Chapter 2
Detecting, Measuring, and Preventing Child Abuse

INCIDENCE AND PREVALENCE OF CHILD MALTREATMENT

Statistics on child abuse are difficult to interpret and compare because there is little consistency in how information is collected. The definitions of abuse vary from study to study, as do the methods of counting incidents of abuse. Some methods count only reported cases of abuse. Some statistics are based on estimates projected from a small study, whereas others are based on interviews.

Researchers use two terms—incidence and prevalence—to describe the estimates of the number of victims of child abuse and neglect. Andrea J. Sedlak and Diane D. Broadhurst, in the Third National Incidence Study of Child Abuse and Neglect (1993; NIS-3), define incidence as the number of new cases occurring in the population during a given period. The incidence of child maltreatment is measured in terms of incidence rate: the number of children per one thousand children in the U.S. population who are maltreated annually. Surveys based on official reports by child protective services (CPS) agencies and community professionals are a major source of incidence data. (The term "child protective services" refers to the services provided by an agency authorized to act on behalf of a child when his or her parents are unable or unwilling to do so. This term is also often used to refer to the agency itself.)

Prevalence, as defined by NIS-3, refers to the total number of child maltreatment cases in the population at a given time. Some researchers use lifetime prevalence to denote the number of people who have had at least one experience of child maltreatment in their lives. To measure the prevalence of child maltreatment, researchers use self-reported surveys of parents and child victims. Examples of self-reported surveys are the landmark 1975 National Family Violence Survey and the 1985 National Family Violence Resurvey conducted by Murray A. Straus and Richard J. Gelles.

Studies based on official reports depend on a number of things happening before an incident of abuse can be recorded. The victim must be seen by people outside the home, and these people must recognize that the child has been abused. Once they have recognized this fact, they must then decide to report the abuse and find out where to report it. Once CPS receives and screens the report for appropriateness, it can then take action.

In some cases the initial call to CPS is prompted by a problem that must be handled by a different agency. It may be a case of neglect because of poverty rather than abuse, although the initial report is still recorded as abuse.

For the data to become publicly available, CPS must keep records of its cases and then pass them on to a national group that collects those statistics. Consequently, final reported statistics are understated estimates—they are valuable as indicators but not definitive findings. Because of the hidden nature of child abuse, it is unlikely that accurate statistics on it will ever be available.

COLLECTING CHILD MALTREATMENT DATA

The 1974 Child Abuse Prevention and Treatment Act (CAPTA) created the National Center on Child Abuse and Neglect (NCCAN) to coordinate nationwide efforts to protect children from maltreatment. As part of the former U.S. Department of Health, Education, and Welfare, NCCAN commissioned the American Humane Association to collect data from the states.

In 1985 the federal government stopped funding data collection on child maltreatment. In 1986 the National Committee to Prevent Child Abuse (NCPCA; now called Prevent Child Abuse America) picked up where the government left off. The NCPCA started collecting detailed information from the states on the number of children abused, the characteristics of child abuse, the number of child abuse deaths, and the changes in the funding and extent of child welfare services.

In 1988 the Child Abuse Prevention, Adoption, and Family Services Act replaced the 1974 CAPTA. The new law mandated that NCCAN, as part of the U.S. Department of Health and Human Services (HHS), establish a national data collection program on child maltreatment. In 1990 the National Child Abuse and Neglect Data System (NCANDS), designed to fulfill this mandate, began collecting and analyzing child maltreatment data from CPS agencies in the fifty states and the District of Columbia. The first three surveys were known as Working Paper 1, Working Paper 2, and Child Maltreatment 1992. NCANDS has since conducted the Child Maltreatment survey annually. The most current survey as of this writing was Child Maltreatment 2004 (2006, http://www.acf.hhs.gov/programs/cb/pubs/cm04/cm04.pdf).

The data collected from states cannot be completely relied on because each state has its own method of gathering and classifying the information. Most states collect data on an incident basis; that is, they count each time a child is reported for abuse or neglect. If the same child is reported several times in one year, each incident is counted. Consequently, the reported number of incidents of child maltreatment may be greater than the reported number of maltreated children.

As part of the 1974 CAPTA, Congress also mandated NCCAN to conduct a periodic National Incidence Study of Child Abuse and Neglect (NIS). Data on maltreated children are collected not only from CPS agencies but also from professionals in community agencies, such as law enforcement, public health, juvenile probation, mental health, and voluntary social services, as well as from hospitals, schools, and day care centers. The NIS is the single most comprehensive source of information about the incidence of child maltreatment in the United States, because it analyzes the characteristics of child abuse and neglect that are known to community-based professionals, including those characteristics not reported to CPS. The most recent study is the above-mentioned NIS-3 (1993). This report is based on a nationally representative sample of more than 5,600 professionals in 842 agencies serving forty-two counties. NIS-3 includes not only child victims investigated by CPS agencies but also children seen by community institutions (such as day care centers, schools, and hospitals) and other investigating agencies (such as public health departments, police, and courts). In addition, victim counts were unduplicated, which means that each child was counted only once.

In 2003 the Keeping Children and Families Safe Act directed the collection of data for the Fourth National Incidence Study of Child Abuse and Neglect. Data from this study will be available by February 2008.

Definition Standards

NIS-3 used two standardized definitions of abuse and neglect:

• Harm Standard—required that an act or omission must have resulted in demonstrable harm to be considered as abuse or neglect
• Endangerment Standard—allowed children who had not yet been harmed by maltreatment to be counted in the estimates of maltreated children if a non-CPS professional considered them to be at risk of harm or if their maltreatment was substantiated or indicated in a CPS investigation

VICTIMS OF MALTREATMENT

Rates of Victimization

CPS DATA

According to Child Maltreatment 2004, in 2004 CPS agencies received an estimated three million referrals, or reports, alleging the maltreatment of about 5.5 million children, which may include some children who were reported and counted more than once. States may differ in the rates of child maltreatment reported. States differ not only in definitions of maltreatment but also in the methods of counting reports of abuse. Some states count reports based on the number of incidents or the number of families involved, rather than on the number of children allegedly abused. Other states count all reports to CPS, whereas others count only investigated reports.

In 2004 forty-five states and the District of Columbia submitted child-level data for each report of alleged maltreatment. Child-level data include, among other things, the demographics about the children and the perpetrators, types of maltreatment, and dispositions (findings after investigation or assessment of the case). The remaining five states submitted only summary statistics, such as the number of child victims of maltreatment. CPS agencies screened in (accepted for further assessment or investigation) nearly 1.3 million (62.7%) referrals. Overall, the rate of maltreatment referrals ranged from 22.8 per one thousand children (Hawaii) to 102.2 per one thousand children (Colorado) under age eighteen. (See Table 2.1.)

In 2004 an estimated 872,000 children were victims of maltreatment in the United States. A total of 11.9 children for every one thousand children in the population were victims of abuse or neglect. (See Table 2.2.) According to Child Maltreatment 2002 (2004, http://www.acf.hhs.gov/programs/cb/pubs/cm02/cm02.pdf), this was the lowest victim rate since 1999, when the rate was 11.8 children per one thousand children in the population. The rate of maltreatment peaked at 15.3 per one thousand children in 1993.

Table 2.3 shows the types of maltreatment children suffered in 2004. In that year 544,050 of the 872,088 children reported maltreated to CPS agencies had suffered neglect. Another 17,968 suffered medical neglect. In other words, 64.5% of all children found to be maltreated by CPS agencies in 2004 were victims of neglect or medical neglect. Another 152,250 children (17.5%) were victims of physical abuse and 84,398 children (9.7%) were victims of sexual abuse. Child Maltreatment 2004 reports that 61,272 children (7%) were victims of emotional, or psychological, maltreatment, and another 126,856 children (14.5%) experienced other types of maltreatment, including abandonment, congenital drug addiction, and threats to harm them. Some children were victims of more than one type of maltreatment.

Figure 2.1 shows that while rates of different types of abuse fluctuate somewhat from year to year, they remained fairly steady between 2000 and 2004. According to CPS statistics, in 2004, 2.1 out of every one thousand children were physically abused; 7.4 out of every one thousand children were neglected; 1.2 out of every one thousand children were sexually abused; 0.9 out of every one thousand children were emotionally abused; and 3.2 out of every one thousand children suffered from some other form of abuse.

NIS DATA

The NIS, while providing older data, gives a clearer picture of the incidence of child maltreatment because it collects data not just from child protective service agencies but also from other community professionals as well. In 1993, under the Harm Standard, nearly 1.6 million children were victims of maltreatment, a 66.9% increase from the Second National Incidence Study of Child Abuse and Neglect (1986; NIS-2) estimate (931,000 children) and a 148.5% increase from the First National Incidence Study of Child Abuse and Neglect (1980) estimate (625,100 children). Significant increases occurred for all types of abuse and neglect, as compared with the two earlier NIS surveys. The 1.6 million child victims of maltreatment in 1993 reflected a yearly incidence rate of 23.1 per one thousand children under age eighteen. (See Table 2.4.)

In 1993, under the Endangerment Standard, more than 2.8 million children experienced some type of maltreatment. This figure doubled the NIS-2 estimate of 1.4 million. As with the Harm Standard, marked increases occurred for all types of abuse and neglect. The incidence rate was 41.9 per one thousand children under age eighteen. (See Table 2.5.)

Gender of Victims

CPS DATA

In 2004 CPS agencies found a higher rate of child maltreatment among girls (12.6 cases per one thousand children) than among boys (11.2 cases per one thousand children). About 48.3% of maltreated children were boys and 51.7% were girls. (See Table 2.6.)

NIS DATA

NIS data allow comparisons of types of maltreatment suffered by boys and girls. Under both the Harm and Endangerment Standards of NIS-3, more females were subjected to maltreatment than males. Females were sexually abused about three times more often than males. Males, however, were more likely to experience physical and emotional neglect under the Endangerment Standard. Under both standards, males suffered more physical and emotional neglect, whereas females suffered more educational neglect. Males were at a somewhat greater risk of serious injury and death than females. (See Table 2.7 and Table 2.8.)

Age of Victims

CPS DATA

Younger children represented most of the maltreated victims among CPS agencies in 2004. Older children are less likely to be victimized than younger children. The victimization rate for infants and toddlers up through age three was 16.1 per one thousand children of the same age group, compared with 13.4 per one thousand for children ages four to seven. The rate of victimization for children ages eight to eleven was 10.9 per one thousand; for ages twelve to fifteen, 9.3 per one thousand; and for ages sixteen and seventeen, 6.1 per one thousand. (See Figure 2.2.)

Children of different ages suffered different types of maltreatment in 2004. Nearly three-quarters (72.9%) of the youngest children under age three suffered from neglect, whereas only a little more than half (52.4%) of those age sixteen and older did. By contrast, only 12.8% of the youngest group suffered physical abuse and only 2.2% of this group suffered sexual abuse. However, 24.9% of maltreated children age sixteen and older suffered physical abuse, and 16.3% of these children suffered sexual abuse. (See Table 2.9.)

NIS DATA

NIS-3 finds a low incidence of maltreatment in younger children, particularly among those ages zero to five. This may be because, before reaching school age, children are less observable to community professionals, especially educators—the group most likely to report suspected maltreatment. NIS-3 notes a disproportionate increase in the incidence of maltreatment among children as they reach ages six through fourteen. (See Figure 2.3 and Figure 2.4.) Sedlak and Broadhurst note the incidence of maltreatment among children older than age fourteen decreases. Older children are more likely to escape if the abuse becomes more prevalent or severe. They are also more able to defend themselves and/or fight back.

Under the Harm Standard only ten per one thousand children in the zero-to-two age group experienced overall maltreatment. The numbers were significantly higher for children ages six to seventeen. Under the Endangerment Standard twenty-six per one thousand children ages zero to two were subjected to overall maltreatment. A slightly higher number of children (thirty-three per one thousand children) in the oldest age group (fifteen to seventeen years old) suffered maltreatment of some type. As with the Harm Standard, children between the ages of six and fourteen had a higher incidence of maltreatment.

Race and Ethnicity of Victims

CPS DATA

In 2004 rates of child maltreatment as recorded by CPS agencies were highest among African-American children (19.9 per one thousand children) and lowest among Asian-American children (2.9 per one thousand children). Pacific Islanders had a rate of 17.6 per one thousand children; Native American and Alaskan Native children had a rate of 15.5 per one thousand children; whites had a rate of 10.7 per one thousand children; and Hispanics had a rate of 10.4 per one thousand children. (See Figure 2.5.)

WHY ARE MINORITY CHILDREN OVERREPRESENTED IN CPS DATA?

In Children of Color in the Child Welfare System: Perspectives from the Child Welfare Community (2003, http://www.childwelfare.gov/pubs/otherpubs/children/index.cfm), Susan Chibnall et al. of the HHS's Children's Bureau explore the attitudes and perceptions of CPS personnel regarding the overrepresentation of minority children, particularly African-American children, in the child welfare system. According to Chibnall et al., while African-American children make up 15% of all children in the United States, they represent 25% of substantiated maltreatment victims. In addition, these children account for 45% of all children in foster care.

Chibnall et al. conducted the study in nine child welfare agencies across the country. They interviewed agency administrators, supervisors, and caseworkers. The child welfare personnel gave a variety of reasons minority children are overrepresented in the child welfare system, including:

• Poverty and poverty-related issues—Child welfare personnel thought that African-American families are more likely to be poorer than are other ethnic/racial groups. This makes them more vulnerable to social problems such as child maltreatment, domestic violence, and substance abuse. Moreover, these families typically live in areas lacking resources where they can go for assistance.
• Visibility—Poor families are more likely to use public services, such as public health care, making them more visible to mandated reporters when they are experiencing problems, including child abuse and neglect.
• Overreporting—Many study participants proposed that, because poor families are more visible to mandated reporters such as doctors and nurses, they are more likely to be reported to CPS.
• Worker bias—When investigating particular families, some caseworkers may not understand the cultural norms and practices of minorities; this may influence their decisions at different stages of child welfare services, including child maltreatment reporting, investigation, substantiation, and the child's removal from home and placement in foster care. A caseworker's bias may also make it more likely, for example, that he or she would remove an African-American child than a white child from comparable home environments.

Some child welfare personnel who were interviewed for the study believed that the Multi-ethnic Placement Act of 1994, which allows the placement of African-American children in nonminority homes, does not serve children's best interests. They were concerned that transracial placements might be harmful to minority children's self-esteem and ethnic/racial identity.

NIS DATA

NIS-3 finds no significant differences in race in the incidence of maltreatment. Sedlak and Broadhurst note that this finding may be somewhat surprising, considering the overrepresentation of African-American children in the child welfare population and in those served by public agencies. They attribute this lack of race-related difference in maltreatment incidence to the broader range of children identified by NIS-3, compared with the smaller number investigated by public agencies and the even smaller number receiving child protective and other welfare services. NIS-2 also had not found any disproportionate differences in race in relation to maltreatment incidence.

Children with Disabilities Particularly at Risk

Children with disabilities are potentially at risk for maltreatment because society generally treats them as different and less valuable, thus possibly tolerating violence against them. Some parents may feel disappointment at not having a "normal" child. Others may expect too much and feel frustrated if the child does not live up to their expectations. These children require special care and attention, and parents may not have the social

support to help ease stressful situations. Caring for children with disabilities can also be expensive, creating even more stress and with it risk of maltreatment.

In "Assessment of Maltreatment of Children with Disabilities" (Pediatrics, August 2001), the Committee on Child Abuse and Neglect and the Committee on Children with Disabilities—two committees of the American Academy of Pediatrics—note that children with disabilities may also be vulnerable to sexual abuse. Dependent on caregivers for their physical needs, these children may not be able to distinguish between appropriate and inappropriate touching of their bodies. The opportunities for sexual abuse may also be increased if the child depends on several caregivers for his or her needs.

Patricia M. Sullivan, in "Violence against Children with Disabilities: Prevention, Public Policy, and Research Implications" (Dorothy K. Marge, ed., A Call to Action: Ending Crimes of Violence against Children and Adults with Disabilities—A Report to the Nation, 2003), calls attention to the fact that the federal government does not collect specific data on children with disabilities in its crime statistics systems nor in national incidence studies mandated by law. Although CAPTA required that national incidence studies of child maltreatment include data on children with disabilities, the latest survey, the NIS-3, does not satisfy this mandate. Moreover, NCANDS, which releases annual state data on maltreated children, does not gather information relating to children's disability status.

Sullivan undertook two epidemiological studies on maltreated children with disabilities. (Epidemiological studies consider individuals' sex, age, race, social class, and other demographics.) The incidence of maltreatment (the number of new cases during a given period, such as per week, per month, or per year) and its prevalence (the total number of maltreated children with disabilities at a given time) were measured. The hospital-based study of six thousand children found a 64% prevalence rate of maltreatment among disabled children, twice the prevalence rate (32%) among nondisabled children. The school-based study included 4,954 children; 31% of disabled children had been maltreated, 3.4 times that of the nondisabled comparison group.

Family Characteristics of Victims

The only reliable information on family characteristics of victims come from NIS data, as the living arrangements data on children reported to CPS were incomplete. For example, in 2004 nearly half (44.2%) had living arrangement data that were missing or incomplete. The following discussion comes from NIS-3.

FAMILY STRUCTURE

According to NIS-3, under the Harm Standard, among children living with single parents, an estimated 27.3 per one thousand under age eighteen suffered some type of maltreatment—almost twice the incidence rate for children living with both parents (15.5 per one thousand). The same rate held true for all types of abuse and neglect. Children living with single parents also had a greater risk of suffering serious

injury (10.5 per one thousand) than did those living with both parents (5.8 per one thousand). (See Table 2.10.)

Under the Endangerment Standard an estimated 52 per one thousand children living with single parents suffered some type of maltreatment, compared with 26.9 per one thousand living with both parents. Children in single-parent households were abused at a 45% higher rate than those in two-parent households (19.6 versus 13.5 per one thousand) and suffered more than twice as much neglect (38.9 versus 17.6 per one thousand). Children living with single parents (10.5 per one thousand) were also more likely to suffer serious injuries than those living with both parents (5.9 per one thousand). (See Table 2.11.)

FAMILY INCOME

Family income was significantly related to the incidence rates of child maltreatment. Under the Harm Standard children in families with annual incomes less than $15,000 had the highest rate of maltreatment (47 per one thousand). The figure is almost twice as high (95.9 per one thousand) using the Endangerment Standard. Children in families earning less than $15,000 annually also sustained more serious injuries than did children living in families earning more than that amount. (See Table 2.12 and Table 2.13.)

PERPETRATORS OF CHILD MALTREATMENT

CPS Data

The law considers perpetrators of child abuse to be those people who abuse or neglect children under their care. They may be parents, foster parents, other relatives,

or other caretakers. People who victimize children that are not under their care are not considered to have committed child abuse, but rather assault, battery, rape, or other crimes. According to CPS data, perpetrators are more likely to be women (57.8%) than men (42.2%). In 2004, 38.8% of victims were maltreated by their mothers acting alone; 18.3% experienced maltreatment from their fathers acting alone. Another 18.3% were maltreated by both parents. About 6.8% of the victims were maltreated by their mothers and another person whose relationship with the mother was not known, and 1.2% were maltreated by their fathers and another person. One in ten victims (10.1%) were maltreated by nonparental perpetrators, and another 6.5% were maltreated by unknown individuals. (See Figure 2.6.)

CPS data indicate that most perpetrators of child maltreatment are in their twenties and thirties. In 2004 the median age of female perpetrators was thirty-one years; the median age of male perpetrators was thirty-four years. Almost half (44.4%) of the female perpetrators were younger than thirty, whereas only about one-third (34.1%) of male perpetrators were. (See Figure 2.7.)

CPS data show that overall, more than half of perpetrators of maltreatment (57.9%) neglected one or more children, 10.3% physically abused children, and 6.9% sexually abused children. Variations existed in this pattern, however, depending on the perpetrator's relationship to the child or children. Parents who maltreated their children were most likely to neglect them (62.9%). Ten percent of parental perpetrators physically abused their children, and 2.6% sexually abused their children. Among friends and neighbors who maltreated children, 73.8% sexually abused them, 9.9% neglected them, and 4.1% physically abused them. Residential facility staff members (as well as other professionals) were relatively more likely to physically abuse children; 19.8% of residential facility perpetrators physically abused children, 46.7% neglected children, and 12.1% sexually abused children. (See Figure 2.8.)

NIS Data

Like CPS data, NIS-3 finds that most child victims (78%) were maltreated by their birth parents. Parents accounted for 72% of physical abuse and 81% of emotional abuse. Almost half (46%) of sexually abused children, however, were violated by someone other than a parent or parent substitute. More than a quarter (29%) were sexually abused by a birth parent, and 25% were sexually abused by a parent substitute, such as a stepparent or a mother's boyfriend. In addition, sexually abused children were more likely to sustain fatal or serious injuries or impairments when birth parents were the perpetrators. (See Table 2.14.)

Overall, children were somewhat more likely to be maltreated by female perpetrators (65%) than by males (54%). Among children maltreated by their natural parents, most (75%) were maltreated by their mothers, and almost half (46%) were maltreated by their fathers. (Children who were maltreated by both parents were included in both "male" and "female" perpetrator counts.) Children who were maltreated by someone other than parents and parent substitutes were more likely to have been maltreated by a male (85%) than by a female (41%). Of the other adults who maltreated children, 80% were males and 14% were females. (See Table 2.15. Note that the numbers will not add to 100% because many children were maltreated by both parents.)

Neglected children differed from abused children with regard to the gender of the perpetrators. Because mothers or other females tend to be the primary caretakers, children were more likely to suffer all forms of neglect by female perpetrators (87%, versus 43% by male perpetrators). In contrast, children were more often abused by males (67%) than by females (40%). (See Table 2.15.)

REPORTING CHILD ABUSE

Mandatory Reporting

In 1974 Congress enacted the first Child Abuse Prevention and Treatment Act (CAPTA) that set guidelines for the reporting, investigation, and treatment of child maltreatment. States had to meet these requirements to receive federal funding to assist child victims of abuse and neglect. Among its many provisions, CAPTA required the states to enact mandatory reporting laws and procedures so that CPS agencies could take action to protect children from further abuse.

The earliest mandatory reporting laws were directed at medical professionals, particularly physicians, who were considered the most likely to see abused children. As of 2006 each state designated mandatory reporters, including health care workers, mental health professionals, social workers, school personnel, child care providers, and law enforcement officers. Any individual, however, whether or not he or she was a mandatory reporter, could report incidents of abuse or neglect.

Some states also require maltreatment reporting from other individuals, such as firefighters, Christian Science practitioners, battered women's counselors, animal control officers, veterinarians, commercial/private film or photograph processors, and even lawyers. As of June 2003, nineteen states and Puerto Rico required all citizens to report suspected child maltreatment. (See Table 2.16.)

Some state statutes include provisions pertaining to the right of confidentiality of communications between professionals and their clients. In "Clergy as Mandatory Reporters of Child Abuse and Neglect" (March 2005, http://childwelfare.gov/systemwide/laws_policies/statutes/clergymandated.cfm), the Child Welfare Information Gateway reports that as of March 2005 clergy were mandated reporters in twenty-five states. In eighteen other states any person who suspected child abuse or neglect was required to report—including clergy. In twenty-one states, "pastoral communications" between clergy and penitent (a person repenting sin) were privileged (pastoral communications are confessions or conversations in which the member of the clergy is acting in the capacity of spiritual adviser), but in two states that privilege was denied in cases of child abuse and neglect. Few states recognized the physician-patient and mental health professional-client privileges as exempt from mandatory reporting laws. Ohio and Wyoming recognized

privileged communications between physicians and patients, while Oregon exempted from mandatory reporting privileged communications between mental heath professionals and patients.

Who Reports Child Abuse?

In 2004 more than half (55.7%) of all reports of alleged child maltreatment came from professional sources—educators (16.5%); legal, law enforcement, and criminal justice personnel (15.6%); social services personnel (10.5%); medical personnel (7.9%); mental health personnel (3.8%); child day care providers (0.9%); and foster care providers (0.5%). Friends and neighbors, parents, and other relatives comprised nearly one-fifth (19.6%) of the reporters, whereas alleged victims and self-identified perpetrators reported abuse in 0.7% of the cases. Another 17.8% of reports came from anonymous and other sources. (See Figure 2.9.)

All states offer immunity to individuals who report incidents of child maltreatment "in good faith" or with sincerity. Besides physical injury and neglect, most states include mental injury, sexual abuse, and the sexual exploitation of minors as cases to be reported.

Failure to Report Child Maltreatment

Many states impose penalties, either a fine and/or imprisonment, for failure to report child maltreatment. A mandated reporter, such as a physician, may also be sued for negligence for failing to protect a child from harm. Although all states have enacted legislation requiring, among other things, the mandatory reporting of child maltreatment by certain professionals, states vary in the standard for reporting. The standard to report child maltreatment varies from having "reasonable cause to suspect," to having "reason to believe," to having "observed conditions which would reasonably result," to "know or suspect."

The 1976 landmark California case Landeros v. Flood et al. illustrates a case involving a physician's failure to report child maltreatment. Eleven-month-old Gita Landeros was brought by her mother to the San Jose Hospital in California for treatment of injuries. Besides a fractured lower leg, the girl had bruises on her back and abrasions on other parts of her body. She also appeared scared when anyone approached her. At the time Gita was also suffering from a fractured skull, but this was never diagnosed by the attending physician, Dr. A. J. Flood.

Gita returned home with her mother and subsequently suffered further serious abuse at the hands of her mother and the mother's boyfriend. Three months later Gita was brought to another hospital for medical treatment, where the doctor identified and reported the abuse to the proper authorities. After surgery for her injuries the child was placed with foster parents. The mother and boyfriend were eventually convicted of the crime of child abuse. The guardian ad litem (a court-appointed special advocate) for Gita filed a malpractice suit against Dr. Flood and the San Jose Hospital, citing painful permanent physical injury to the plaintiff as a result of the defendants' negligence.

The trial court of Santa Clara County dismissed the Landeros complaint, and the case was appealed to the California Supreme Court. The California Supreme Court agreed that Dr. Flood should have identified Gita's abuse. The court ruled that the doctor's failure to do so contributed to the child's continued suffering, and Dr. Flood and the hospital were found liable. While this case applied specifically to a medical doctor, the principles reached by the court are applicable to other professionals. Most professionals are familiar with the court's decision in Landeros.

On August 10, 2002, two-year-old Dominic James was brought to Cox South Hospital in Springfield, Missouri. Paramedics told emergency nurse Leslie Ann Brown that the boy, who was having seizure-like symptoms, had bruises on his back and to report this to the attending physician. Told by Dominic's foster parents that the child got bruised by leaning back on a booster seat, Brown did not report the bruises to the physician, nor did she include the presence of bruises on her medical reports. Dominic was hospitalized again a week later and died soon after.

In February 2003 the state of Missouri charged Brown with failure to report child abuse. In September 2003 Green County Judge Calvin Holden dismissed the criminal charges, stating that the Missouri statute with the "reasonable cause to suspect" standard for reporting child abuse was unconstitutionally vague in violation of the U.S. and Missouri Constitutions. The state appealed the case in May 2004. In August 2004 the Missouri Supreme Court reversed Judge Holden's ruling, allowing the case to proceed to trial. However, later that year charges were dismissed against Brown after an agreement was reached requiring Cox South Hospital to revise its training for mandated reporters and implement annual refresher courses.

Why Mandated Reporters Fail to Report Suspected Maltreatment

Gail L. Zellman and C. Christine Fair, in "Preventing and Reporting Abuse" (John E. B. Myers et al., eds., The APSAC Handbook on Child Maltreatment, 2002), conducted a national survey to determine why mandated reporters may not report suspected maltreatment. The researchers surveyed 1,196 general and family practitioners, pediatricians, child psychiatrists, clinical psychologists, social workers, public school principals, and heads of child care centers. Nearly eight out of ten (77%) survey participants had made a child maltreatment report at some time in his or her professional career. More than nine out of ten (92%) elementary school principals reported child maltreatment at some time, followed closely by child psychiatrists (90%) and pediatricians (89%). A lesser proportion of secondary school principals (84%), social workers (70%), and clinical psychologists (63%) reported child maltreatment at some time in their careers.

Nearly 40% of the mandated reporters, however, indicated that at some time in their careers they had failed to report even though they had suspected child maltreatment. Almost 60% failed to report child maltreatment because they did not have enough evidence that the child had been maltreated. One-third of the mandated reporters thought the abuse was not serious enough to warrant reporting. An equal proportion of mandated reporters did not report suspected abuse because they felt they were in a better position to help the child (19.3%) or they did not want to end the treatment (19%) they were giving the child. Almost 16% failed to report because they did not think CPS would do a good job.

In Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence (2002), Felicia Cohn, Marla E. Salmon, and John D. Stobo examined the curricula on family violence for six groups of health professionals: physicians, physician assistants, nurses, psychologists, social workers, and dentists. They find that, in fact, although child abuse is a well-documented social and public health problem in the United States, few medical schools and residency training programs include child abuse education and other family violence education in their curricula. What training there is consists of lectures and case discussions, and the training duration varies from program to program. Suzanne P. Starling and Stephen Boos, in "Core Content for Residency Training in Child Abuse and Neglect" (Child Maltreatment, November 2003), suggest offering a core curriculum in residency programs that would enable primary care physicians (including pediatricians, family doctors, and emergency-medicine doctors) to recognize, evaluate, and manage cases of child abuse and neglect.

In "Child Maltreatment Training in Doctoral Programs in Clinical, Counseling, and School Psychology: Where Do We Go from Here?" (Child Maltreatment, August 2003), Kelly M. Champion et al. sought to gain information on the type and amount of training psychologists received regarding child maltreatment in American Psychological Association-accredited doctoral programs. Their study examined surveys sent to training directors of doctoral programs in 1992 and 2001. Champion et al. find that doctoral programs had generally remained unchanged within those years. Few doctoral programs offered specific courses on child maltreatment in 1992 and 2001, just 13% and 11%, respectively. Although 65% of programs in 1992 and 59% in 2001 covered child maltreatment in three or more courses, these courses were rarely required to complete a doctoral program. Twenty percent of programs in 1992 and 22% in 2001 offered training in child maltreatment in clinical settings; most programs, however, reported that students completed just 1% to 10% of such training. Finally, research activities in child maltreatment decreased from 60% in 1992 to 47% in 2001.

What Happens after a Child Maltreatment Report?

CPS

On receipt of a report of suspected child maltreatment, CPS screens the case to determine its proper jurisdiction. For example, if it is determined that the alleged perpetrator of sexual abuse is the victim's parent or caretaker, CPS screens in the report and conducts further investigation. If the alleged perpetrator is a stranger or someone who is not the parent or caregiver of the victim, the case is screened out, or referred elsewhere, in this case, to the police because it does not fall within CPS jurisdiction as outlined under federal law.

A state's child welfare system, under which CPS functions, consists of other components designed to ensure a child's well-being and safety. These include foster care, juvenile and family courts, and other child welfare services. Other child welfare services include family reunification, granting custody to a relative, termination of parental rights, and emancipation (releasing a subject from the system because he or she is now recognized by the court as an adult). Cases of reported child abuse or neglect typically undergo a series of steps through the child welfare system. (See Figure 2.10.)

DISPOSITIONS OF INVESTIGATED REPORTS

After a CPS agency screens in a report of child maltreatment, it initiates an investigation. Some states follow one time frame for responding to all reports, whereas others follow a priority system, investigating high-priority cases within one to twenty-four hours. According to Child Maltreatment 2004, the twenty-six states that reported response time in 2004 showed an average response time of ninety-seven hours, or approximately four days.

Following investigation of the report of child maltreatment, the CPS agency assigns a disposition, or finding, to the report. Before 2000, reports of alleged child maltreatment received one of three dispositions—indicated, substantiated, or unsubstantiated. In 2000 several states announced plans to establish an alternative response program to reports of alleged child maltreatment. If the child is at a serious and immediate risk of maltreatment, CPS responds with the traditional formal investigation, which may involve removing the child from the home. If it is determined, however, that the parent will not endanger the child, CPS workers use the alternative response to help the family. This involves a more informal approach. Instead of removing the child from the home environment, CPS steps in to assist the whole family by, for example, helping reduce stress that may lead to child abuse through provision of child care, adequate housing, and education in parenting skills. In 2004 ten states implemented the alternative response program.

Other dispositions, used by all states, included:

• A disposition of "substantiated," which means that sufficient evidence existed to support the allegation of maltreatment or risk of maltreatment
• A disposition of "indicated or reason to suspect," which means that the abuse and/or neglect could not be confirmed, but there was reason to suspect that the child was maltreated or was at risk of maltreatment

• A disposition of "unsubstantiated," which means that no maltreatment occurred or sufficient evidence did not exist to conclude that the child was maltreated or was at risk of being maltreated

Of the 1.9 million investigated reports in 2004, 60.7% were unsubstantiated. More than one-fourth (25.7%) were substantiated, and another 3% were indicated. Dispositions that were identified "closed with no finding" referred to cases in which the investigation could not be completed because the family moved out of the jurisdiction, the family could not be found, or the needed reports were not filed within the required time limit. Such dispositions accounted for 1.6% of investigated cases. (See Figure 2.11.)

COURT INVOLVEMENT

The juvenile or family court hears allegations of maltreatment and decides if a child has been abused and/or neglected. The court then determines what should be done to protect the child. The child may be left in the parents' home under the supervision of the CPS agency, or the child may be placed in foster care. If the child is removed from the home and it is later determined that the child should never be returned to the parents, the court can begin proceedings to terminate parental rights so that the child can be put up for adoption. The state may also prosecute the abusive parent or caretaker when a crime has allegedly been committed.

THE DEBATE ABOUT FAMILY PRESERVATION

The Adoption Assistance and Child Welfare Act of 1980 mandated: "In each case, reasonable efforts will be made (A) prior to the placement of a child in foster care, to prevent or eliminate the need for removal of the child from his home, and (B) to make it possible for the child to return to his home." Because the law, however, did not define the term reasonable efforts, states and courts interpreted the term in different ways. In many cases child welfare personnel took the "reasonable efforts" of providing family counseling, respite care, and substance abuse treatment, thus preventing the child from being removed from abusive parents.

The law was a reaction to what was seen as zealousness in the 1960s and 1970s, when children, especially African-American children, were taken from their homes because their parents were poor. At the beginning of the twentieth-first century, however, some feel that problems of drug or substance abuse can mean that returning the child to the home is likely a guarantee of further abuse. Others note that some situations exist where a parent's live-in partner, who has no emotional attachment to the child, may also present risks to the child.

Richard J. Gelles, a prominent family violence expert and once a vocal advocate of family preservation, had a change of heart after studying the case of fifteen-month-old David Edwards, who was suffocated by his mother after the child welfare system failed to come to his rescue. Although David's parents had lost custody of their first child because of abuse, and despite reports of David's abuse, CPS made "reasonable efforts" to let the parents keep the child. In The Book of David: How Preserving Families Can Cost Children's Lives (1996), Gelles points out that CPS needed to abandon its blanket solution to child abuse in its attempt to use reasonable efforts to reunite the victims and their perpetrators. He contends that those parents who seriously abuse their children are incapable of changing their behaviors.

By contrast, in "Foster Care vs. Family Preservation: The Track Record on Safety" (August 2005, http://www.nccpr.org/newissues/1.html), the National Coalition for Child Protection Reform (NCCPR), a nonprofit organization of experts on child abuse and foster care who are committed to the reform of the child welfare system, contends that many allegedly maltreated children are unnecessarily removed from their homes—and in fact that children are in more danger when placed in foster care than when given services to help preserve the family. The NCCPR recognizes that, while there are cases in which the only way to save a child is to remove him or her from an abusive home, in many cases providing support services to the family in crisis, while letting the child remain at home, helps ensure child safety.

The NCCPR states in "What Is 'Family Preservation'?" (December 2003, http://www.nccpr.org/newissues/10.html) that, with the proper assistance, a family in crisis can change its behavior. This assistance can range from basic, concrete monetary help (e.g., a place in a day care center) to intensive intervention procedures involving twenty-four-hour, on-call counseling and emergency services. Above all, the organization insists that the current system of CPS must be reformed.

CONTROVERSIES SURROUNDING THE CHILD PROTECTIVE SERVICES SYSTEM

Child Welfare Workforce

Child welfare caseworkers perform multiple tasks in the course of their jobs. Among other things, they investigate reports of child maltreatment, coordinate various services (mental health, substance abuse, etc.) to help keep families together, find foster care placements for children if needed, make regular visits to children and families, arrange placement of children in permanent homes when they cannot be safely returned to their parents or caretakers, and document all details pertaining to their cases. Caseworker supervisors monitor and support their caseworkers, sometimes taking on some of the cases when there is a staff shortage or heavy caseload. In the report Child Welfare: HHS Could Play a Greater Role in Helping Child Welfare Agencies Recruit and Retain Staff (March 2003, http://www.gao.gov/new.items/d03357.pdf), the Government Accountability Office (GAO), the investigative arm of Congress, examines the child welfare workforce and how challenges in recruiting and retaining caseworkers affect the children under their care and reported its findings. Among other things, GAO examines exit interview documents of caseworkers who had left their jobs from seventeen states, forty counties, and nineteen private child welfare agencies. The GAO also interviewed child welfare officials and experts and conducted on-site visits to agencies in four states: California, Illinois, Kentucky, and Texas.

The GAO finds that CPS agencies continued to have difficulty attracting and retaining experienced caseworkers. The low pay not only made it difficult to attract qualified workers but also contributed to CPS employees leaving for better-paying jobs. Because the federal government has not set any national hiring policies, employees have college degrees that may not necessarily be related to social work. Workers whom the GAO interviewed in different states also mentioned risk to personal safety, increased paperwork, lack of supervisory support, and insufficient time to attend training as things that affected their job performance and influenced their decision to leave.

Heavy Caseloads

In the four states GAO visited, caseworkers spent from 50% to 80% of their time doing paperwork. Staff shortage because of workers quitting their jobs resulted in excessive caseloads. Figure 2.12 shows the GAO's findings for worker caseloads as compared with recommended standards. The Child Welfare League of America, a private child welfare organization, recommends a caseload of twelve to fifteen cases per caseworker, while the Council on Accreditation for Children and Family Services, which evaluates organizations against best-practice standards, recommends no more than eighteen cases per worker. The GAO finds that, in reality, individual case-workers handled anywhere from ten to 110 cases, with the average being twenty-four to thirty-one cases.

SLIPPING THROUGH THE CRACKS

Some CPS workers at times fail to monitor the children they are supposed to protect. In Florida the Department of Children and Families could not account for the disappearance of a five-year-old foster child, Rilya Wilson, who had been missing for more than a year before the agency noticed her absence in April 2002. At around that time the agency had reportedly lost track of more than 530 children. Rilya's disappearance was only discovered after her caseworker was fired and the new caseworker could not locate the child. The former caseworker had reported that Rilya was fine, even though that caseworker had not visited the child at her foster home for months. Authorities discovered that her foster mother continued to receive welfare payments for the girl in her absence. Witnesses had also testified that the foster mother and her roommate abused the child before her disappearance. The women faced charges of aggravated child abuse, and her foster mother was convicted of fraud and sentenced to three years in jail. In March 2005, one of the caregivers was indicted on charges of murdering the girl. Rilya's foster mother eventually confessed to murdering Rilya, although her body has never been recovered.

New Jersey's child welfare system had also come to national attention because of its failure to protect adopted and foster children. In October 2003 four brothers of the Jackson family in Collingswood, New Jersey, ages nine, ten, fourteen, and nineteen, were removed from their adoptive parents' home and the couple was arrested. Investigations later revealed the brothers were systematically starved over many years. They weighed no more than forty-five pounds and stood less than four feet tall. The children reportedly subsisted on peanut butter, pancake batter, and wallboard. Authorities admitted two of the boys had fetal alcohol syndrome and two had eating disorders, which were the reasons the adoptive parents gave to neighbors for the brothers' emaciated appearance. The brothers, however, had put on weight and height since living with other foster families.

Investigations also revealed that Division of Youth and Family Services (DYFS) workers visited the adoptive parents' home thirty-eight times in the past to check on three other foster children but never asked about the brothers. In 1995, when DYFS was notified by the oldest boy's school that he seemed malnourished, DYFS did not require a medical examination and even agreed to the adoptive mother's decision to home school the brothers. DYFS policies regulating foster homes required an annual medical evaluation and interview of each household member, but these never took place. In May 2004 the adoptive parents were indicted on twenty-eight counts of aggravated assault and child endangerment.

These cases and others like them serve to focus public and media attention on the failure of CPS. While many departments are conscientiously and effectively doing their jobs, there are sometimes failures that result in great harm and even death to the children under their care.

Holding States Accountable

The HHS released Child Welfare Outcomes 2002: Annual Report—Safety, Permanency, Well-Being (http://www.acf.hhs.gov/programs/cb/pubs/cwo02/cwo02.pdf), the fifth in a series of annual reports on states' performances in meeting the needs of at-risk children who have entered the child welfare system. The report finds that states were succeeding in some areas and failing in others. For instance, in 2002 many states were unable to prevent many recurrences of child maltreatment; several states with a high percentage of reunifications between foster children and birth families also had a high percentage of those children reentering foster care; and few states met national standards for getting children adopted into permanent homes within twenty-four months of their entry into foster care. By contrast, most states kept children in foster care safer in 2002 than they had in 1999 by using a variety of measures such as tougher licensing requirements for foster homes; most states were successful in achieving permanency for foster children leaving care; and most states had improved their adoption rates in the past few years.

According to The AFGARS Report: Interim FY 2003 Estimates as of June 2006 (June 2006, http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report10.pdf), an estimated 282,000 children entered and 281,000 exited foster care in 2003. Of those children who exited foster care, 55% were reunited with their parents or primary caretakers, 11% went to live with relatives, 18% were adopted, and 8% were emancipated (they became legal adults). Two percent were transferred to another CPS agency, and another 4% were put under guardianship. One percent of foster children had run away. Another 586 children had died. (See Table 2.17.) As of September 30, 2003, an estimated 523,000 children remained in foster care.

States Should Use the Adoption and Safe Families Act

Richard Wexler notes in "Take the Child and Run: Tales from the Age of ASFA" (New England Law Review, Fall 2001) that "in passing ASFA [Adoption and Safe Families Act], Congress failed to learn the lessons some states have begun to learn after experiencing foster care panics—huge, sudden increases in placements that follow intensive media coverage of the death of a child who was known to the [child welfare] system." Wexler describes how, in the aftermath of foster care panics, child abuse deaths tend to increase. Caseworkers, fearing the scrutiny of politicians and the media and overwhelmed with more cases, may remove children from homes that could have been made safe with the right services, while leaving others in dangerous homes.

Wexler observes that while the ASFA encourages states to terminate parental rights within a restricted time period and provides monetary incentives for adoptions, nothing in the law prevents states from providing parents with housing or child care. States do not have to use the "take the child and run" approach. Instead, states can provide rent subsidies so that parents will not lose their children because of lack of decent housing. Moreover, states can provide day care so that single working parents who might otherwise leave children unsupervised to earn a living will not lose those children because they have been found neglectful.

Lives Saved

Although CPS agencies have had many problems and are often unable to perform as effectively as they should, many thousands of maltreated children have been identified, many lives have been saved, and many more have been taken out of dangerous environments. It is impossible to tally the number of child abuse cases that might have ended in death; these children have been saved by changes in the laws, by awareness and reporting, and by the efforts of the professionals who intervened on their behalf.