities lies in its capacity to disseminate information about child abuse and neglect. Since 1975, this has been accomplished through the NCCAN Clearinghouse on Child Abuse and Neglect Information. Established primarily as a major resource center for professionals concerned with child maltreatment issues, the Clearinghouse functions as the information component of NCCAN. The Clearinghouse maintains a database of documents, audiovisual materials, service programs, excerpts of State statutes, and ongoing research projects concerning child abuse and neglect. This work has been further enhanced through a system of resource centers that provide information, training, and technical assistance to professionals and volunteers across the country. xix Assisting States and Communities in Implementing Child Abuse Programs The primary responsibility for responding to cases of child maltreatment rests with State and local agencies. Supporting various State efforts to develop, strengthen, and implement prevention and treatment programs represents another significant aspect of NCCAN's activities. States that meet Federal guidelines receive grants to support startup activities which, if proven successful, may be continued by the State with other funds. In addition, through the leadership of NCCAN, an informal yet very effective information exchange and peer support system of State Child Protective Services agencies has been developed and maintained. Each State selects a CPS State liaison officer (SLO). The SLO's meet twice a year with NCCAN staff to discuss Federal and State policy issues. NCCAN also provides funds to States that have programs or procedures in their child protection systems that enable them to respond to reports of medical neglect, including instances of withholding medically indicated treatment from disabled infants with life-threatening conditions. Through the Children's Justice and Assistance Act of 1986, NCCAN provides grants to assist States in developing, establishing, and operating programs designed to improve the handling of child abuse cases, especially those involving sexual abuse, in a manner that reduces additional trauma to the child and improves procedures for the investigation and prosecution of such cases. To be eligible for funds, a State must have a State Task Force that reviews judicial and administrative procedures for handling child abuse cases and recommends improvements. Funds for this program are allocated from the Department of Justice's Victims of Crime Fund. Since 1985, NCCAN has provided Challenge Grants to States to encourage the establishment and maintenance of trust funds of other funding mechanisms to support child abuse and neglect prevention activities. To receive these funds, States must have established, in the year prior to the funding request, a trust fund or other funding mechanism available only for child abuse and neglect prevention. Coordinating Federal Efforts Recently enacted amendments in 1988 established a new interagency task force to coordinate Federal efforts in child abuse prevention and treatment programs. In addition, a newly structured Advisory Board on Child Abuse and Neglect composed of individuals who represent the many disciplines involved in the intervention, treatment, and prevention of child maltreatment evaluates the Nation's efforts to accomplish the purposes of the Child Abuse Prevention and Treatment Act and makes recommendations on ways in which those efforts can be improved. THE STATE ROLE IN COMBATING CHILD MALTREATMENT As stated previously, States must comply with the Federal child abuse and neglect guidelines to receive Federal funds. However, beyond that, States have some autonomy in how services are provided to abused and neglected children and their families. As previously mentioned, all States have enacted three types of laws which play a role in the reporting, intervention, and prevention of child abuse and neglect: reporting laws, juvenile and family court laws, and criminal laws. xx State Reporting Laws All States, the District of Columbia, and other jurisdictions have enacted statutes requiring that maltreatment of children be reported to a designated agency or official. The major purposes of such a law are to: ? provide a single definition of child abuse and neglect to promote uniformity in terms and definitions; ? specify the conditions under which the State intervenes in family life; ? specify reporting requirements and procedures both for those persons mandated to report and those persons encouraged to report; ? encourage a therapeutic and treatment-oriented approach to child abuse and neglect, rather than a punitive one; ? designate the administrative structures that have primary responsibility for dealing with child maltreatment; and ? encourage coordination and cooperation among all disciplines which deal with abused and neglected children. Juvenile and Family Court Laws The concept of social justice and the doctrine of parens patriae are applied throughout our country through the establishment of juvenile or family court laws. The primary purpose of juvenile and family courts is to resolve conflict and otherwise intervene in the lives of families in a manner that promotes the best interest of children. Juvenile and family courts specialize in resolving conflicts relating to children and families. The conflict may be between parents, such as domestic violence, alimony, divorce, division of property, child custody, and child support, or the conflict may be between parents and children as in the case of child maltreatment. Court intervention may be required in cases of child maltreatment when families refuse to cooperate after an initial assessment has determined that an incident of abuse or neglect has occurred; the child is determined to be in imminent danger of harm and the child's safety cannot be assured in the home through services provided to the family; or families are unwilling to accept needed services, yet maltreatment exists and the safety of the child is a concern. There are basically four types of court hearings held in family or juvenile courts: ? Emergency hearings are convened to determine the need for emergency protection of a child who may have been a victim of alleged maltreatment. ? Adjudicatory hearings are held to determine whether a child has been maltreated or whether some other legal basis exists for the State to intervene to protect the child. ? Dispositional hearings are convened to determine the action to be taken on the case after adjudication, for example, whether placement is necessary and what services the children and family will need to reduce the risk of maltreatment and to address the effects of maltreatment. ? Review hearings are held to review dispositions (usually every 6 months or at least every 18 months) and to determine the need to continue placement, services, and/or court jurisdiction of a child. xxi For a more detailed description of the various types of hearings, read Working with the Courts in Child Protection. Reporting and juvenile and family court laws further specify the responsibilities of CPS agencies to protect children and help families change the behaviors and conditions which contribute to the risk of maltreatment. In some States, the reporting law and the juvenile or family court law are combined into one Child Protection Act. In addition, there are civil protections which give the court jurisdiction to issue "orders of protection" (for example, restraining orders and orders to vacate the household? both directed at the adult perpetrator of spouse and child abuse). Criminal Laws Each State also has enacted criminal statutes which define those forms of child abuse and neglect which are criminally punishable. Responsibility for investigation of crimes related to child abuse and neglect rests with law enforcement agencies and the district attorney or local prosecutor. They are charged with the responsibility for deciding under what circumstances prosecution of child abuse and neglect will occur. Criminal courts serve to protect victims and the public from offenders and to rehabilitate those who break the law. The burden of proof, beyond a reasonable doubt, in criminal court is greater than the standard of evidence of child maltreatment in juvenile or family court. The defendant in a criminal case is entitled to the full protections guaranteed by the fourth, fifth, and sixth amendments of the Constitution, including right to jury, strict adherence to rules of evidence, right to cross-examination, right to appointed counsel, and right to a public and speedy trial. Criminal prosecution may result in such penalties as probation or incarceration in a penal institution, but criminal courts have no authority concerning the child victim. Thus, criminal prosecution is directed at deterring or rehabilitating the defendant rather than at ensuring the safety of the child. xxii WORKING TOGETHER As stated previously, child maltreatment is a community problem, and this chapter focuses on the roles and responsibilities of each professional involved in the child protection system and the essential elements of a well-coordinated child protection system at the local level. PRINCIPLES ESSENTIAL FOR COORDINATION OF SERVICES In order for all the professionals and agencies to work together effectively, there must be agreement on common goals; an understanding of professional roles and expertise; open communication; and written protocols, formalized working agreements, policies, and procedures. Each is described below. Agreement on Common Goals A well-coordinated system is based on an agreement between all involved parties on common goals. The common community goals for child protection are prevention of child abuse and neglect, protection of children from harm, and reduction of risk of maltreatment. In spite of the fact that the professions involved in the community's response to child maltreatment have differences in philosophy, focus, and perceptions which may sometimes come in conflict with one another, it is possible to agree on common goals. By maintaining a focus on shared goals and by remembering the vital part each professional and agency has to play in the child abuse and neglect response system, conflicts can be avoided and/or resolved more readily. Understanding of Professional Roles and Expertise All professionals involved in child protection efforts must have a clear understanding of their own and other professionals' and agencies' roles and responsibilities in the community's child abuse and neglect response system. Additionally, community professionals need to be aware of and respect the expertise and resources offered by each professional and agency. The roles of all the community professionals and agencies must mesh to form a complete child protection system. Open Communication Interagency communication is crucial if service delivery is to be properly coordinated. Communication between agencies must be maintained on a formal and informal basis. Formal All key agencies involved in the community's child protection system, for example, the CPS agency, the schools, hospitals, mental health centers, law enforcement, and the judicial system, should establish a central person to serve as a liaison on the issue of child abuse and neglect. The liaison may take the lead role in developing written policies and procedures for appropriate roles and activities which will vary depending on the agency. For example, school policies would focus primarily on reporting instances of child abuse and neglect. (Policies and protocols are discussed in the next section.) xxiv The liaison may also have responsibility for case reporting, case coordination, education of agency personnel, development of prevention programs, enhancement of agency services for abused and neglected children, representation on the community's case consultation team, and general information dissemination. Informal Informal, ongoing communication must occur among professionals involved with the same child and family. Ongoing communication regarding case progress, changes in behavior or circumstances, problems encountered, and outstanding issues are critical to preventing contradiction and duplication in services. As well, open communication among professionals involved in the same case provides for ongoing assessment and enables changes in intervention approaches and services, as necessary. Protocols, Policies, and Procedures Reporting Policies Each agency comprised of professionals with a mandated responsibility to report suspected child abuse and neglect should establish written procedures for making referrals. These procedures provide standard internal mechanisms to be followed when a case is reported. The policies may address: ? the statutory and operational definitions of child abuse and neglect in the State; ? the name and telephone number of the official in the agency serving as liaison with CPS; ? the name(s) and telephone number(s) for the agencies designated to receive reports of child maltreatment; ? the type and specificity of the information to be reported; ? description of the forms to be completed (if appropriate); and ? the legal rights and responsibilities of agency personnel. Protocols A protocol is helpful for agencies that intervene in cases of child abuse and neglect to delineate professional roles and responsibilities and provide step-by-step intervention procedures. Protocols are equally essential when two or more agencies together intervene in cases of child abuse and neglect, for example, joint initial assessments/investigations. A protocol may address: ? roles and responsibilities of different professionals; ? the steps that must be completed at each stage of intervention, the time frames for completion, and who is responsible for completing the steps; and ? concrete and practical tips for handling special issues. Protocols help guide intervention and standardize practice. With clearly defined roles and responsibilities and procedures to follow, coordination and collaboration problems are less likely to arise. xxv Procedures for Feedback Good coordination and collaboration among agencies and professionals are based not only on open communication but also on a system that allows for feedback regarding case status. Feedback is useful in assessing intervention on a case-by-case basis. It can also be used to discuss successes and problems in collaboration and coordination among agencies and professionals. Feedback can identify gaps in services and strategies for closing these gaps and enhancing service delivery. By agreeing on common goals, developing a clear understanding of professional roles and responsibilities, maintaining open communication, developing procedures for intervention and collaboration, and instituting procedures for feedback, collaboration and coordination will be enhanced. ROLES AND RESPONSIBILITIES OF COMMUNITY PROFESSIONALS CPS is one of the key agencies in each community's child abuse and neglect response system and most often has the lead role in coordinating between the various disciplines responsible for combating child maltreatment. CPS is the agency mandated by law in most States to conduct an initial assessment/investigate reports of child abuse and neglect and offer rehabilitative services to families where maltreatment has occurred or is likely to occur. Nevertheless, CPS cannot take full responsibility for child protection. All relevant professionals must be aware of their role in child protection and the unique knowledge and skills they bring to their community's prevention and intervention efforts. They must also understand the roles, responsibilities, and expertise of other professionals. (Figure 1, Roles and Responsibilities of Various Professional Groups in Responding to Child Abuse and Neglect, graphically depicts the roles and responsibilities of each profession.) Child Protective Services CPS is generally the central agency in the community child protection system. CPS is responsible for receiving reports of child abuse and neglect; conducting initial assessments; conducting family assessments; developing individualized case plans; providing direct services and coordinating services provided by other professionals; completing case management functions such as maintaining case records, systematically reviewing case plans, and developing court reports; educating the community regarding the problem of child abuse and neglect; and developing and enhancing community prevention and treatment resources. For a more detailed discussion on the roles and responsibilities of the CPS agency, see Child Protective Services: A Guide for Caseworkers. Law Enforcement In the initial stages of the child protection response, law enforcement and CPS often have similar responsibilities. Law enforcement's involvement in the initial assessment/investigation of child abuse and neglect varies in different communities. Whether the community has a protocol for joint or separate initial assessments/investigations, a high degree of coordination between CPS and law enforcement is necessary to minimize the confusion and trauma to the child as a result of system intervention. xxvi Family Assessment and Case Planning Case Management Treatment and Case Evaluation Court Action Secondary Prevention and Self-Help Primary Prevention Resource Enhancement, Evaluation, and Training Local CPS Agency Intake, Initial Assessment/ Investigation Identification and Reporting Figure 1 ROLES AND RESPONSIBILITIES OF VARIOUS PROFESSIONAL GROUPS IN RESPONDING TO CHILD ABUSE AND NEGLECT Lead Lead Lead Lead Provide Provide Provide Lead Health Care System Lead Provide Advise Lead Advise Lead Lead Lead Mental Health System Lead Provide Advise Lead Advise Lead Lead Lead Education System Lead Provide Advise Lead Advise Lead Lead Lead Legal System Lead Provide Advise Advise Lead Advise Provide Lead Law Enforcement System Lead Provide Advise Advise Provide Provide Provide Lead Support Services Lead Lead Provide Provide Provide* Advise Lead Definitions: Lead = Responsible for initiating action and/or coordinating activities, including providing and advising functions Provide = Responsible for participating in actions related to this function, including advising functions Advise = Responsible for providing input regarding actions or activities under this function *In some jurisdictions, law enforcement will have a lead role, with the CPS agency providing assistance in investigation, particularly in terms of physical and sexual abuse. The primary responsibilities of law enforcement include identifying and reporting suspected child maltreatment; receiving reports of child abuse and neglect; conducting investigations of reports of child maltreatment when there is a suspicion that a crime has been committed; gathering physical evidence; determining whether sufficient evidence exists to prosecute alleged offenders; assisting with any need to secure protection of the child; providing protection to CPS staff when a caseworker's personal safety may be in jeopardy if confrontation occurs with alleged offenders; supporting the victim through the criminal court process; and participating in multidisciplinary team activities. For a more detailed discussion of the roles and responsibilities of law enforcement personnel, see The Role of Law Enforcement in the Response to Child Abuse and Neglect. Educators xxvii Principals, teachers, school counselors, and other school-related personnel and early childhood educators play a critical role in the community child protection system. Their responsibilities include identifying and reporting suspected intrafamilial child abuse and neglect; recognizing and reporting child abuse and neglect occurring in the school system/early child care program; developing a school/program policy for reporting instances of child abuse and neglect and cooperating with CPS investigations; after reporting, keeping CPS informed of the changes or improvements in the child's behavior and condition; providing input in diagnostic and treatment/remedial services for the child; supporting the child through potentially traumatic events, for example, court hearings and out-of-home placement; providing treatment for parents such as school/program-sponsored self-help groups; developing and implementing prevention programs for children and parents; and serving on child maltreatment multidisciplinary teams. For a more detailed description of the roles and responsibilities of educators, please read The Role of Educators in the Prevention and Treatment of Child Abuse and Neglect. Health Care Providers Physicians, nurses, and other medical personnel play a major role in the child protection system in every community. Key functions of health care providers include identifying and reporting suspected cases of child abuse and neglect; providing diagnostic and treatment services (medical and psychiatric) for maltreated children and their families; providing consultation to CPS regarding medical aspects of child abuse and neglect; participating on the community multidisciplinary case consultation team; providing expert testimony in child protection judicial proceedings; providing education for parents regarding the needs, care, and treatment of children; identifying and providing support for families at risk of child maltreatment; developing and conducting primary prevention programs; and providing training for medical and nonmedical professionals regarding the medical aspects of child abuse and neglect. Mental Health Professionals Mental health services are a prerequisite for any community system designed to prevent and treat child abuse and neglect. Psychiatrists, psychologists, social workers, and other mental health professionals must identify and report suspected cases of child abuse and neglect; conduct necessary evaluations of abused and neglected children and their families; provide treatment for abused and neglected children and their families; provide clinical consultation to CPS; provide expert testimony in child protection judicial proceedings; provide self-help groups for parents who have maltreated or are at risk of maltreating their children; develop and implement prevention programs; and participate on community multidisciplinary teams. Legal and Judicial System Professionals Responsibilities of legal professionals vary depending upon who the attorney's client is and depending upon the stage of a judicial proceeding. Attorneys representing the CPS agency who are responsible for presenting child maltreatment cases in court assure that CPS personnel are given appropriate legal advice and consultation, for example, on decisions regarding emergency removal of children; prepare necessary and sufficient legal pleadings when court intervention becomes necessary; participate in multidisciplinary team meetings when potential legal actions on behalf of the child may be explored; and prepare CPS caseworkers, expert witnesses, and other witnesses, especially children, for testifying in court. Criminal prosecutors assure that any criminal action is coordinated with a civil child protection proceeding involving the same child; assure that the child is adequately prepared for testifying; see that the child is provided with victim advocacy services when necessary; when a conviction is obtained, assist the court in arriving at a sentence that serves the interest of justice and assures that proper treatment is provided; and participate in multidisciplinary team meetings when potential legal actions on behalf of the child may be explored. xxviii Guardians ad litem, legal counsel for children, and court appointed special advocates (CASAs) assure that the needs and interests of a child in child protection judicial proceedings are fully protected; conduct an independent investigation into background and facts of case; determine the child's educational, psychological, and other treatment needs and help assure that the judicial intervention leads to appropriate treatment; and facilitate a speedy, nonadversarial resolution of the case whenever possible and appropriate. Attorneys for the parents or other maltreating caretaker (defense attorneys) assure that the caretakers' statutory and constitutional rights are fully protected in any judicial proceeding and assure that the parents understand the judicial process and the potential impact of the process. Juvenile or family court judges provide emergency protective orders, when necessary, 24 hours a day, 7 days a week; speedily resolve all court cases of alleged child maltreatment; know the relevant case law and adjust the court process, as appropriate, to deal sensitively with child victims; and encourage the development of greater community resources for maltreated children and their families. Court personnel help assure that children and families are dealt with sensitively throughout the judicial process and identify possible child maltreatment in cases before the court for other reasons, for example, delinquency. For a more detailed description of the juvenile and criminal court process, please read Working With the Courts in ChildProtection. Support Services Providers There are many other individuals who support the community intervention efforts: foster parents, child and residential care providers, youth service workers, volunteers, and parent aides. These individuals primarily offer treatment and supportive services to abused and neglected children and their parents. In addition, when children have to be removed from their parents' care and placed in foster care or residential care to ensure their safety, foster parents and residential care providers become an integral part of the treatment team, which is first and foremost focused on the goal of family reunification. PROBLEMS ENCOUNTERED Conflict in any relationship, whether it is personal or professional, may be encountered.Within the interdisciplinary intervention system, conflict is often a tension or breakdown that results from problems associated with decision making, interpersonal relationships, competition, territorialism, and/or a lack of cooperation. Some individuals have more difficulty than others in developing and maintaining effective collaborative relationships. For example, to the extent that professionals are only interested in addressing their own personal and/or organizational needs, they may not be very effective at agreeing on common goals and participating in strategies to resolve conflict when it may occur. In contrast, certain individuals within the community system may be prone to avoid conflict, and their behavior may tend to be interpreted as uncooperative. Consider team members who only participate in meetings on a sporadic basis, fail to follow through with assignments, and particularly withdraw from discussions when problem solving needs to occur. Often, community members who present avoiding behavior need to be "convinced" of the value of collaboration. xxix True collaboration requires a commitment to considering the needs of other team members and the needs of the individuals served while not losing sight of individual professional and/or organizational positions. When conflict occurs, the team members can focus discussion around common goals and carefully review creative options for solving problems together. When these principles can be applied, it is usually easier to agree eventually on the process needed to achieve mutual goals. xxx CHILD PROTECTION SYSTEM The primary responsibility for responding to cases of child abuse and neglect rests with local agencies. This chapter describes the community response to child maltreatment. IDENTIFICATION The first step in any child protection response system is the identification of possible incidents of child abuse and neglect. Medical personnel, educators, early childhood professionals, mental health professionals, law enforcement personnel, the clergy, and other professionals are in a position to observe families and children on an ongoing basis and identify abusive or neglectful situations when they occur. Private citizens (concerned family members, friends, and neighbors) may also identify suspected incidents of child maltreatment. Preservice and inservice training for professionals involved with children and families must be provided on an ongoing basis to ensure that community professionals are able to recognize possible indicators of child maltreatment. In addition, comprehensive public awareness campaigns should be carefully planned and implemented to maintain and enhance community awareness of the problem. REPORTING The next step in responding to possible child maltreatment is to report the suspected incident. As previously described, every State and all the U.S. territories have enacted laws addressing this critical community responsibility. Although there is tremendous variation in the requirements set forth in State reporting laws, they typically: ? Specify certain professionals, classes of individuals, or institutions required to report suspected cases of child abuse and neglect and those individuals permitted to report. Most States identify the following categories of professionals or occupational groups as required to report: - Medical professionals such as physicians, nurses, dentists, and medical examiners. - Mental health professionals such as psychologists, therapists, or counselors. - Educators such as teachers and administrators. - Child care providers such as staff in day care centers, preschools, and family day care; foster parents; and residential/institutional care personnel. - Social service providers such as social workers and social services personnel. - Law enforcement personnel. Some States require the clergy (rabbis, priests, and ministers) to report suspected child maltreatment. xxxii It is important to remember that the rights of client-professional confidentiality (with the exception of the attorney-client relationship) are usually waived in child abuse and neglect reporting. Therefore, professionals are expected to report suspected child maltreatment even if their knowledge of the incident comes from a client. Additionally, most State reporting laws include a provision that any person having knowledge of abuse or neglect may report. The same legal protections from lawsuits or criminal prosecution are provided to individuals mandated and permitted to report. ? Provide penalties for failure to report. ? Provide immunity from legal liability for reporters reporting in good faith. ? Define reportable conditions and age limits of reportable children. ? Describe who may be reported under child protection statutes (as contrasted with criminal statutes). ? Explain how, when, and to whom reports are to be filed and the information to be contained in the report. ? Outline the protective actions that may be taken. States require the reporting of suspected child abuse and neglect. The law may specify reporting of "suspected" incidents or include the phrase "reason to believe." In any case, the intent is clear; incidents are to be reported as soon as they are noticed. Waiting for proof may place the child in grave danger. Reporting Procedures Child abuse and neglect reporting laws contain specific directions to reporters concerning how to report, to whom reports are made, when to report, and the contents of the reports. How and When To Report The majority of States require that oral reports (telephone or in-person contacts) of child maltreatment be made immediately to the specified authority. Many States require that a written report follow the oral report. Some of these States require written reports from mandated reporters only. In other States, written reports are to be filed only upon request. The time frames for submission of the written report vary from within 36 hours to 5 days of the initial report. Who Receives Reports Every State designates specific agencies to receive reports of child abuse and neglect. In some States, CPS has the exclusive responsibility for receiving reports. Other States allow reports to be made to either CPS or law enforcement. Sometimes, State laws require certain forms of maltreatment (physical or sexual abuse) to be reported to the police in addition to reports made to CPS. The nature of the relationship of the alleged perpetrator may also affect where reports are made. Clearly, all alleged cases of child maltreatment within the family are reportable to CPS. Depending on the State, allegations of abuse or neglect by other caretakers, such as foster parents, day care providers, teachers, or residential care providers, may fall outside the purview of local CPS. In some States, allegations of abuse in out-of-home care are reported to a centralized investigative body within CPS at the State or regional level and/or a combination of xxxiii CPS and licensing personnel. In most instances, alleged child maltreatment by someone outside the family is also investigated by law enforcement. Contents of the Report Reporting laws describe the information that must be contained in the report. The information typically specified includes: ? the name, age, sex, and address of the child(ren); ? the nature and extent of the child's injuries/condition; and ? the name and address of the parent or other person responsible for the child. It is absolutely essential that reporters provide as much detailed information as possible about the child, the child's condition, and the whereabouts of the child; the parents and their whereabouts; the person alleged to have caused the child's condition and his/her current location; the family, including other children in the home; the type and nature of the maltreatment (for example, the length of time it has been occurring, whether the maltreatment has increased in severity and frequency, and whether instruments were used); the reporter's name, address, and telephone number; and the reporter's view of what should happen in the case. In addition, for reports of alleged maltreatment in out-of-home care settings, it is important to provide information about the setting (foster home, day care center, etc.) such as hours of operation, number of other children (if known) in the facility, and identification of any others in the facility who may have information about the alleged maltreatment. Immunity to Reporters Reporting laws also contain provisions to protect reporters from civil lawsuits and criminal prosecution resulting from filing a report. This immunity is provided as long as the report is made in "good faith." In order to initiate a report, an individual must suspect that a child has been maltreated. Determining whether child abuse or neglect is substantiated ("some credible evidence exists") is the responsibility of the CPS agency and the courts. As long as the reporter has a basis to "suspect" that maltreatment has occurred, it is assumed that the report has been made in "good faith," and therefore the reporter is immune from criminal or civil liability. Penalties for Failure To Report Most States have criminal penalties for failure to report. There is also the risk of civil lawsuit liability for failure to report by those persons designated as mandated reporters. Typically, failure to report is punishable by fines and/or jail terms of usually 6 months or less. Since reporting laws vary greatly, professionals should obtain a copy of their State's reporting statutes and study it carefully. xxxiv Problems in Reporting Data indicate that many abused and neglected children recognized by educational, medical, and mental health professionals are not reported to the local CPS.57 One of the biggest obstacles to reporting is personal feelings. Some people do not want to get involved. Others have difficulty reporting the person they suspect is an abuser, especially if they know that person well. Others may think they can help the family more by working with the child and/or family themselves. Another obstacle is the professional-client relationship. When a professional has established a relationship with a parent or family prior to recognizing maltreatment, reporting becomes a delicate issue. However, handled with honesty and support, the report could strengthen the alliance by indicating the professional's willingness to stand by the family. Finally, difficulties with CPS sometimes inhibit reporting. Some professionals become convinced that nothing will be done if they report or the case will not be handled to their satisfaction, so they choose not to report. Therefore, the feedback that CPS caseworkers provide reporters is critical. Professionals must report regardless of their concerns or previous experiences. The law requires it, and no exemptions are granted to those who have had a bad experience. In addition, while reporting does not guarantee that the situation will improve, not reporting guarantees that, if abuse and neglect exists, the child will continue to be at risk of further and perhaps more serious harm. Once reported, each case proceeds through similar steps in the intervention and treatment process: Intake; Initial Assessment; Family Assessment; Case Planning; Case Management and Treatment; Evaluation of Family Process; and Case Closure. (See Figure 2, Child Protective System Case Process.) INTAKE Intake is the point at which reports are received concerning children who are suspected of being abused or neglected by the agency designated by the State. Regardless of the agency receiving the report, there are two primary decisions at intake: ? Does the reported information meet the agency guidelines for child maltreatment? ? How urgent is the referral? The first decision consists of three essential steps: gathering sufficient information from the reporter to allow accurate decision-making; evaluating the information to determine if it meets the statutory and agency guidelines; and assessing the credibility of the reporter. Once the CPS agency determines that an initial assessment is warranted, the immediacy of the response is evaluated. The decision regarding the urgency of the response is based on an analysis of the information gathered to determine the level of risk of harm to the child. Some CPS agencies provide guidelines for initial assessment response times. For example, in most States, if it is determined that a child is high risk, a caseworker must respond immediately or at least within 24 hours. INITIAL ASSESSMENT/INVESTIGATION The initial assessment of cases of child abuse and neglect is also referred to as the investigation. CPS agencies and law enforcement are each responsible for conducting initial assessments/investigations in cases of child abuse and neglect. xxxv In addition, in cases of out-of-home child maltreatment, investigation must be completed by an independent authority designated by the State. The primary decisions or issues to consider at this stage of the child protection process are: ? Did the child suffer maltreatment or is he/she threatened by harm as defined by the State reporting law? (CPS) ? Did a crime occur? (law enforcement) xxxvi ? Is the parent(s)/caretaker(s) responsible for the maltreatment? (CPS) Who is the alleged offender? (law enforcement) ? Do sources of corroboration or witnesses exist? (CPS and law enforcement) ? Has all physical evidence been obtained/preserved? (CPS and law enforcement) ? Are there any other victims? (CPS and law enforcement) ? Is maltreatment likely to occur in the future? If so, what is the level of risk of maltreatment? (CPS) ? Is there evidence to arrest the alleged offender? (law enforcement) ? Is the child safe? If not, what measures are necessary to ensure the child's safety? (CPS) Should the child be taken into protective custody? (CPS and law enforcement) ? Are there emergency needs in the family that must be met?(CPS) ? Are continuing agency services necessary to protect the child and reduce the risk of maltreatment occurring in the future?(CPS) For cases involving out-of-home care abuse, there are other decisions and issues to consider:58 ? Are personnel actions indicated, and (if so) are they being initiated appropriately by the child care facility? (licensing personnel) ? What responsibility do others in the facility have for any incident of maltreatment, and is a corrective action plan needed to prevent the likelihood of future incidents? (CPS and licensing personnel) ? Should the facility's or foster care or other child care provider's license be revoked? (licensing) These decisions are made by thoroughly gathering and analyzing sufficient information from and about the child, family, and/or in some cases, the out-of-home provider. Typically, a protocol is employed for interviewing the child victim, family members, the person alleged to have maltreated the child, and others possessing information about the child and the family. In addition to CPS and law enforcement, other disciplines have a role in the initial assessment process: ? Foster care, residential, or child care licensing personnel may participate in the initial assessment if abuse is allegedly committed by an out-of-home caretaker. ? Medical personnel may be involved in assessing and responding to medical needs of a child or parent and perhaps in documenting the nature and extent of maltreatment. ? Mental health personnel may be involved in assessing the effects of any alleged maltreatment and in helping to determine the validity of specific allegations. xxxvii ? Teachers may be involved in providing direct information about the effects of maltreatment and in describing information pertinent to risk assessment. ? Military family advocacy personnel may be directly involved by providing information when one of the members of the family is in the military. ? Other community service providers may have had past experience with the child and/or family and may be a resource in helping to address any emergency needs that the child or family may have. FAMILY ASSESSMENT Once a determination of child abuse and neglect has been made and the child's immediate safety has been ensured, the family assessment phase of the child protection process begins. The purpose of the family assessment is to obtain as complete a picture as possible about the nature, extent, and causes of the factors contributing to the risk of maltreatment and the effects of maltreatment on the child victim and other family members. Gaining a complete understanding of the causes for the risk to the child enables community professionals to identify correctly strategies to prevent maltreatment in the future. The primary decisions and issues to consider at the family assessment stage include: ? What are the nature, extent, and causes of the factors contributing to the risk of maltreatment? ? What are the effects of the maltreatment and the treatment needs of all family members? ? What are the individual and family strengths that can be tapped in the intervention process? ? What conditions/behaviors must change for the risk of maltreatment to be reduced? ? What is the prognosis for change? Information is gathered by interviewing and observing all family members, using other evaluative/assessment methods, and reviewing agency records (for example, open CPS records, school records, etc.). The overall goal of family assessment is to reach a mutual understanding between the CPS caseworker, community treatment providers, and the family regarding the most critical needs to be addressed and the strengths on which to build. While CPS takes a lead in conducting the family assessment, other professionals such as mental health and substance abuse professionals may be involved. CASE PLANNING Once the family assessment has been completed, the next step is to determine, in conjunction with the family members and other community service providers, the strategies to be used to change the conditions/behaviors resulting in child abuse and neglect. The major decisions and issues to consider at this stage of the process include: ? What are the goals that must be achieved to reduce the risk of maltreatment and meet the treatment needs identified? ? What are the priorities among the goals? ? What interventions or services will be used to achieve the goals? xxxviii ? What steps or tasks must be completed for goals to be achieved? What is the CPS caseworker responsible for? What are family members responsible for? What are other service providers responsible for? ? What are the time frames for goal achievement? ? How and when will the case plan be evaluated to determine goal accomplishment? The goals of the planning process are to engage family members in deciding what they need to change in order to reduce or eliminate the risk of maltreatment and what the client, caseworker, and other service providers will do to ensure that the necessary changes occur. TREATMENT Since child maltreatment is complex and multidimensional, most families served have multiple problems. Therefore, comprehensive treatment services (for example, therapy, self-help groups, supportive services, concrete services, respite care, etc.) must be available in each community to help parents change their dysfunctional patterns of behavior resulting in child abuse and neglect and to meet the child's treatment needs. Historically, abused and neglected children have received medical attention for their injuries, but little in terms of therapeutic services. Physically and sexually abused children not only have to deal with the effects of physical and sexual assault, but must also deal with the psychological effects of being harmed by the very person who is supposed to love and care for them. Maltreated children experience a mixture of anger, suspicion, isolation, and fear. This highly volatile mixture can dramatically affect the child's behavior. Consequently, several different community agencies or service providers may be involved with a particular family. It is CPS' role to arrange for and coordinate the delivery of treatment services to maltreating families. This critical case management function requires open and continuous communication among CPS, the family, and other service providers; developing a teamwork relationship; clarifying roles and responsibilities in delivering and monitoring services; and reaching consensus on goals and methods for monitoring progress toward goal achievement. EVALUATION OF FAMILY PROGRESS Assessment is an ongoing process; it begins with the very first client contact and continues throughout the life of a case. In cases involved in the child protection system, ongoing assessment evaluates: ? the child's safety; ? the achievement of goals and tasks; ? the reduction of the risk of maltreatment; and ? the success in meeting the child's and other family members' needs caused by the maltreatment. Evaluation of family progress is achieved by engaging family members and other service providers in measuring observable behavior against goals and tasks. Frequently community treatment providers coordinate their evaluation of case progress through periodic team meetings. xxxix CASE CLOSURE Optimally, cases are closed when it has been determined that the risks of maltreatment have been reduced sufficiently or eliminated so that the family can meet the child's developmental needs and protect the child from maltreatment without societal intervention. However, sometimes cases are closed because the family resists all intervention efforts. Other times, cases are closed because it is determined that the parents will not be able to protect the child and meet his/her developmental needs in a time frame that is reasonable for the child's growth and development. In these cases residual parental rights are terminated so that permanent alternatives for the child can be found. xl PREVENTING CHILD ABUSE AND NEGLECT Providing treatment to abusive and neglectful families alone cannot break the cycle of child maltreatment. Therefore communities must develop strategies to prevent abusive or neglectful patterns from happening. While experts agree that the causes of child abuse and neglect are complex, it is possible to isolate some of the factors contributing to child maltreatment and develop prevention initiatives to reach children and families at large and "high-risk" populations. For example, a lack of understanding of child development and of effective child care skills may contribute to parental difficulties in providing adequate care to children and can potentially result in maltreating behavior.Also, young parents who are isolated and did not receive nurturing during their own childhood, may not be prepared to provide the loving care that their infants need. Many communities are developing family resource programs designed to provide families with the information and support necessary to strengthen family and community life and enhance the growth and development of children. Examples of family resource programs are center-based programs such as drop-in centers and parent education centers; parent network programs intended to support parents through informal meetings in community locations such as churches and schools; "warmlines," which offer free telephone consultation services to young children's parents who have concerns or questions about their child's development or behavior, or simply need someone to talk to; and parent groups formed for a specific purpose, such as education, self-help, and support.59 Providing home health visitor services to high-risk mothers has proven to reduce the likelihood of maltreating behavior compared with the likelihood for control groups of high-risk mothers who received no intervention.60 Still other prevention activities are geared directly to children. These include personal safety programs designed to increase children's knowledge about sexual abuse and potential sex offenders and to help children take action if someone tries to abuse them sexually.61 TYPES OF PREVENTION EFFORTS Prevention is commonly categorized as primary, secondary, or tertiary. "Primary prevention addresses a sample of the general population, e.g., a program administered to all students in a school district regarding how to prevent sexual abuse."62 Secondary prevention is targeted at "preventing breakdowns and dysfunctions among families at risk for abuse and neglect."63 "Tertiary prevention, or treatment, involves situations in which child maltreatment has already occurred, and the goal is to decrease recidivism and avoid the harmful effects of child maltreatment."64 While many prevention programs are interdisciplinary, they are typically initiated by one sector of the community: the medical/health care profession, community support systems, the workplace, social services, and educational institutions.65 Thus, all members of the community have a role in working together toward the prevention of child maltreatment. Prevention Initiatives in Health Care 66 Activities which protect and promote the health of children and their parents can contribute to the prevention of child maltreatment. Some examples of these include: xlii ? prenatal and early childhood health care to improve pregnancy outcomes and health among new mothers and young children; ? family-centered birthing and perinatal coaching to strengthen the early, positive bonding between parents and their children; ? home health visitors to provide support, education, and community linkage for new parents; and ? support programs for parents of special-needs children to assist parents of children with special health and developmental problems. Community-Based Prevention67 Families rely on organizations that provide social and recreational opportunities such as Boys and Girls Clubs, scouting troops, and local YMCA/YWCA's; community-based, grassroots service agencies such as family day care providers, community centers, food banks, emergency assistance programs, and shelters; and organized self-help, support, and mutual assistance groups. They are also involved with a vast array of service and fraternal organizations; advocacy groups; and ethnic, cultural, and religious organizations. A number of community-based family support initiatives have been proposed or developed to help strengthen families and prevent child maltreatment. ? self-help and mutual aid groups to provide nonjudgmental support and assistance to troubled families; ? strengthening natural support networks to provide families with a supportive network of informal "helpers" and community resources; ? child care programs/respite care to reduce the stress employed parents experience, and provide positive modeling and contact for parents and children; ? programs for children in self-care to reduce the emotional and physical risks which "latchkey" children may face; ? programs that address the impact of lack of resources on children and families such as the lack of adequate shelter, nutrition, and health care; and ? public education and media campaigns to increase public knowledge and awareness about important issues in the prevention of child abuse and neglect. xliii Role of the Workplace in Strengthening Families68 As the number of parents working outside the home continues to grow, there is an increased potential for employment and workplace policies to enhance family functioning and prevent child maltreatment. For all working parents, a supportive work environment can help ease the stress of the dual responsibilities to work and family. For some already vulnerable parents a supportive work climate may prevent family dysfunction, breakdowns, and abuse. Family-focused initiatives for the workplace include: ? flexible work schedules and benefits to help families balance the demands of their work and parental commitments; ? education and support programs offered at the worksite to help parents better cope with the challenges of parenting; ? parental leave policies to reduce stress on new parents and help facilitate positive attachments between parents and their infants; ? employer-supported child care to help provide quality child care options for working parents; and ? family-oriented policies to support parents in their dual roles as parents and wage earners by creating healthy and humane working conditions and ensuring adequate family income and equality in wages for women. Targeting Social Services on Prevention69 Increasingly, social service agencies and professionals are expanding their focus to include programs which prevent family problems from escalating into family breakdown and violence. Particularly effective social service initiatives for strengthening families and preventing child maltreatment include: ? parent education to help parents develop adequate child-rearing knowledge and skills; ? parent aide programs to provide a supportive, one-on-one relationship for parents who may be at risk of maltreating their children; ? crisis and emergency services to provide respite for parents and children at times of exceptional stress or crisis; ? treatment for abused children to prevent an intergenerational repetition of family violence; and ? comprehensive prevention programs to provide multidisciplinary services and support to families at risk of maltreating their children. The social service community plays an important role in addressing issues of maltreatment in institutional settings, by supporting policies which prohibit corporal punishment in all custodial (for example, residential facilities for juveniles convicted of crimes) and treatment settings for children. Social service agencies also train foster parents and group child care workers in nonviolent discipline alternatives. xliv Prevention in the Schools70 With increasing public and professional attention to the serious social problems affecting children and adolescents, schools have become the focus for many new prevention efforts, including: ? comprehensive, integrated prevention curricula to equip children with the diverse skills, knowledge, and information they need to cope successfully with the challenges of childhood and adolescence; two components of such a curriculum would include: - self-protection training to enhance children's capacity to protect themselves from abuse or exploitation and seek appropriate help (word of caution: these training programs must be carefully evaluated; children need to learn what is "good and bad" touch, but placing the burden on the victims for their own protection must be avoided); and - family life education to equip children and adolescents with skills for coping with family problems and transitions and prepare them for their future roles as parents; ? policies to eliminate corporal punishment to stop the physical punishment of children in institutional settings; and ? programs for children with special needs to help reduce the stress on families with a "special" or disabled child. xlv SUMMARY In addition to being aware of their own roles and responsibilities in the child protection system and the roles of other key professionals and agencies, professionals must work together on behalf of abused and neglected children and their families. Since many roles overlap, it is critical that professionals communicate and collaborate with one another and develop formal and informal mechanisms for working together. Child abuse and neglect is a community problem requiring a coordinated community response to prevent and treat it successfully. Beyond the responsibilities that all professionals have for combating child maltreatment, private citizens must be able to identify and report suspected cases and may be involved in their community's prevention efforts. Therefore, no one agency or individual has the necessary knowledge, skills, and resources to prevent and treat child maltreatment. Together the community can make a difference in the lives of maltreated children and their families. xlvi GLOSSARY OF TERMS Adjudicatory Hearings - held by the juvenile and family court to determine whether a child has been maltreated or whether some other legal basis exists for the State to intervene to protect the child. CASA - court-appointed special advocates (usually volunteers) who serve to ensure that the needs and interests of a child in child protection judicial proceedings are fully protected. Case Plan - the professional document which outlines the outcomes, goals, and strategies to be used to change the conditions and behaviors resulting in child abuse and neglect. Case Planning - the stage of the child protection case process when the CPS caseworker and other treatment providers develop a case plan with the family members. Dispositional Hearings - held by the juvenile and family court to determine the disposition of children after cases have been adjudicated such as whether placement of the child in out-of-home care is necessary and what services the children and family will need to reduce the risk of maltreatment and to address the effects of maltreatment. Emergency Hearings - held by the juvenile and family court to determine the need for emergency protection of a child who may have been a victim of alleged maltreatment. Evaluation of Family Progress - the stage of the child protection case process (after the case plan has been implemented) when the CPS caseworker and other treatment providers evaluate and measure changes in the family behaviors and conditions which led to child abuse and neglect, monitor risk elimination/reduction, and determine when services are no longer necessary. Frequently, community treatment providers coordinate their evaluation of case progress through periodic team meetings. Family Assessment - the stage of the child protection process when the CPS caseworker, community treatment providers, and the family reach a mutual understanding regarding the most critical treatment needs that need to be addressed and the strengths on which to build. Guardians Ad Litem - legal counsel assigned to represent the best interest of children in juvenile and family court proceedings. Good Faith - the standard used to determine if a reporter has a reason to "suspect" that child abuse or neglect has occurred. In general, good faith applies if any reasonable person, given the same information, would draw a conclusion that a child "may" have been abused or neglected. Immunity - established in all child abuse laws to protect reporters from civil lawsuits and criminal prosecution resulting from filing a report of child abuse and neglect. This immunity is provided as long as the report is made in "good faith." Intake - the stage of the child protection case process when community professionals and the general public report suspected incidents of child abuse and neglect to CPS and/or the police; CPS staff and the police must determine the appropriateness of the report and the urgency of the response needed. xlviii Initial Assessment - the stage of the child protection case process when the CPS caseworker and law enforcement personnel determine the validity of the child maltreatment report, assess the risk of maltreatment, and determine the safety of the child and the need for further intervention. Frequently, medical, mental health, and other community providers are involved in assisting in the initial assessment. Interview Protocol - a structured format to ensure that all family members are seen in a planned strategy, that community providers collaborate, and that information gathering is thorough. Juvenile and Family Courts - established in most States to resolve conflict and to otherwise intervene in the lives of families in a manner that promotes the best interest of children. These courts specialize in areas such as child maltreatment, domestic violence, juvenile delinquency, divorce, child custody, and child support. Liaison - the designation of a person within an organization who has responsibility for facilitating communication, collaboration, and coordination between agencies involved in the child protection system. Multidisciplinary Team - established between agencies and professionals within the child protection system to mutually discuss cases of child abuse and neglect and to aid decisions at various stages of the child protection system case process. These terms may also be designated by different names, including child protection teams, interdisciplinary teams, or case consultation teams. Out-of-Home Care - child care, foster care, or residential care provided by persons, organizations, and institutions to children who are placed outside their families, usually under the jurisdiction of juvenile/family court. Parent/Caretaker - person responsible for the care of the child. Parens Patriae Doctrine - originated in feudal England, this doctrine vests in the State a right of guardianship of minors. This concept has gradually evolved into the principle that the community, in addition to the parent, has a strong interest in the care and nurturing of children. Our schools, juvenile courts, and social service agencies all derive their authority from the State's power to ensure the protection and rights of children as a unique class. Primary Prevention - activities geared to a sample of the general population to prevent child abuse and neglect from occurring. Protocol - an interagency agreement between CPS and law enforcement that delineates joint roles and responsibilities and establishes criteria and procedures for working together on cases of child abuse and neglect. Reporting Policies/Procedures - written referral procedures which delineate how to initiate a suspected child maltreatment report and to whom it should be made. These procedures were established by professional agencies with a mandated responsibility to report suspected child abuse and neglect cases. Response Time - a determination made by CPS and law enforcement after receiving a child abuse report regarding the immediacy of the response needed by CPS or law enforcement. Review Hearings - held by the juvenile and family court to review dispositions (usually every 6 months) and to determine the need to maintain placement in out-of-home care and/or court jurisdiction of a child. Risk - the likelihood that a child will be maltreated in the future. xlix Risk Assessment - an assessment and measurement of the likelihood that a child will be maltreated in the future, usually through the use of checklists, matrices, scales, and/or other methods of measurement. Risk Factors - behaviors and conditions present in the child, parent, and/or family, which will likely contribute to child maltreatment occurring in the future. Secondary Prevention - activities targeted to prevent breakdowns and dysfunctions among families who have been identified as at risk for abuse and neglect. Tertiary Prevention - treatment efforts geared to address situations where child maltreatment has already occurred with the goals of preventing child maltreatment from occurring in the future and avoiding the harmful effects of child maltreatment. Treatment - the stage of the child protection case process when specific treatment and services are provided by CPS and other service providers geared toward the reduction of risk of maltreatment. l NOTES 1. E. Lindsay, "Interpersonal Helping Skills," The Georgia Certification Training Program (Atlanta: Child Welfare Institute, 1989). 2. Ibid. 3. Ibid. 4. U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect, Study Findings: Study of National Incidence and Prevalence of Child Abuse and Neglect: 1988 (Washington, DC: Government Printing Office, 1988). 5. U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect, Child Protection: Guidelines for Policy and Program (Washington, DC: Government Printing Office, June 1982), 4. 6. W. Holder and M. Corey, Child Protective Services Risk Management: A Decision Making Handbook (Charlotte, NC: ACTION for Child Protection, 1987), 26. 7. J. Garbarino, "What Have We Learned About Child Maltreatment?" in U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect, ed., Perspectives on Child Maltreatment in the Mid '80s, (OHDS) 84-30338 (Washington, DC: Government Printing Office, 1984), 6-8; and A. P. Goldstein, H. Keller, and D. Erne, Changing the Abusive Parent (Champaign, IL: Research Press, 1985), 14. 8. A. H. Maslow, Motivation and Personality (New York: Harper and Row, 1970). 9. Garbarino, "What Have We Learned About Child Maltreatment?" 6-8. 10. See for example: Goldstein, Keller, and Erne, Changing the Abusive Parent, 16; and W. M. Holder and C. Mohr, Helping in Child Protective Services: A Casework Handbook (Denver: American Humane Association, 1980), 58-63. 11. D. Daro and L. Mitchel, "Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1989 Annual Fifty State Survey." Working Paper Number 808. (Chicago: National Committee for Prevention of Child Abuse, 1990). 12. Ibid. 13. Ibid. 14. National Association of Public Child Welfare Administrators, "Forum Explores Interventions With Substance Abusing Families," Network 6(April 1990):1-10. 15. Goldstein, Keller, and Erne, Changing the Abusive Parent, 17. lii 16. National Center on Child Abuse and Neglect, Child Protection: Guidelines for Policy and Program. 17. Garbarino, "What Have We Learned About Child Maltreatment?" 6-8. 18. R. J. Gelles, "Violence in the Family: A Review of Research in the Seventies," Journal of Marriage and the Family 42(1980):873-885. 19. J. Caffey, "Multiple Fractures in the Long Bones of Infants Suffering From Chronic Subdural Hematoma," American Journal of Roentgenology 56(1946):167; and C. H. Kempe et al., "The Battered Child Syndrome," Journal of the American Medical Association 181(1962):17-24. 20. J. Caffey, "The Whiplash Shaken Infant Syndrome," Pediatrics 54(1974):396. 21. E. Elmer, G. S. Gregg, and P. Ellison, "Late Results of the Failure To Thrive Syndrome," Clinical Pediatrics 8(1969):559-589; and R. S. Kempe, C. Cutler, and J. Dean, "The Infant With Failure To Thrive," in C. H. Kempe and R. E. Helfer, eds., The Battered Child, 3rd ed. (Chicago: University of Chicago Press, 1980), 163-179. 22. Garbarino, "What Have We Learned About Child Maltreatment?" 6-8. 23. P. G. Ney, "Triangles of Abuse: A Model of Maltreatment," Child Abuse and Neglect 12(1988):363-373. 24. L. Eisenberg, "Cross-Cultural and Historical Perspectives on Child Abuse and Neglect," Child Abuse and Neglect 5(1981):229-308. 25. M. Soeffing, "Abused Children Are Exceptional Children," Exceptional Children 42(1975):126-133. 26. P. K. Jaudes and L. S. Diamond, "The Handicapped Child and Child Abuse," Child Abuse and Neglect 9(1985):341-347. 27. B. Justice and R. Justice, The Broken Taboo (New York: Human Sciences Press, 1979), 134. 28. D. Finkelhor, Child Sexual Abuse: New Theory and Research (New York: Free Press, 1984), 24. 29. See for example: National Center on Child Abuse and Neglect, Child Protection: Guidelines for Policy and Program; M. A. Straus, "Family Patterns and Child Abuse in a Nationally Representative American Sample," Child Abuse and Neglect 3(1979):213-225; R. E. Helfer, "The Etiology of Child Abuse," Pediatrics 51(1973):777-779; J. S. Milner and R. L. Wimberly, "Prediction and Explanation of Child Abuse," Journal of Clinical Psychology 36(1980):875-884; and J. M. Giovannoni and A. Billingsley, "Child Neglect Among the Poor: A Study of Parental Adequacy in Families of Three Ethnic Groups," Child Welfare 49(1970):196-204. 30. Garbarino, "What Have We Learned About Child Maltreatment?" 6-8. 31. B. Egeland and D. Brunnquell, "An at Risk Approach to the Study of Child Abuse: Some Preliminary Findings," Journal of the American Academy of Child Psychiatry 18(1979):219-235. 32. J. B. Reid, P. S. Taplin, and R. Lorber, "A Social Interactional Approach to the Treatment of Abusive Families," in R. B. Stuart, ed., Violent Behavior Social Learning Approaches to Proneness, Management and Treatment (New York: Brunner/Mazel, 1981); W. H. Kimball, R. B. Stewart, R. D. Conger, and R. liii L. Burgess, "A Comparison of Family Interaction in Single- Versus Two-Parent Abusive, Neglectful, and Control Families," in T. Field, ed., High Risk Infants and Children (New York: Academic Press, 1980). 33. R. Starr, "Clinical Judgement of Abuse-Proneness Based on Parent-Child Interactions," Child Abuse and Neglect 11(1987):87-92. 34. Goldstein, Keller, and Erne, Changing the Abusive Parent, 17. 35. R. Hunter et al., "Antecedents of Child Abuse and Neglect in Premature Infants: A Prospective Study in a Newborn Intensive Care Unit," Pediatrics 6(1978):629-635. 36. Garbarino, "What Have We Learned About Child Maltreatment?" 6-8. 37. Ibid. 38. Goldstein, Keller, and Erne, Changing the Abusive Parent, 19. 39. E. A. W. Seagul, "Social Support and Child Maltreatment: A Review of the Evidence," Child Abuse and Neglect 11(1987):41-52. 40. Ibid. 41. Goldstein, Keller, and Erne, Changing the Abusive Parent, 11. 42. See for example: H. P. Martin et al., "The Development of Abused Children," Advances in Pediatrics 21(1974):25-73; and A. H. Green, K. Voeller, R. W. Gaines, and J. Kubie, "Neurological Impairment in Maltreated Children," Child Abuse and Neglect 5(1981):129-134. 43. See for example: A. S. Appelbaum, "Developmental Retardation in Infants as a Concomitant of Child Abuse," Journal of Abnormal Child Psychology 5(1977):417-423; W. N. Friedrich, A. J. Einbender, and W. J. Luecke, "Cognitive and Behavioral Characteristics of Physically Abused Children," Journal of Consulting and Clinical Psychology 51(1983):313-314; and M. J. Fitch et al., "Cognitive Development of Abused and Failure To Thrive Children," Journal of Pediatric Psychology 1(1976):32-37. 44. E. Elmer, "Effects of Early Neglect and Abuse on Latency Age Children," Journal of Pediatric Psychology 3(1978):14-19; and R. H. Starr, "A Research Based Approach to the Prediction of Child Abuse," in R. H. Starr, ed., Child Abuse Prediction: Policy Implications (Cambridge, MA: Ballinger, 1982). 45. Goldstein, Keller, and Erne, Changing the Abusive Parent, 140. 46. H. P. Martin and P. Beezley, "Personality of Abused Children," in H. P. Martin, ed., The Abused Child: A Multidisciplinary Approach to Developmental Issues and Treatment (Cambridge, MA: Ballinger, 1976), 105-111. 47. H. P. Martin and P. Beezley, "Behavioral Observations of Abused Children," Developmental Medicine and Clinical Neurology 19(1977):373-387; and D. F. Kline, "Educational and Psychological Problems of Abused Children," International Journal of Child Abuse and Neglect 1(1977):301-307. 48. A. H. Green, "Self Destructive Behavior in Battered Children," American Journal of Child Psychiatry 135(1978):579-582. liv 49. E. D. Farber and J. A. Joseph, "The Maltreated Adolescent: Patterns of Physical Abuse," Child Abuse and Neglect 9(1985):201-206. 50. J. McCord, "A Forty Year Perspective on Effects of Child Abuse and Neglect," Child Abuse and Neglect 7(1983):265-270. 51. L. Coleman, S. Simonds, M. Frank et al., The Adolescent Stabilization Project: Final Report (Portland, ME: University of Southern Maine, Human Services Development Institute, 1984). 52. D. F. Kline, Long Term Impact of Child Maltreatment (Abuse, Neglect and Sexual Abuse) on the Victims as Determined by Contact With the Utah Juvenile Court and the Utah Department of Adult Corrections: Final Report (Logan, UT: Utah State University, Developmental Center for Handicapped Persons, August 31, 1987), 77. 53. A. Browne and D. Finklehor, "The Impact of Child Sexual Abuse: A Review of the Research," Psychological Bulletin 99(1986):66-67; and Annual Progress in Child Psychiatry and Child Development 1987 (New York: Brunner/Mazel, 1988). 54. Ibid. 55. J. R. Conte and L. Berliner, "The Impact of Sexual Abuse on Children: Empirical Findings," in L. E. A. Walker, ed., Handbook on Sexual Abuse of Children: Assessment and Treatment Issues (New York: Springer, 1988), 72-93. 56. H. Davidson, "The Statutory and Legal Framework of Child Welfare Services," in The Child Welfare Inservice Training Curriculum (Washington, DC: Creative Associates, 1981). 57. U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect, Study Findings: Study of National Incidence and Prevalence of Child Abuse and Neglect: 1988, 23. 58. D. DePanfilis and E. Oleson, Report to Delaware Task Force on Institutional Abuse (Charlotte, NC: ACTION for Child Protection, 1986). 59. J. S. Musick and B. Weissbourd, Guidelines for Establishing Family Resource Programs (Chicago: National Committee for Prevention of Child Abuse, 1988). 60. See for example: J. Gray, C. Cutter, J. Dean, and C. Kempe. "Prediction and Prevention of Child Abuse and Neglect," Child Abuse and Neglect 1(1980):45-58; and D. Olds, C. Henderson, R. Chamberlin, and R. Tatelbaum, "Preventing Child Abuse and Neglect: A Randomized Trial of Nurse Home Visitation," Pediatrics 78(1986):65-78. 61. D. Finkelhor, "Prevention: A Review of Programs and Research," in D. Finkelhor, ed., Sourcebook on Child Sexual Abuse (Beverly Hills, CA: Sage Publications, 1986). 62. H. Dubowitz, "Prevention of Child Maltreatment: What Is Known," Pediatrics 83(April 1989):570-577. 63. M. Meyers and J. Bernier, Preventing Child Abuse: A Resource for Policymakers and Advocates (Boston: Massachusetts Committee for Children and Youth, November 1987). 64. H. Dubowitz, "Prevention of Child Maltreatment: What Is Known," 570. lv 65. M. Meyers and J. Bernier, Preventing Child Abuse: A Resource for Policymakers and Advocates, 56. 66. Adapted from M. Meyers and J. Bernier, Preventing Child Abuse: A Resource for Policymakers and Advocates. 67. Ibid. 68. Ibid. 69. Ibid. 70. Ibid. lvi SELECTED BIBLIOGRAPHY GENERAL OVERVIEWS OF CHILD MALTREATMENT Bavolek, S. J. A Handbook for Understanding Child Abuse and Neglect. 2d ed. Eau Claire, WI: Family Development Resources, 1985. Besharov, D. J. Recognizing Child Abuse: A Guide for the Concerned. New York: Free Press, 1990. Clark, R. E., and Clark, J. The Encyclopedia of Child Abuse. New York: Facts on File, Inc., 1989. Finkelkor, D. A Sourcebook on Child Sexual Abuse. Newbury Park, CA: Sage Publications, 1987. Garbarino, J.; Guttmann, E.; and Seeley, J. W. The Psychologically Battered Child. San Francisco: Jossey-Bass, 1987. Gelles, R. J., and Lancaster, J. B. Child Abuse and Neglect: Biosocial Dimensions. New York: Aldine de Gruyter, 1987. Goldstein, J.; Freud, A.; Solnit, A. J.; and Goldstein, S. In the Best Interests of the Child. New York: Free Press, 1986. Helfer, R. E., and Kempe, R. S. The Battered Child. 4th ed. Chicago: University of Chicago Press, 1987. Russell, D. E. H. The Secret Trauma: Incest in the Lives of Girls and Women. New York: Basic Books, 1986. U.S. Department of Health and Human Services. National Center on Child Abuse and Neglect. Perspectives on Child Maltreatment in the Mid '80s. (OHDS)84-30338. Washington, DC: Government Printing Office, 1984. U.S. Department of Health and Human Services. National Center on Child Abuse and Neglect. Study Findings: Study of National Incidence and Prevalence of Child Abuse and Neglect: 1988. Washington, DC: Government Printing Office, 1988. Walker, L. E. A., ed. Handbook on Sexual Abuse of Children: Assessment and Treatment Issues. New York: Springer, 1988. CAUSES OF CHILD MALTREATMENT Baily, W., and Baily, T. "Etiology of Neglect." In Social Work Treatment With Abused and Neglected Children, edited by C. M. Mouzakitis and R. Varghese. Springfield, IL: Charles C Thomas, 1985. Browne, D. H. "The Role of Stress in the Commission of Subsequent Acts of Child Abuse and Neglect." Journal of Family Violence 1(1986):289-297. lviii Garbarino, J., and Ebata, A. "The Significance of Ethnic and Cultural Differences in Child Maltreatment." In Violence in the Black Family: Correlates and Consequences, edited by R. L. Hampton. Lexington, MA: D. C. Heath, 1987. Garbarino, J.; Schellenbach, C. J.; and Sebes, J. M. Troubled Youth, Troubled Families: Understanding Families At-Risk for Adolescent Maltreatment. Hawthorne, NY: Aldine de Gruyter, 1986. Schene, P. "Economic Correlates of Neglect." In Multidisciplinary Advocacy for Mistreated Children, edited by D. C. Bross. Denver: National Association of Counsel for Children, 1984. Smith, S. L. "Significant Research Findings in the Etiology of Child Abuse." Social Casework 65(June 1984):337-346. Young, G., and Gately, T. "Neighborhood Impoverishment and Child Maltreatment: An Analysis From the Ecological Perspective." Journal of Family Issues 9(June 1988):240-254. EFFECTS OF CHILD MALTREATMENT Browne, A., and Finkelhor, D. "Impact of Child Sexual Abuse: A Review of the Research." In Annual Progress in Child Psychiatry and Child Development 1987, edited by S. Chess; A. Thomas; and M. Hertzig. New York: Brunner/Mazel, 1988. Bryer, J. B.; Nelson, B. A.; Miller, J. B.; and Krol, P. A. "Childhood Sexual and Physical Abuse as Factors in Adult Psychiatric Illness." American Journal of Psychiatry 144(November 1987):1426-1430. Conte, J. R., and Berliner, L. "The Impact of Sexual Abuse on Children: Empirical Findings." In Handbook on Sexual Abuse of Children: Assessment and Treatment Issues, edited by L. E. A. Walker. New York: Springer, 1988. Farmer, S. Adult Children of Abusive Parents. A Healing Program for Those Who Have Been Physically, Sexually, or Emotionally Abused. Los Angeles: Lowell House, 1989. Kashani, J. H.; Shekim, W. O.; Burk, J. P.; and Beck, N. C. "Abuse as a Predictor of Psychopathology in Children and Adolescents." Journal of Clinical Child Psychology 16(1987):43-50. Kelley, S. J. "Learned Helplessness in the Sexually Abused Child." Issues in Comprehensive Pediatric Nursing 9(1987):193-207. McCord, J. "A Forty Year Perspective on Effects of Child Abuse and Neglect." Child Abuse and Neglect 7(1983):265-270. Summit, R. C. "The Child Sexual Abuse Accommodation Syndrome." Child Abuse and Neglect 7(1983):177-193. Wyatt, G. E., and Powell, G. J., eds. Lasting Effects of Child Sexual Abuse. Sage Focus Editions, vol. 100. Newbury Park, CA: Sage Publications, 1988. lix THE CHILD PROTECTION SYSTEM Anderson, P. G. "The Origin, Emergence, and Professional Recognition of Child Protection." Social Service Review 63(June 1989):222-244. Besharov, D. J. Child Abuse and Neglect Reporting and Investigation: Policy Guidelines for Decision Making. Chicago: American Bar Association, 1988. California Department of the Youth Authority and the California Association of Services for Children. Assuring a Safe Environment in Residential Facilities for Children and Youth. Sacramento: California Department of the Youth Authority, November 1987. Caulfield, B. A., and Horowitz, R. M. Child Abuse and the Law: A Legal Primer for Social Workers. 2nd ed. Chicago: National Committee for Prevention of Child Abuse, 1987. Child Welfare League of America. Standards for Services for Abused or Neglected Children and Their Families. Washington, DC: Child Welfare League of America, 1989. DeFrancis, V. The Fundamentals of Child Protection: A Statement of Basic Concepts and Principles. Denver: American Humane Association, 1988. Filip, J.; Schene, P.; and McDaniel, N., eds. Helping in Child Protective Services: A Casework Handbook. Englewood, CO: American Humane Association, forthcoming January 1991. Freeman, L., ed. Managing Risks While Protecting Children. Denver: National Association of Counsel for Children, 1986. Holder, W., and Corey, M. Child Protective Services Risk Management: A Decision Making Handbook. Charlotte, NC: ACTION for Child Protection, 1987. Martin, H. P., ed. Helping the Battered Child and His Family. Philadelphia: J. B. Lippincott, 1972. Nunno, M. A., and Motz, J. "The Development of an Effective Response to the Abuse of Children in Out-of-Home Care." Child Abuse and Neglect 12(1988):512-528. U.S. Department of Health and Human Services. National Center on Child Abuse and Neglect. Child Protection: Guidelines for Policy and Program. Washington, DC: Government Printing Office, 1982. Wells, S. J. How We Make Decisions in Child Protective Services Intake and Investigation. Washington, DC: American Bar Association, 1985. ROLES AND RESPONSIBILITIES OF COMMUNITY PROFESSIONALS Bentovim, A. "Physical and Sexual Abuse of Children? The Role of the Family Therapist." Journal of Family Therapy 9(November 1987):383-388. Besharov, D. J. Combating Child Abuse. Guidelines for Cooperation Between Law Enforcement and Child Protective Services. Washington, DC: AEI Press, 1990. Bross, D. C., and Michaels, L. F. Foundations of Child Advocacy: Legal Representation of the Maltreated Child. Longmont, CO: Bookmakers Guild, 1987. lx Dziech, B. W., and Schudson, C. B. On Trial: America's Courts and Their Treatment of Sexually Abused Children. Boston: Beacon Press, 1989. Erickson, E. L.; McEvoy, A. W.; and Colucci, N. D. Child Abuse and Neglect: A Guidebook for Educators and Community Leaders. 2d ed. Holmes Beach, FL: Learning Publications, 1984. Horowitz, R. M., and Davidson, H. A., eds. Legal Rights of Children. Family Law Series. Colorado Springs, CO: Shepard's/McGraw-Hill, 1984. Maney, A., and Wells, S. Professional Responsibilities in Protecting Children: A Public Health Approach to Child Sexual Abuse. New York: Praeger, 1988. McKinnon, I. "The Nurse and the Police: Dealing With Abused Children." In Nursing Care of Victims of Family Violence, edited by J. Campbell and J. Humphreys. Reston, VA: Reston Publishing, 1984. Michaels, L. F., comp. Using the Law To Protect Children. Denver: National Association of Counsel for Children, 1989. Mouzakitis, C. M., and Varghese, R., eds. Social Work Treatment With Abused and Neglected Children. Springfield, IL: Charles C Thomas, 1985. Nelson, M., and Clerk, K., eds. The Educator's Guide To Preventing Child Sexual Abuse. Santa Cruz, CA: Network Publications, 1986. Nightingale, N. N., and Walker, E. F. "Identification and Reporting of Child Maltreatment by Head Start Personnel: Attitudes and Experiences." Child Abuse and Neglect 10(1986):191-199. Rindfleisch, N., and Bean, G. J., Jr. "Willingness To Report Abuse and Neglect in Residential Facilities." Child Abuse and Neglect 12(1988):509-520. Schetky, D. H., and Green, A. H. Child Sexual Abuse: A Handbook for Health Care and Legal Professionals. New York: Brunner/Mazel, 1988. Vivian, V. L. Child Abuse and Neglect: A Medical Community Response. Association, 1985. Chicago: American Medical COMMUNITY COORDINATION Eastern Kentucky University. Training Resource Center Project. Professionals Together: Intervening With Neglectful Families. Kentucky Department for Social Services, Frankfort, KY, n.d. Mouzakitis, C. M., and Goldstein, S. C. "A Multidisciplinary Approach To Treating Child Neglect." Social Casework 66(April 1985):218-224. Ronnau, J., and Poertner, J. "Building Consensus Among Child Protection Professionals." Social Casework 70(September 1989):428-435. Smith, B. E.; Bulkley, J.; and Jackson, J. A. Improving the Coordinated Response of Agencies to Child Abuse in Out-of-Home Care Settings. Chicago: American Bar Association, November 1988. lxi Tzeng, O. C. S., and Jacobsen, J. J. Sourcebook for Child Abuse and Neglect: Intervention, Treatment, and Prevention Through Crisis Programs. Springfield, IL: Charles C Thomas, 1988. Wycoff, M. A., and Kealoha, M. Creating the Multidisciplinary Response to Child Sex Abuse: Implementation Guide. Washington, DC: Police Foundation, 1987. AUDIOVISUALS AND PUBLIC AWARENESS MATERIALS For information on audiovisuals or public awareness materials on these topics, please contact: National Clearinghouse on Child Abuse and Neglect Information 330 C St., SW Washington, DC 20447 (800) FYI-3366 (703) 385-7565 lxii An OTHER RESOURCES ACTION for Child Protection 4724 Park Road Unit C Charlotte, NC 28203 (704) 529-1080 Child Welfare League of America 440 First Street, NW Suite 310 Washington, DC 20001 (202) 638-2952 American Academy of Pediatrics 141 Northwest Point Boulevard P.O. Box 927 Elk Grove Village, IL 60009-0927 (800) 433-9016 Childhelp USA 6463 Independence Avenue Woodland Hills, CA 91367 Hotline: (800) 4-A-CHILD or (800) 422-4453 American Bar Association Center on Children and the Law 1800 M Street, NW Suite 200 Washington, DC 20036 (202) 331-2250 Clearinghouse on Child Abuse and Neglect Information P.O. Box 1182 Washington, DC 20013 (703) 385-7565 C. Henry Kempe Center for Prevention and Treatment of Child Abuse and Neglect 1205 Oneida Street Denver, CO 80220 (303) 321-3963 American Humane Association American Association for Protecting Children 63 Inverness Drive East Englewood, CO 80122-5117 (303) 792-9900 (800) 227-5242 Military Family Resource Center (MFRC) Ballston Centre Tower Three Ninth Floor 4015 Wilson Boulevard Arlington, VA 22203 (703) 385-7567 American Medical Association Health and Human Behavior Department 535 North Dearborn Chicago, IL 60610 (312) 645-5066 National Association of Counsel for Children 1205 Oneida Street Denver, CO 80220 (303) 321-3963 American Public Welfare Association 810 First Street, NE Suite 500 Washington, DC 20002 (202) 682-0100 lxiv National Association of Social Workers 7981 Eastern Avenue Silver Spring, MD 20910 (301) 565-0333 National Council on Child Abuse and Family Violence 1050 Connecticut Avenue, NW Suite 300 Washington, DC 20036 (800) 222-2000 National Center on Child Abuse and Neglect (NCCAN) Administration on Children, Youth and Families Administration for Children and Families Department of Health and Human Services P.O. Box 1182 Washington, DC 20013 National Criminal Justice Reference Service (NCJRS) P.O. Box 6000 Rockville, MD 20850 (301) 251-5000 (800) 851-3420 National Center for Missing and Exploited Children 2101 Wilson Boulevard Suite 550 Arlington, VA 22201 (703) 235-3900 (800) 843-5678 National Education Association (NEA) Human and Civil Rights Unit 1201 16th Street, NW Room 714 Washington, DC 20036 (202) 822-7711 National Center for the Prosecution of Child Abuse 1033 North Fairfax Street Suite 200 Alexandria, VA 22314 (703) 739-0321 National Network of Runaway and Youth Services 1400 J Street, NW Suite 330 Washington, DC 20005 (202) 682-4114 National Committee for Prevention of Child Abuse 332 South Michigan Avenue Suite 1600 Chicago, IL 60604 (312) 663-3520 Parents Anonymous 6733 South Sepulveda Boulevard Suite 270 Los Angeles, CA 90045 (800) 421-0353 (toll-free) (213) 410-9732 (business phone) National Council of Juvenile and Family Court Judges P.O. Box 8970 Reno, NV 89507 (702) 784-6012 Parents United/Daughters and Sons United/ Adults Molested as Children United 232 East Gish Road San Jose, CA 95112 (408) 453-7616 lxv