Research and Practices in Child Maltreatment Prevention, Volume 2: Societal, Organizational, and International Approaches

By Randell Alexander, MD, PhD

430 pages, 30 images, 50 contributors


STM Learning’s Research and Practices in Child Maltreatment Prevention, Volume 2: Societal, Organizational, and International Approaches provides in-depth examinations of prevention models across social spheres. This comprehensive second volume includes chapters on the roles of community, corporate business, government, nonprofits, and research organizations in child abuse prevention.


Written by and for multidisciplinary professionals in medicine, law, social work, and public health, this all-new title is a vital resource for those working to prevent child abuse in all its forms. Readers across fields will benefit from an expansive collection of studies in the most up-to-date best practices in child abuse prevention and child safety.

• Language: English
• Publisher: STM Learning
• Release date: Jan 15, 2017
• ISBN: 9781936590384

Randell Alexander, MD, PhD

Randell Alexander is a professor of pediatrics at the University of Florida and the Morehouse School of Medicine. He currently serves as chief of the Division of Child Protection and Forensic Pediatrics and interim chief of the Division of Developmental Pediatrics at the University of Florida-Jacksonville. He is the statewide medical director of child protections teams for the Department of Health's Children's Medical Services and is part of the International Advisory Board for the National Center on Shaken Baby Syndrome. He has also served as vice chair of the US Advisory Board on Child Abuse and Neglect, on the American Academy of Pediatrics Committee on Child Abuse and Neglect, and the boards of the American Professional Society on the Abuse of Children (APSAC) and Prevent Child Abuse America. He is an active researcher, lectures widely, and testifies frequently in major child abuse cases throughout the country.

Book preview

SECTION I

COMMUNAL AND SOCIETAL PREVENTION

Chapter 1

PREVENTING CHILD MALTREATMENT THROUGH THE POSITIVE COMMUNITY NORMS FRAMEWORK

Jeffrey W. Linkenbach, EdD

J. Bart Klika, MSW, PhD

Jennifer Jones, BSW

Valerie Roche, MFA

While efforts to reduce and prevent child maltreatment have made progress, recent research suggests that more can be done to improve outcomes.¹,² In 2013, over 3 million referrals were placed to Child Protective Services for allegations of abuse and/or neglect, and, through formal investigation, over 679 000 of those children were determined to be victims of child abuse and/or neglect.³ This represents only the cases that come to formal attention and not the many more instances where abuse is never reported. Despite increased federal funding through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program for state-level expansion of evidence-based home visiting services (a touted strategy for child abuse prevention), rates of child abuse and neglect remain unacceptably high.

Recently, the Division of Violence Prevention (DVP) at the Centers for Disease Control and Prevention (CDC) initiated a new approach to addressing the prevention of child maltreatment that is both socio-ecological and positive in nature. The Essentials for Childhood (EfC) framework embraces a public health strategy and is rooted in the notion that all children deserve safe, stable, and nurturing relationships and environments.⁴ As written by the CDC:

Safe, stable, and nurturing relationships (SSNR) between children and their caregivers are the antithesis of maltreatment and other adverse exposures that occur during childhood and compromise health over the lifespan...From a public health perspective, the promotion of SSNRs is, therefore, strategic in that, if done successfully, it can have synergistic effects on a broad range of health problems as well as contribute to the development of skills that will enhance the acquisition of healthy habits and lifestyles.⁵

The focus of the EfC framework is, therefore, less about problem amelioration (eg, preventing child abuse and neglect) and more about cultivating environments that support all children and families.

The EfC framework is not a prescriptive intervention but instead provides a roadmap for how states, counties, and agencies can create the conditions and contexts that promote health and well-being of children and families. Safe, stable, and nurturing relationships and environments can be realized by working on the 4 goals outlined in the EfC framework⁴:

1.Raise awareness and commitment to promote safe, stable, and nurturing relationships and environments and prevent child maltreatment.*

2.Use data to inform actions (ie, use available data, such as emergency room records, child and family service data) to make data-informed programming decisions and to identify key gaps in data collection.

3.Create the context for healthy children and families through norms change and programs by applying the Positive Community Norms framework to understand and promote positive community norms regarding the promotion of safe, stable, and nurturing relationships and environments.

4.Create context for healthy children and families through policy.*

Studies have long demonstrated the need to address complex issues like child maltreatment through multiple strategies across individual, family, community, and societal levels, much like the EfC framework; however, the individual and family-focused frames of child maltreatment are overly entrenched in the public mind.⁶,⁷,⁸ For example, an analysis of roughly 120 news articles collected by Prevent Child Abuse America in 2003 showed that child maltreatment stories are typically framed by a Parental Deficit model, in which irresponsible parents are blamed for everything from crime to poverty to a breakdown in civility.⁷

The framing of social issues impacts public perceptions of problems and, ultimately, their solutions. When negative individual and family frames are used to explain the occurrence of child maltreatment, the solutions are often directed toward fixing parents, often after child abuse and neglect have occurred. In addition, the overreliance on negative individual and family frames of child maltreatment can lead to the unintended consequence of distorting public perceptions of the true scope of the problem and can leave the public feeling helpless and hopeless that positive change can ever occur. These frames shift attention away from positive community norms that exist in all communities in support of child and family health and well-being.

Research on how public health strategies can prevent or change attitudes toward child maltreatment at community and societal levels is scant. This chapter explores a new approach to promoting safe, stable, and nurturing relationships and environments for all children. The Positive Community Norms (PCN) framework can create both change and transformation across the social ecology by uncovering and correcting misperceptions of norms.⁹ The PCN Model, guided by the Science of the Positive,¹⁰ is a process that has successfully promoted cultural transformation around a variety of health and safety issues through a 3-part focus on (1) transformational leadership, (2) normative communications, and (3) a portfolio of strategies. This chapter focuses on how the PCN framework can contribute to preventing child maltreatment by identifying and correcting misperceptions of norms at community and societal levels.

BACKGROUND

More than half a million children are determined to be victims of child maltreatment each year.³ Traditional approaches to child maltreatment are guided by a medical model, wherein interventions are delivered individually after abuse occurs and are focused on amelioration.¹¹ Problem-based models are limited in at least 3 important ways:

1.If child abuse and neglect are viewed as individual or family problems, an opportunity is missed to address the ways that maltreatment is socially embedded. Individuals are part of families nested within communities and larger societies.¹²

2.Focusing interventions on the problem (ie, abuse and neglect) blinds us from seeing the many community protective factors that may facilitate health and well-being for a child and family.

3.Traditional approaches to child abuse and neglect are reactionary in nature (ie, occurring after abuse and neglect). The social, emotional, and financial costs of child abuse and neglect could be avoided if interventions were targeted upstream, before maltreatment occurs.

To stem the tide, approaches to child abuse and neglect must be ecologically grounded, focused on naturally occurring strengths and protective factors across the social ecology, and take effect upstream to ensure that maltreatment does not occur in the first place. Although much has been learned in recent years about the epidemiology of violence against women and children, information on evidence-based approaches in both primary care and community settings for preventing child maltreatment and family violence is seriously lacking.¹³ This is especially true in regard to prevention approaches directed toward impacting norms at the community and societal levels.⁵

SOCIO-ECOLOGICAL APPROACHES: THE RELATIONSHIPS OF SYSTEMS

The quest to prevent child abuse and neglect is rooted in a desire to understand and, ultimately, alter human behavior. Bronfenbrenner¹² argued that in order to understand human behavior, one must first understand how environments shape people and how people, in turn, can shape their environments. The environment, according to Bronfenbrenner, is conceptualized as a set of hierarchical, interconnected systems (Figure 1-1). These systems are open and exchange flows of energy through communication and other means and can be understood and measured through such energy flows across different levels.¹⁴ This flow of energy through intersystemic interaction presents important opportunities for structuring interventions, policies, and resource allocation in the prevention of child abuse and neglect.

Figure1-1

Figure 1-1. PCN Ecological Model.

Although ecological models of behavior have been around for over 50 years, they have only recently begun to have a significant impact on health education practice.¹⁵ Klevens and Whitaker¹⁶ identified 188 primary prevention programs or strategies for child maltreatment, yet few interventions addressed modifiable risk and protective factors across the socio-ecological continuum. Multileveled interventions are typically requisite to bring about widespread population-level changes in health behavior.¹⁷,¹⁸,¹⁹

At the outermost level of the social ecology are the community and societal realms. Through careful examination of societal values, beliefs, norms, and perceptions at this level, shaping policies and interventions to promote positive community norms toward the health and well-being of children and families can begin to be understood.

NORMATIVE INFLUENCE APPROACHES

Social norms refer to the values, beliefs, attitudes, and behaviors of a group of people.²⁰ A community’s normative standards affect parenting and other forms of child protections because they establish context.²¹ Over the past 2 decades, an increasing number of federal agencies involved in prevention work (eg, National Institutes of Health [NIH], National Academies of Sciences, Institute of Medicine, National Highway Traffic Safety Administration, Department of Education) have endorsed normative influence as a class of health intervention to address social issues such as substance abuse, seat belt use, smoking, alcohol abuse, intimate partner violence, energy conservation, and drunk driving.

Social norms research examines the behaviors, values, and beliefs held by members of a community.²⁰ Two types of norms are often examined in this line of inquiry:

1.Actual norms refer to those things that members of a community actually believe, value, and do.

2.Perceived norms, on the other hand, are the beliefs, values, and behaviors that members of a community perceive as being subscribed to by others. Perceived norms are further divided into 2 categories in the literature:

—Descriptive social norms: perceptions of friends’ actual behaviors

—Injunctive social norms: perceptions of friends’ opinions of behaviors²²

Social norms research measures the gap between actual and perceived norms and the influence of this gap on attitude and behavior.²³ The gap between actual and perceived norms often occurs because there is a misperception of a positive community norm. Misperceptions of norms have consistently been shown to be correlated with individual risk behavior.²³-²⁸ A key finding about misperceptions is that they typically operate in 2 directions: the overestimating of risk and the underestimating of protections.²⁹,³⁰ To the extent that people misperceive safety norms, such that dangerous behavior is perceived to be normal and sanctioned, their own behavioral choices will be biased in the direction of assuming greater risk.

Social norms regarding physical discipline may be the most prevalent risk factor for child abuse in the United States.³¹ Although acceptance of physical discipline has been decreasing, around 74% of parents report hitting their children³² and 47% report hitting very young children,³³ despite the growing evidence of increased risk for developmental harm.³¹ There is, as of yet, little available data on how to address community or societal norms around this issue, and few studies document the gaps between perceived and actual norms of child abuse, physical discipline, and the relationship between societal denial and tacit acceptance of abuse.³⁴ If misperceptions of norms about abuse and protection are operating at multiple levels of the child protection system, similar positive outcomes may be realized by correcting misperceptions.

While research about community and societal-level misperceptions regarding child maltreatment is limited, the application of normative approaches at these levels of the social ecology is promising. Studies demonstrate that community and societal-level misperceptions of norms can be corrected to reveal positive changes in attitudes, behaviors, and support for policies.³⁵-⁴³

THE POSITIVE COMMUNITY NORMS APPROACH

The Positive Community Norms (PCN) framework is a new approach to cultivating communities and cultures around health and safety issues that can be applied to the prevention of child maltreatment. PCN is a community, or environmental, transformational approach that engages many different audiences across the social ecology to improve community health and safety.²⁰ PCN is based on the Science of the Positive: the study of how positive factors impact culture and experience.¹⁰ Several theories guide the PCN framework: social ecology, social cognitive theory, theory of reasoned action, normative theories, and transformational learning theory.

Like many community and population-focused approaches, PCN employs methods of health communication, social norms, and social marketing. Data from interventions focusing on reducing misperceptions of health norms demonstrate that messages and images that portray health as a normal and expected behavior result in increased health protections and lowered risk.¹¹ In addition to correcting misperceptions of health norms at the individual level, the PCN framework also aims to shift the cultural and structural environments in which health risk behaviors occur.

Applying the PCN Logic Model (Figure 1-2) to the issue of child maltreatment prevention calls for a 3-pronged approach:

1.Develop leadership skills fostering transformation within communities dedicated to reducing child maltreatment.

2.Communicate positive norms related to child protection and maltreatment and designed to correct misperceptions.

3.Develop an integrated prevention portfolio to reduce child maltreatment, including policy changes, resource allocation, and other systemic changes.

By developing leadership skills among community members, the PCN approach attempts to recognize the positive resources that already exist in communities and to build strength from within, rather than imposing external solutions and blaming victims of a systemic problem. By correcting misperceived social norms through a broad-based communications campaign, PCN attempts to address both hope and concerns (ie, hope found in community-based solutions and concerns related to confronting fear, denial, and tacit acceptance of a health risk) as well as cultural and community myths linked to the chronic underestimation of protective factors. Finally, by actively managing an integrated prevention portfolio, PCN engages communities in more effective resource allocation and working toward policy change, thereby addressing the ecological roots of child maltreatment.

Figure1-2

Figure 1-2. The PCN Logic Model.

Communities can promote positive community norms by engaging in the 7-step process of the PCN framework.⁴⁴,⁴⁵ These steps include:

1.Planning and environmental advocacy

2.Baseline data

3.Message development

4.Communications planning

5.Pilot test and refining materials

6.Implementation

7.Evaluation

The Montana 7 Step Model was developed to promote the context and development of positive norms at the macro-levels of the social ecology, mainly at the community and state levels. The steps, although presented here in a linear manner, are actually overlapping and cyclical in nature, as seen in Figure 1-3.⁴⁴,⁴⁶ This communications cycle begins with engaging and educating key stakeholders and continues into assessing community norms to reveal gaps in knowledge and misperceptions of norms; developing messages designed to establish a common understanding and close perceptual gaps; developing a communications plan based upon prioritizing opportunities and developing a portfolio of strategies; engaging in a continuous process of pilot testing and refining messages; strategically implementing the portfolio of strategies; and evaluating the effectiveness and assessing future needs. A typical cycle usually takes about a year in order to develop the readiness and capacities of the stakeholder team.

Figure1-3

Figure 1-3. The Montana Model of PCN Communications.

APPLYING PCN TO CHILD MALTREATMENT: THE WISCONSIN CASE STUDY

In 2009, the Wisconsin Children’s Trust Fund and Children’s Hospital of Wisconsin embarked on a journey to transform the way they think about and implement child abuse prevention strategies in Wisconsin. At the time, many of the frames regarding child abuse and neglect in Wisconsin and across the United States were focused on negative aspects of child abuse and neglect (eg, consequences) while little attention was paid to extant positive community norms regarding the protection of children. The images that filled popular media were of child death, injury, and prosecution of child abusers (ie, fear-based messages). The goal of the Wisconsin project was to reframe the community conversation about child maltreatment and its prevention. Early on, leaders in Wisconsin realized that if they were to truly transform the health and well-being trajectories for Wisconsin’s children and families they needed to move beyond just reducing risk for child maltreatment at the individual and family level and place a greater emphasis on building safe, stable, and nurturing relationships and environments at the outer levels of the social ecology. The process of communicating positive norms in Wisconsin required a message that balanced both hope and concern. The following is a description of how leaders in Wisconsin engaged in the PCN process to promote safe, stable, and nurturing relationships and environments for all children and families.

Step 1: Planning and Environmental Advocacy

Leaders in Wisconsin focused on 3 strategic areas to begin the transformation process:

1.The Children’s Trust Fund (CTF) of Wisconsin engaged in a year-long strategic planning process to focus and align strategies and community investments to achieve greater impact with families at risk for child abuse and neglect.

2.The CTF and key partners invested in gathering data on the prevalence and impact of childhood adversity among Wisconsin residents through the Adverse Childhood Experiences module in the Wisconsin Behavioral Risk Factor Surveillance System Survey (BRFSS).

3.Leaders implemented the Positive Community Norms framework to help communicate strategically and effectively about child abuse and neglect prevention efforts.

Guided by the Science of the Positive process,¹⁰ leaders in Wisconsin reflected upon the core essence or spirit of their work. After months of deliberation, they decided the purpose of the project was to build a context with system linkages statewide across the social ecology that increase safe, stable, nurturing environments in which children are healthy, thrive and develop free of maltreatment.⁴⁷

In March 2012, Wisconsin held a 2.5-day Positive Community Norms Institute training program with over 40 key partners across the state and several national agency representatives. During the training, participants learned about the value of using a positive frame in messaging about child abuse and neglect prevention, the impact of perceived norms, and the 7 steps of the Positive Community Norms framework.

Step 2: Baseline Data: Assessing Norms and Establishing a Common Understanding

An explicit goal of the project was to understand the actual and perceived norms of Wisconsin citizens so they could identify potential gaps between actual and perceived norms and focus on giving Wisconsinites specific ways to be engaged in not only preventing child maltreatment but in building safe, stable, and nurturing relationships and environments where all children can grow and thrive. Following the PCN Institute, leaders in Wisconsin spent the next year working on developing the Wisconsin Child Abuse and Neglect Prevention Survey to measure actual and perceived norms aligned with the CDC’s Essentials for Childhood Initiative. They designed questions to uncover the values, beliefs, and behaviors that Wisconsin residents have about safe, stable, and nurturing relationships and environments. Theories of social norms and the Integrated Behavior Model (IBM) were used to measure the actual and perceived norms among a random sample of Wisconsin adults.

A total of 697 survey responses were obtained (a 27% response rate). Sample demographics were as follows⁴⁸:

—44% male and 56% female.

—83% were or had been primary caregivers of children.

—39% rural, 25% urban, and 36% suburban.

Some of the key findings of the Wisconsin survey demonstrating positive community norms included⁴⁸:

—81% of participants thought that preventing child abuse and neglect was one of the top 3 priority issues.

—70% of Wisconsinites strongly agreed that protecting children from abuse improves brain development.

—82% strongly agreed that reducing child abuse saves public money in the long-term.

—66% strongly agreed that more financial support for children in poverty should be provided.

—Most agreed with paying more taxes to address child abuse.

—90% believed that more than 10% of families receiving economic support are frauding the system. Forty percent thought that more than 50% of families were frauding the system. Audits conducted by Wisconsin’s Legislative Audit Bureau showed that less than 1% of FoodShare recipients had committed fraud.

Steps 3 and 4: Message Development and Communication Planning

Wisconsin leaders focused on growing positive norms and correcting misperceptions. They felt strongly that they needed to begin the strategic communications campaign with values, because shared values build community trust and spirit, which allow positive context to grow. Findings from the baseline survey were used to guide the messaging process.

Working with a public relations firm that attended the PCN Institute, leaders in Wisconsin developed a creative messaging campaign based on the PCN survey results. One of the main findings guiding this process was that 70% of Wisconsinites strongly agree improving the well-being of children and families is important for healthy and strong communities; yet, 72% did not think most other Wisconsin adults felt the same way.⁴⁸ This gap between the actual norm and the misperception provided the focus and opportunity for the PCN campaign. Based on this finding, the following campaign was created (Figures 1-4-a and 1-4-b).

Step 5: Pilot Testing and Refining

The original message was pilot tested with a group of early care and education providers, as well as with the general public. The messaging was altered slightly based on received feedback.

Step 6: Campaign Implementation

A communications strategy was created that involved a landing page/Web site, social media, print and radio ads, and a Twitter campaign.

Figure1-4-aFigure1-4-b

Figures 1-4-a and b. Wisconsin’s in it for kids: Every Wisconsin child is part of something greater. When even one child is at risk, Wisconsin rises to the challenge. Reprinted with permission from the Wisconsin Child Abuse and Neglect Prevention Board.

PCN in Wisconsin: Summary

Though Wisconsin is still in the process of implementing strategies and evaluating their effectiveness, the impact of this work has already been felt. The PCN focus on hopeful messages related to norms, complemented by the ACES research on concerns, is changing how Wisconsin leaders direct their efforts. Rather than focusing solely on reducing risks, Wisconsin remains committed to a process of cultural transformation by identifying and correcting misperceptions of positive community norms regarding the health and well-being of children and families. The application of PCN in Wisconsin is in a formative stage and will need continued support from state leaders to achieve desired aims of changed attitudes, perceptions, and behaviors related to norms of safety, stability, and nurturing.

CONCLUSION

Interventions to address and ultimately prevent child abuse and neglect must combine normative communication with policy change and leadership transformation in order to create context for societal change. The PCN framework provides a process for cultivating new community cultures that promote safe, stable, and nurturing relationships for children. It is a process that marries the social norms approach with an ecological perspective, building on positive norms existent within communities and addressing the problem broadly, not just on an individual basis.

The PCN framework offers substantial promise in prevention of child maltreatment and the promotion of safe, stable, and nurturing relationships and environments for children. As a continually developing framework, PCN offers to build upon prior theories and models of public health and community development by integrating communications that address both hope and concern within a positive context; however, before PCN can be applied on a broad scale, more opportunities are needed for pilot testing, experimentation, and development of tools and approaches. The PCN approach is being implemented by prevention leaders involved in child well-being in states other than Wisconsin and nationally through Prevent Child Abuse America. PCN leaders aim to transform efforts to reduce child maltreatment by focusing on growing positive norms and by moving beyond the family bubble to engage all levels of the social ecology. These pilot projects are developing baseline surveys to understand and measure existing positive norms, especially around safe, stable, and nurturing relationships and to reveal gaps that provide opportunities for intervention.

Any intervention or model of change that looks at systemic causes of child maltreatment behavior and seeks to grow sources of safe, stable, and nurturing relationships across the social ecology will be more difficult to achieve, will be more long-term in nature, and will require the determination of courageous leaders to accomplish. Cultural transformation, after all, is not for the meek.

At its core, PCN is about supporting a new story in communities—a story in which most citizens acknowledge and engage in their roles in preventing child maltreatment. By providing communities and families with a framework focused on reducing risk factors, growing protective factors, and uniting a broad spectrum of social, political, and legal factors, PCN can improve and expand on what individuals, families, schools, workplaces, and communities are doing well. It is an approach that strives to correct misper-ceptions across the community and grow positive norms at all levels of the social ecology.

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47.Jones JA, Knox B. Wisconsin Child Abuse and Neglect Prevention Board 2011-2013 Biennial Report. Madison, WI: Wisconsin Child Abuse and Neglect Prevention Board; 2013.

48.Jones J. Transforming child maltreatment prevention in Wisconsin: 2014 Montana Summer Institute. https://issuu.com/sotp/docs/transforming_child_maltreatment_pre. Accessed November 18, 2016.

*This aim also includes focusing on collective impact by building collaborative relationships with traditional and nontraditional partners

Chapter 2

THE POWER OF CHILD DEATH REVIEW TO PREVENT MALTREATMENT

Theresa Covington, MPH

Stephen Wirtz, PhD

INTRODUCTION

Child death review (CDR) is a multiagency, community-based process in which a multidisciplinary team of professionals meet to review and document the circumstances surrounding child deaths, including deaths from maltreatment, and take action on their findings.¹-³ In fact, CDR began as a response to the challenges faced in investigating, identifying, and reporting fatal maltreatment.⁴-⁷ The purpose of CDR is multidimensional and includes:

1.Accurately identifying the cause and manner of death

2.Ensuring comprehensive and high-quality death investigations

3.Promoting services to protect other children and support families

4.Promoting criminal justice remedies when appropriate and ensuring justice for victims through the courts

5.Improving agency systems that protect children and/or respond to deaths

6.Most importantly, promoting actions, programs, and policies to prevent future deaths and keep children safe and healthy

In 2010, all but 1 state in the United States had a CDR system in place, 30 were conducting state-level reviews, and 37 had local review teams as well. All of these states review deaths from maltreatment, and most have expanded to review deaths from unintentional injuries (accidents), homicides, suicides, undetermined manner, and even some natural medical causes such as sudden unexpected infant deaths (SUIDs) including SIDS. Twelve states are actually reviewing deaths from all causes. Forty-two states and many local teams also produce annual reports that provide aggregate information on the child deaths they review and the recommendations they generate.

Based on their multiagency memberships, CDR teams are often able to improve the investigation of, and response to, child deaths by facilitating more effective communication and collaboration among agencies, surfacing additional relevant case information, and suggesting and promoting ways to improve the investigative process and the child welfare system response.⁸,⁹ But most importantly, a successful review of a child’s death should always lead directly to the question: What can be done to prevent future deaths? All 49 states report that the prevention of child deaths is the primary purpose of their CDR system. This evolution in the CDR process, from the focus in the early 1990s on the identification of maltreatment deaths to today’s focus on prevention, is laudable. Although it is difficult to attribute casual linkages, there are thousands of examples throughout the United States (and other counties) in which CDR teams have catalyzed local and state actions to prevent injuries and deaths. The potential of teams for promoting systems improvements and prevention has been well recognized; however, there are only a small number of published studies on the quality and usefulness of the information, activities, and recommendations generated by CDR teams.¹⁰-¹⁸ To improve the likelihood of being effective in preventing deaths, CDR teams need to approach the prevention of child fatalities in a systematic way. This chapter provides a framework for using the CDR process as an effective tool for preventing maltreatment deaths.

A SYSTEMATIC APPROACH

Just as CDR teams should approach their case reviews and data reporting systematically (ie, by having organized case presentations, a focus on quality investigations and identification of risk factors, use of a standard data collection form, and written reports on what the aggregate data demonstrates), so should teams approaching prevention. However, teams often struggle to translate their findings into preventive actions and potential measurable outcomes. In a study of the quality of CDR team recommendations, the authors found that teams are doing a better job of ‘assessing the problem’ than in ‘proposing solutions’ as indicated by their written recommendations.¹⁹ There is a growing body of literature that stresses the importance of making this knowledge to action process explicit. Available evidence suggests approaches that use a planned action model to deliberately engineer change are more effective than more haphazard efforts.²⁰

In this chapter, we propose a paradigm based on the public health model that is used to understand and prevent diseases and infections. For example, when a child dies or becomes ill from tainted foods, the source of the contamination and its extent of distribution are methodically traced to reduce its impact on additional victims, and then steps are taken to address the prevention of future outbreaks (eg, product recalls, improved inspections, new regulations, public education, etc). The CDR process can address the prevention of child deaths in the same systematic way:

—Explore how, where, and why specific types of child deaths occur

—Understand why they occurred and who is most at risk

—Identify evidence-based prevention strategies and assess what will work in their own communities based on existing circumstances

—Promote effective prevention policies and interventions through well-prepared and crafted recommendations and collaborations

A set of guidelines based on this paradigm is presented that can be used as a practical tool to help CDR practitioners be more successful in transforming their findings from CDRs into actions to prevent future child injuries and deaths. While these guidelines have only recently begun to be evaluated, they are based on extensive field experience by CDR practitioners and have been endorsed and used widely as a training tool by the National Center for Child Death Review (NCCDR) in its work throughout the United States and international community.²¹ The premise is that the CDR process, when conducted well, can be a strong advocate for prevention of child maltreatment (CM) and a powerful community agent for change.

MAKING A COMMITMENT TO PREVENTION

To make prevention a priority, CDR teams must start with a focus on several structural and functional aspects of the review process that enhance the likelihood that reviews will actually result in effective prevention activities. First and most importantly, teams and their leadership must value and embrace the process of moving from discussions on the circumstances of individual deaths to developing and catalyzing action on prevention strategies. Unfortunately, this process is often taken for granted and not valued as a central function. Thus, it may be left to the last part of a team review and not given sufficient time or thought, resulting in recommendations that are generic, vague, and/or not grounded in best practices or local conditions.

Many state CDR programs and local teams have asked for assistance from the NCCDR in making prevention an important part of their reviews. For example, 1 state realized that in 10 years their reviews had led to no substantive prevention actions. They held a 2-day summit to review their data and make recommendations. As a result of this assessment and a renewed commitment to prevention, they created a new approach to developing recommendations for state actions.

A similar process occurred in Michigan, which has a system of 78 county review panels and a state advisory board. State law required this state board to issue annual recommendations to the Governor of Michigan and Michigan Legislature. For 3 years, the state board issued a comprehensive annual report on child mortality that reviewed team findings and included a set of recommendations. Each year more than 50 recommendations were presented, addressing the investigation, provision of services, and the prevention of the major causes of child deaths. In 2001, the state panel assessed the progress made on implementing their recommendations. The sobering conclusion was that little to no progress had been made—few recommendations were even being addressed by state policymakers.

The state panel asked the newly appointed state director of social services for her leadership in moving the recommendations forward. She agreed, but asked that the State Child Death Review Board ensure that in developing their recommendations they:

—Explicitly state what state agency should be responsible for implementation.

—Share the recommendation(s) with those agencies ahead of publication to identify and address potential barriers to implementation.

—Ensure that all recommendations be based on state and/or local reviews of child deaths.

—Ensure that all recommendations be developed after a study of evidence-based and promising practices, as well as current state initiatives.

The state board recommitted themselves to the recommendations process. The following year, they had 22 recommendations, all of them more specific. Although all of the board’s recommendations have yet to be implemented, there is now more action and accountability within state agencies in addressing all of the recommendations as they are developed and reported out each year. Table 2-1 shows the progress made after the full panel improved their recommendation process.

Second, teams need to consider how the focus on prevention fits into their team structure. For example, teams can bundle the review of similar types of cases (eg, toddler drowning deaths) together so that recommendations can be based on multiple child deaths. Another example is to use a 2-tier process consisting of a technical team that reviews the circumstances surrounding child deaths and a community action team or prevention committee to create recommendations and promote action on them. A national study of the Fetal Infant Mortality Review Programs (over half of which were combined with CDR teams) documented that on average 2-tier systems were more likely to report implementation of recommendations…than those with 1-tier systems (88% versus 56%, p < .001). Two-tier systems also conducted significantly more activities associated with 5 essential maternal child health services.²²

In California, the Sacramento County’s CDR team has had a separate Prevention Committee since the mid-90s. Perhaps its biggest success was its efforts to promote home visitation services. Instead of a broad recommendation about these programs, the team assessed the current resources and political context and promoted the formation of a high-level task force (chaired by a member of the Board of Supervisors, a home visitation champion) to develop a plan for creating and sustaining evidence-based home visitation services. The result was a multimillion-dollar commitment by the Board of Supervisors to establish a Birth and Beyond home visitation program in 8 high-risk neighborhoods. The team documented a significant decline in CM homicides in Sacramento County from 1997 through 1998 to 2003 through 2004. Although funding has diminished and death rates are no longer declining, the program continues today.²³

Third, leadership is essential to ensure that prevention gets the attention it deserves. For example, in the early 1990s the Mobile, Alabama CDR reviewed a cluster of infant abandonment deaths. The Mobile District Attorney, John Tyson, Jr., took the lead on the team and worked to establish the Secret Safe Place for Newborns program, permitting mothers to voluntarily, and with some anonymity, surrender their babies to authorities. This program grew to a statewide effort and eventual law, and now at least 40 other states have implemented Safe Haven laws and programs.

Fourth, even with strong leadership, the team still needs to include the right kind of membership to be effective with prevention. By definition, CDR team members represent many disciplines. Their primary interests may be investigation, medical care, prosecution, service delivery, or case management. Most team members will agree that prevention is important, but it is often not what they as individuals do. For example, the role of the medical examiner on the team is to provide information on the cause and manner of death. Law enforcement may attend to provide investigative information. The prosecutor may see his/her job on the team as that of interpreting the circumstances to determine if criminal activity was involved. Child welfare comes to offer information on the child and other siblings and assess their agency’s role. There are similar outlooks for each additional member. Therefore it is also useful for teams to broaden their membership to include professional disciplines, such as injury prevention and health education, to ensure they have the expertise to know what is already being done locally and what has been shown to work elsewhere.

But prevention efforts will be more effective and have greater long-term impact if the team buys in to the process and collectively determines how to turn the team findings into action to prevent future deaths, rather than simply leaving this task to the prevention experts at the table. Team members who do not traditionally think of themselves in a preventive role have much to contribute to the recommendations, promotion, and design of prevention programs. For example, the law enforcement representative often knows much about what causes and might prevent motor vehicle crashes. The prosecutor has insight into public safety. Child welfare knows the families involved in child abuse and neglect. The medical examiner should know the general history of the teen who commits suicide. These professionals have respect and standing in their community and can often provide insights into their community’s readiness and political will to take specific actions that can increase the likelihood of a prevention initiative’s success. For example, if a prosecutor is the public voice to advocate for the importance of home visitation services for first time parents, the idea might carry greater weight and may lead to quicker action.

Fifth, teams must make a commitment to systematically collect and report information gained from the team reviews. This requires an allocation of resources (often in-kind staff time) from one or more agencies to ensure data are collected and entered into a database and used in later analyses. Although important prevention efforts can move forward without such data (eg, on the strength of a single case or an individual champion), the power of the CDR process for prevention lies in its ability to provide a systematic source of information on the underlying patterns of circumstances (ie, risk and protective factors) surrounding child deaths. The team’s systematic effort to collect more detailed information on the circumstances surrounding child deaths can serve as a quality improvement tool for their participating investigative agencies. For example, not knowing the answer to an important question, such as was there a documented history of poor supervision? during a review of a drowning death, can lead the investigative agencies to seek this information in their next drowning case.

The NCCDR Case Reporting System was developed to provide states and local CDR teams with a Web-based system for capturing, analyzing, and reporting on the full set of information shared at CDRs.²⁴ Thirty-five states are currently enrolled in the system and have entered more than 84 000 reviewed child deaths. This comprehensive system includes over 1700 data elements, including information relevant to determining whether abuse or neglect was a casual or contributing factor in the death. As shown in Figure 2-1, one section of the report form collects comprehensive information on all acts of omission or commission. Both a direct cause and a contributed cause of maltreatment can be checked (eg, direct cause of abuse by shaking a baby and contributing cause of neglect by failure to protect from a known hazard). This section is designed to assist teams to make a determination and record whether CM was involved in the death. Table 2-1 summarizes all of the information on maltreatment a completed case report form can collect.

Sixth, the CDR process must address explicitly the task of identifying and defining CM deaths which is rife with difficulties. First, definitions of CM are social constructions that represent social judgments based in a dynamic historical and societal context. At any given time and place, they reflect a negotiated settlement between a society’s diverse social and political values and cultures and the current state of scientific knowledge. Second, federal and state legal definitions of CM are often very broad and require professional judgments to apply them in practice. At the federal level, child abuse and child neglect is defined, at a minimum, as an act or failure to act on the part of a parent or caregiver which results in death, or presents an imminent risk of serious harm.²⁵ Each state, in turn, has its own definitions based on these federal minimum standards. In addition, as shown in Figure 2-2, each investigative agency is mandated to use their specific legal standards to identify and report CM. For example, District Attorneys are ultimately constrained by the legal beyond a reasonable doubt standard of evidence. Coroners and medical examiners are only required to determine the cause and manner of death (eg, homicide), not who the perpetrator or what their relationship with the victim was (eg, father), thus not resolving the issue of whether to count the death as a CM fatality. In a similar fashion, law enforcement agencies often do not continue to investigate cases thought to be accidental, even if there may be a high degree of neglect involved (eg, unattended toddler left next to an unfenced pool or hot tub). Finally, child welfare has a different standard of evidence for substantiating CM cases (ie, preponderance of evidence), and may not even be notified of a child death if there are no siblings in the home; or if notified, they may not have the resources to respond. Therefore, the definition and classification of CM deaths is often not consistent across states or agencies, which results in inconsistent and likely undercounts of the number of CM deaths reported at state and national levels. Several studies have documented a systematic undercount of CM fatalities in single data sources such as vital records, law enforcement records, and child protective services records.²⁶-²⁸

Figure2-1

Figure 2-1. Acts of omission or commission including child abuse, neglect, and suicide.

Figure2-2

Figure 2-2. Differing Criteria Among Investigative Agencies for Determining Child Abuse and Neglect (CAN) Fatalities.

CDR teams are often in a unique position to integrate these differing perspectives to gain a better overall understanding of child deaths. The multidisciplinary CDR process has demonstrated its power to improve the ascertainment and reporting of CM fatalities, especially neglect-related deaths due to medical and unintentional injury causes, compared to data captured from single sources.²⁹,³⁰ However, in light of the differing state laws, regulations, and protocols among agencies, there are serious challenges for teams to develop and consistently apply standard CM definitions. For example, California’s state CDR program has provided training to local CDRTs on how to create and implement a consistent operational CM definition based on the conceptual framework shown in Figure 2-3 that breaks the definition into its component parts. For CDR purposes, the operational CM definition developed was a death of a child under the age of 18 directly or indirectly caused by a caregiver’s act(s) of commission or omission that are judged by a CDRT as child abuse or neglect, weighing the risk of harm and the level of social acceptability of the act (s). This means that 4 conditions must be met: (1) live child under 18, (2) caregiver agent, (3) causal link between act(s) and child death, and (4) act(s) are judged to be CM. Team decisions should be based on evidence and professional judgments. Legal definitions should serve as the minimum standard, but they need not be used as the only criterion. As demonstrated in a series of well-designed and executed studies undertaken by SUNY researchers in collaboration with the US military services, it takes a very concerted and systematic effort to establish and maintain a process to allow CDRTs to apply CM definitions consistently.³¹-³³

Figure2-3

Figure 2-3. Conceptual Framework for Creating Consistent Child Abuse and Neglect (CAN) Definitions for CDRTs.

DEVELOPING QUALITY RECOMMENDATIONS

CDRTs have a critical role to play in ensuring the knowledge they gain from child death reviews is translated into effective prevention interventions that actually make a difference. Many teams already have a strong track record of successfully taking their findings to action. However, not all teams are successful (and certainly not all the time) at writing quality recommendations that enhance the likelihood of producing meaningful change.³⁴,³⁵ There are many reasons for these difficulties (as highlighted previously), but a CDR team’s ability to develop, write, disseminate, and follow through with effective recommendations is also a critical component for success. To improve the recommendation generation process, NCCDR and participating states have adapted the Guidelines for Writing Effective Recommendations used in California’s initial assessment study and incorporated into the hands-on training programs used throughout California and the United States to help CDRTs write more effective recommendations.³⁶ Table 2-2 summarizes the 3 broad components of the guidelines and the dimensions within each that need to be addressed in an effective recommendation.

PROBLEM ASSESSMENT

There are 3 essential steps that CDR teams need to take in assessing what the problem is and what can be done to prevent maltreatment deaths:

—Understanding the problem and the risk factors contributing to it

—Identifying effective strategies

—Assessing local relevance of the proposed strategies and capacity to implement them

STEP 1: UNDERSTANDING THE PROBLEM

Following a single or cluster of similar case review(s), teams should have a clear