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Preventing Child Abuse and Improving Responses to Families in Crisis

Wednesday, November 05, 2009

Testimony Subcommittee on Healthy Families & Communities Committee on Education & Labor United States House of Representatives

Rodney Hammond, Ph.D.
Director
Division of Violence Prevention National Center for Injury Prevention & Control
Centers for Disease Control & Prevention U.S. Department of Health and Human Services

Good morning Chairwoman McCarthy, Ranking Member Platts and distinguished Members of the Subcommittee.  My name is Dr. Rodney Hammond, and I am the Director of the Division of Violence Prevention, a Division of the National Center for Injury Prevention & Control (NCIPC) within the Centers for Disease Control & Prevention (CDC).  Thank you for the opportunity to appear before you on behalf of CDC to discuss our Agency′s research and prevention activities addressing child maltreatment.  At CDC, we work to ensure that all people achieve their optimal lifespan with the best possible quality of health at every stage of life. 

Regardless of gender, race or economic status, injuries are a leading cause of death for young Americans.  Violence is a particularly serious threat to the health and well–being of children and adolescents in the United States.  Furthermore, violence such as child maltreatment is preventable.  CDC is leading the nation′s efforts in reducing premature death, disability, human suffering and the medical costs associated with violence.  Working with state and local governments, nonprofit organizations, academic institutions, private entities, other federal agencies and international organizations, CDC continues to document the rates of violence including identifying the risk and protective factors for child maltreatment, finding effective prevention strategies, and promoting widespread adoption of these solutions.  We strongly believe that every child deserves to live his or her life to their fullest potential.  Preventing child maltreatment is one major step toward that end.

I will begin my testimony today by giving an overview of child maltreatment and explaining CDC′s unique public health role in its prevention.  I will share updates on promising interventions and gaps within the field, and I will close by highlighting that the widespread adoption of proven interventions is an effective solution to preventing a majority of childhood injuries and deaths from maltreatment.

Child Maltreatment:  Definition

“Child abuse” is deliberate and intentional words or overt actions that cause harm, potential harm, or threat of harm to a child.  “Child neglect” is the failure to provide for a child's basic physical, emotional, or educational needs or to protect a child from harm or potential harm.   CDC defines child maltreatment as any act or series of acts of commission or omission by a parent or caregiver that results in harm, potential harm, or threat of harm to a child.  Much of the child maltreatment field divides acts of commission into three broad categories – physical, sexual, or emotional abuse.  Acts of omission are often referred to as child neglect and divided into two categories – failure to provide for a child′s basic needs and failure to protect a child.  Thus the term “child maltreatment” as used in this testimony applies to a broad range of harmful activities including “child abuse” and “neglect”.    


The Burden of Child Maltreatment in the U.S.

The magnitude of child maltreatment in the United States is not easily determined, but it is clearly substantial.  In 2007, an estimated 1,760 children younger than 18 years old died as a result of maltreatment and approxi­mately 794,000 children were determined by state and local child protective services agencies to be victims of child abuse or neglect. It is likely that the actual number of children who experience maltreatment each year is even larger, because many cases go unreported or undetected.  Survey data provide a more troublesome picture of the problem of child maltreatment.  Estimates based on a 2008 national survey of children aged 2–17 years indicate that approximately one in ten children reported having experienced maltreatment and one in sixteen were victimized sexually.  Child maltreatment through blunt trauma to the head or violent shaking (also known as abusive head trauma or shaken baby syndrome) is the leading cause of head injury among infants and young children.  Additionally, homicide was the fourth leading cause of death for children ages 1–9 years in 2006.

In addition to injuries and related health issues during childhood, child maltreatment can increase the risk factors for many of the leading causes of death among adults.  CDC research shows that children who experience maltreatment are at an increased risk for a variety of health problems, including heart disease, cancer, chronic lung disease, liver disease, alcoholism, drug abuse, and depression.  In addition, child maltreatment is closely linked with other forms of violence in adulthood such as intimate partner violence.  Furthermore, studies have also shown that witnessing or experiencing abuse as a child can increase the risk factors for becoming a victim or perpetrator of violence. Addressing violence issues at an early stage would aid in assuring optimal prevention and wellness for individuals throughout their lifespan.

CDC′s Role in Child Maltreatment Prevention:  Promoting Safe, Stable, Nurturing Relationships

CDC′s child maltreatment prevention program aims to prevent maltreatment and its consequences through data monitoring to understand the problem and its trends over time, research and development, capacity building to ensure organizations and entities are equipped to engage in prevention efforts, communication, and leadership. CDC′s public health approach emphasizes rigorous science and complements other approaches such as those of the child welfare system, criminal justice and mental health systems. CDC achieves these primarily through data monitoring and sharing; research on possible interventions; community implementation and evaluation of interventions; and widespread adoption of proven interventions.  This multi–pronged effort adds to the knowledge base regarding violence and how to prevent it.  The long–term goal of CDC′s work in child maltreatment prevention is to achieve lasting change in the factors and conditions that place children at risk through making changes at individual, family, community, and societal levels to reduce rates of child maltreatment.

Within this field, there is a great need for primary prevention strategies that stop abuse and neglect before it occurs. Developing effective prevention programs is essential.  CDC in consultation with national experts has identified safe, stable, and nurturing relationships (SSNRs) between caregivers and children as the foundation of a unified strategic approach and message to empower parents and caregivers and to reduce child maltreatment. This approach is aimed at motivating change in parenting behavior and increasing parents′ skills and knowledge to lower incidents of child maltreatment.  SSNRs strengthen parenting practices that prevent child maltreatment by focusing on positive caregiving behaviors.  Accordingly, promotion of SSNRs can have synergistic effects on health problems as well as contribute to development of skills that enhance acquisition of healthy habits and lifestyles throughout the lifespan.  It should also be noted that SSNRs are not only about the direct relationship parents have with their child but also the environment and context within which they parent (e.g., community support such as accessible childcare).  Rather SSNRs becomes a comprehensive approach that focuses on making changes at the individual, family, community, and societal levels to reduce rates of violence in populations.

Promising Interventions

CDC recognizes a number of promising and effective strategies for the prevention of child maltreatment.  There is substantial evidence that promoting SSNRs can be effective in reducing child maltreatment.   The most basic approach to facilitating SSNRs is teaching parents positive child rearing and management skills and strategies that are safe and nurturing.  There is substantial evidence that parent training programs or behavioral family interventions delivered in clinical settings and focused on influencing children′s behavior through positive reinforcement are effective at influencing the child rearing practices of families.

In fact, a new CDC–funded study shows that when parents have access to proven parenting interventions designed to address problems with child behavior (e.g., tantrums), key measures of child maltreatment fall.  For example, Triple P, the Positive Parenting Program, uses a multi–level strategy focusing on parenting and family support that aims to prevent behavioral, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of parents. Triple P incorporates a wide range of support mechanisms for parents including local media, brief public seminars, and parent consultation by specially trained providers in clinics, schools, churches, and community centers.  Research results showed that implementing Triple P in an area containing 100,000 children could translate annually into 688 fewer cases of child maltreatment, 240 fewer out–of–home placements, and 60 fewer children with injuries requiring hospitalization or emergency room treatment.

In addition, early childhood home visitation programs show strong evidence of effectiveness in reducing violence against visited children.  These programs are designed to decrease the likelihood of child maltreatment by providing parents with guidance for and examples of caring and constructive interaction with their young children. This approach facilitates the development of parental life skills, strengthens social support for parents, and links families with social services.  Nurse–Family Partnership, or NFP, is one example of an evidence–based early childhood home visitation program that was developed based on evidence from randomized, controlled trials.  NFP focuses on first–time mothers during pregnancy and works to promote and teach positive health and development behaviors between a mother and her baby.  Additionally, NFP is delivered by registered nurses over a period of time (typically from the mother′s first trimester to the child′s second birthday), thereby fostering a bond between nurse and mother.

This early intervention during pregnancy allows for any critical behavioral changes needed to improve the health of the mother and child.  Several randomized controlled trials have found this program to effectively reduce abuse and injury, improve cognitive and socio–emotional outcomes in children and have a very favorable benefit–cost ratio.  An evaluation of NFP documented a 48 percent decline in rates of child abuse and neglect at the time of a 15–year follow–up study.  Furthermore, studies found reduced rates of crime and antisocial behavior among both children and mothers.

Recognizing the significant benefits of home visiting programs such as the NFP, the President has proposed in his 2010 budget, a home visiting program designed to support the establishment and expansion of evidence–based programs in states and territories.  The President′s proposal gives priority to models that have been rigorously evaluated and shown to have positive effects on critical outcomes, such as the reduction in child abuse and neglect.  This new home visitation program will create long–term positive impacts for children and their families as well as positive impacts for society as a whole.

Areas for Improvement in the field of Child Maltreatment Prevention

Although there are promising interventions within the field of child maltreatment prevention, there are still some areas for improvement.

Improved Monitoring

Routinely collected data for monitoring the rates of fatal and non–fatal child maltreatment are limited.  Simply put, better data on child maltreatment will strengthen the ability to measure the true costs of maltreatment; target crucial programs and policies to populations or areas most in need to determine if progress is made; and help make the best use of limited resources.  Improved ability and capacity to monitor nonfatal and fatal child maltreatment at the national and state levels, will inform efforts to operationalize, measure, and monitor the implementation of SSNR activities.  CDC is working to address this gap by funding the development and implementation of the National Violent Death Reporting System, which monitors fatal child maltreatment across 18 states. 

Development and Evaluation of New Approaches to Prevention

Caregiving behaviors occur in many different contexts and develop with time.  Understanding the development of caregiving behaviors and how the contexts in which they occur influence child development is key to understanding which interventions and policies promote SSNRs and reduce child maltreatment. To gain a full understanding of the ideal times and settings for intervention strategies, research is needed that examines how SSNRs and negative caregiving behaviors, including child maltreatment, develop.  Understanding the development of different forms of child maltreatment perpetration (i.e., physical abuse, neglect, and sexual abuse) is critical because the different forms of child maltreatment might have varying causes and thus require different intervention strategies and timing.  Moreover, although many parenting programs have been evaluated, evaluation research is beneficial to determine if such approaches are effective for the prevention of child maltreatment and for the promotion of SSNRs, paying special attention to whether these approaches are effective in different settings and with different populations. 

Building Community Capacity

The concept of a public health approach to child maltreatment prevention is still relatively new, and capacity to address prevention in community settings is not yet robust.  Building community receptivity and capacity for preventing child maltreatment facilitates the implementation of evidence–based prevention strategies.  Ensuring community participation requires clarification of barriers to cooperation and outlining key actions to foster a multidisciplinary, collaborative approach to child maltreatment prevention and the promotion of SSNRs.  Working with experts within the field of child maltreatment, CDC is developing evidence–based strategies needed to help communities and their leaders understand the magnitude of the problem and the long–term benefits of investments in primary prevention, including tools that can be used to apply public health approaches to child maltreatment and the promotion of SSNRs.  For example, some tools that CDC is reviewing include strategy guidance products that help community planners and practitioners select the appropriate type and mix of SSNR promotion strategies in their community. 

Conclusion

As you have heard, there is a strong and growing scientific basis for the primary prevention of child maltreatment.  In looking toward the future, preventing such adverse exposures as maltreatment by ensuring that all children are protected and raised in a safe, stable, and nurturing environment is strategic for achieving measurable and lasting impacts on health throughout life.  It is critical to develop the evidence for interventions that work and then get these interventions into the hands of parents and caregivers who can use them effectively to prevent child maltreatment.  CDC is working to improve the gap between research and practice and between discovery and delivery and to continue progress in preventing and controlling violence.  To save lives, parents, caregivers, and providers need support for adopting and maintaining interventions over time. Violence is preventable, and thus should not happen.

I would like to use this opportunity to thank the Subcommittee for its continued support of CDC and its injury and violence prevention programs.  I would be happy to answer any questions that you many have.  Thank you.

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