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Office of the Surgeon General (US). Surgeon General's Workshop on Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach: Lister Hill Auditorium, National Institutes of Health, Bethesda, Maryland, March 30-31, 2005 . Rockville (MD): Office of the Surgeon General (US); 2005.

Cover of Surgeon General's Workshop on Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach

Surgeon General's Workshop on Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach: Lister Hill Auditorium, National Institutes of Health, Bethesda, Maryland, March 30-31, 2005 .

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Précis

Frustration or rage, malice or ignorance, drugs or alcohol-whatever the explanation, causing harm, any harm, to a child is not acceptable. "There are no do-overs after you shake a baby to death." (George Lithco, J.D., founder of the Skipper Initiative)

The issues associated with child maltreatment evoke deep discomfort and are often highly charged. "We must break that silence and create a world that is safe for everyone, victims and perpetrators alike, to tell the truth and get the help that they need to stop this cycle of violence once and for all." (Cici Porter, singer, songwriter, survivor)

The Surgeon General's Workshop, Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of Public Health Approach highlights what we currently know about child maltreatment.

Child Maltreatment

No threat can be more devastating than child maltreatment-violence, abuse, and neglect perpetrated by one human being upon another. (See Definitions of Child Abuse and Neglect, from the National Clearinghouse on Child Abuse and Neglect State Statues Series.) In 2003 in the United States, approximately 906,000 children were determined to be victims of maltreatment, often perpetrated by their parents or caregivers. While the precise definition of child maltreatment varies somewhat, child maltreatment includes physical abuse, sexual abuse, emotional abuse, and neglect more than 60 percent of child victims were neglected; 20 percent were physically abused; 10 percent were sexually abused; 5 percent were emotionally maltreated; and, tragically, according to data from National Child Abuse and Neglect Data System some children are victims of more than one type of maltreatment (published by the U.S. Department of Health and Human Services, Administration on Children, Youth and Families in Child Maltreatment 2003; Washington, DC: U.S. Government Printing Office, 2005).

In 2003 young children, birth to 3 years of age, had the highest rate of victimization at 16.4 per 1,000 children in the national population. Girls were slightly more likely to be victims than boys. Pacific Islander children, American Indian or Alaska Native children, and African-American children had the highest rates of victimization. An estimated 1,500 children died due to child abuse or neglect in 2003. More than three-quarters of children who were killed were younger than 4 years old; infant boys (younger than 1 year old) had the highest rate of fatalities. More than one-third of child fatalities were attributed to neglect; physical abuse also was a major contributor to child fatalities.

Approximately 80 percent of perpetrators were parents. Other relatives accounted for 6 percent and unmarried partners of parents and "other" each accounted for 4 percent of all perpetrators. Female perpetrators, mostly mothers, were typically younger than male perpetrators, mostly fathers. Women also comprised a larger percentage of perpetrators than men, 58 percent compared to 42 percent. Nearly 76 percent of all perpetrators of sexual abuse were friends or neighbors and 30 percent were other relatives. In addition, less than 3 percent of all parental perpetrators were associated with sexual abuse.

Federal legislation provides a foundation for States by identifying a minimum set of acts or behaviors that define child abuse and neglect. The Federal Child Abuse Prevention and Treatment Act (CAPTA), (42 U.S.C.A. §5106g), as amended by the Keeping Children and Families Safe Act of 2003, defines child abuse and neglect as, at minimum:

  • Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or
  • An act or failure to act which presents an imminent risk of serious harm.

Within the minimum standards set by CAPTA, each State is responsible for providing its own definitions of child abuse and neglect. Most States recognize four major types of maltreatment: neglect, physical abuse, sexual abuse, and emotional abuse. Although any of the forms of child maltreatment may be found separately, they often occur in combination.

Workshop

As the Nation's doctor, the U.S. Surgeon General is duty bound, "to protect and advance the health of the Nation...and to articulate scientifically based health policy analysis on the full range of critical public health, medical, and health system issues facing the Nation." In fulfillment of this responsibility, U.S. Surgeon General Richard H. Carmona has chosen to focus upon the health and well-being of children. Recognizing that, "the prosperity and future of our nation rest upon the health and well-being of ALL our children," Surgeon General Carmona launched his 2005 agenda, announcing it as The Year of the Healthy Child.

The Year of the Healthy Child agenda focuses on improving the health of children. Strengthening the body, mind, and spirit of the growing child requires discovering the best ways to integrate prevention strategies into all communities and systems of care, as well as incorporating child development knowledge into the national consciousness. Securing a bright future requires both a safe environment and the physical, social, and emotional well-being of the child. It was in this spirit that Surgeon General Carmona sought the opinions of experts in such areas as criminal justice, medicine, child welfare, and education and convened a workshop to focus on the prevention of child maltreatment and promotion of child well treatment.

The Surgeon General's Workshop, "Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach" was held March 30–31, 2005, in Bethesda, Maryland. The Workshop was uniquely structured. It was a strategic listening session to gather expert opinion first hand and build on the sizeable body of work directed toward protecting children from abuse (Effective Intervention In Domestic Violence and Child Maltreatment Cases: Guidelines for Policy and Practice; S Schechter, JL Edleson - 1999 - the National Council of Juvenile and Family Court Judges). The Workshop focused on solutions rather than refinement of the problem definition.

The Workshop concentrated on discovery–what is needed, what is or is not working, what are the opportunities for effective strategies for preventing child maltreatment and promoting child well treatment by:

  • Advancing prevention and promotion as a national public health priority
  • Enhancing evidence-based prevention and promotion strategies
  • Integrating prevention and promotion services into all systems of care
  • Incorporating child development literacy into the national consciousness
  • Strengthening essential public-private care systems
  • Establishing a strategic public health approach for prevention and promotion.

The workshop included representatives from the fields of medicine, public health, child development, childhood disabilities, social services, child welfare, education, law enforcement, juvenile justice, communications, and mental health. A wide range of valued perspectives from academia, foundations, advocacy groups, professional organizations, the faith-based community, and all levels of government were elicited. A forum-type format enabled and encouraged the active exchange of ideas and debate among caring and committed colleagues from diverse backgrounds.

The Surgeon General's Workshop explored two key issues:

  • Defining the public health approach to preventing child maltreatment
  • Achieving the public health approach to preventing child maltreatment

Public Health Approach

The Surgeon General charged workshop participants to articulate a broad public health approach to aid in preventing child maltreatment and promoting child well treatment. Participants were challenged to use the principles of a public health framework, consisting of assessment, policy development, and assurance "to fulfill society's interest in assuring conditions in which people can be healthy and generate organized community efforts to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health" (Institute of Medicine, Committee for the Study of the Future of Public), in addressing the following:

  • Integration of child health, human development, and public health systems
  • Influences of parents, family, community, and society in shaping development
  • Formative and operational systems change
  • Parenting and family innovations and opportunities for prevention
  • Community and societal innovations and opportunities for prevention
  • Critical thinking for a new national public health priority

"Child maltreatment is a public health crisis, the full scale of which is masked by secrecy and denial. It is also a social welfare crisis, a criminal justice crisis, and an educational crisis. No one system or discipline has the answers. But there is synergy in our collective wisdom. We must learn from the public health model and the public health framework." (Charles Wilson, M.S.W., Director, San Diego Children's Hospital and Health Center and David Chadwick, M.D., Ph.D., Professor of Pediatrics, University of Utah)

Advancing Innovations

Workshop participants explored the complex dimensions of abuse and neglect; considered the current state-of-the-science and promising research; and identified several clinical and community-based innovations for prevention. The assembly exchanged a wide range of ideas for eliminating obstacles to change (e.g., resources, traditions, and compartmentalization); for advancing innovations in science, service delivery, and care coordination (e.g., cross disciplinary longitudinal studies, law enforcement as first responders, and systems dynamics); and for engaging community leaders. The broad range of ideas for improving the system belong to private and public entities – that all of us are responsible for preventing child maltreatment. The assembly considered a broad range of issues including:

  • Promoting strengths, resilience, respect, and cultural competence
  • Assessing risk factors and enhancing early identification for maltreatment
  • Identifying underlying developmental, social, and environmental issues
  • Providing age-appropriate, family-centered, culturally competent services
  • Integrating health, mental health, social, educational, and legal services
  • Identifying mechanisms of origins and perpetuation of maltreatment
  • Examining modifiable factors associated with maltreatment
  • Eliminating disparities, including those for children with special needs
  • Strengthening multidisciplinary coordination of care continuum
  • Expanding evidence-based interventions and treatment components
  • Expanding availability of and access to health and social services
  • Minimizing the immediate and long-term consequences of maltreatment
  • Specifying organizational health system enhancements
  • Integrating data and surveillance systems
  • Coordinating Federal programs, policies, standards, and authorities.

Emergent Themes

Several themes emerged from the workshop emphasizing the importance of communication, prevention, education, and community responsibility. A concise summary of the discussion of each theme follows:

The central importance and value of the Surgeon General's leadership is to effectively communicate to the American people and create the "public will" to stop child maltreatment and the intergenerational cycle of violence. His perspective was heralded. The Surgeon General recommended getting involved by supporting programs that support families, by reporting suspected child maltreatment, by helping to educate others in your community about child abuse and neglect, by strengthening the fabric of your community and by being ready to respond in an emergency (http://nccanch.acf.hhs.gov/pubs/prevenres/tips.pdf).

Domains that need to be emphasized include:

The "Human Face" of Child Maltreatment

The importance of creating a penetrating message that combines the tragic devastation hidden behind "impersonal statistics" with the hopefulness of prevention, garnered wide support by the assembly. Formulating a single, powerful message such as "no terror is more devastating than child maltreatment perpetrated by one human being upon another….it is time for preventing child maltreatment by promoting child well treatment to become a new national public health priority" was proposed. The vast number of children who are maltreated is unacceptable. According to the National Child Abuse and Neglect Data System, in 2003, an estimated 906,000 children nationwide were victims of maltreatment. Most experts believe that actual incidents of abuse and neglect are more numerous than statistics indicate (http://nccanch.acf.hhs.gov/pubs/prevenres/tips.pdf). The National Incidence Study of Child Abuse and Neglect reports even higher numbers (http://nccanch.acf.hhs.gov/pubs/statsinfo/nis3.cfm#national). Thus, it is important to formulate a message that conveys that every child matters.

The workshop also addressed extending and sustaining momentum for effective messaging by strong and visible leaders. Discussion concerning the visibility a celebrity would bring, with the credibility of an important public health figure led to the recommendation that the Surgeon General would be the ideal person to deliver a science-based, yet powerful, understandable message for preventing child maltreatment. The Surgeon General could summon the necessary support for the issue in a clear and comprehensible way. In addition there is a need to encourage forthright public dialog and break the silence associated with child maltreatment. This could be accomplished by linking a human face with child maltreatment, by increasing public visibility of adults who were maltreated as children and survived to speak up and advocate for prevention at local, state, and national levels.

The goal is to create an effective message that reaches and engages diverse populations. To this end participants suggested that national polling would be helpful to ascertain what message style and components resonate with the public. There was much discussion about funding for such polling and methods for identifying additional approaches to elicit national opinions.

Comprehensive Primary, Secondary, and Tertiary Care Systems

The importance of prevention at all levels - primary prevention - preventing the onset of child maltreatment prior to any evidence of at-risk conditions; secondary prevention - preventing the onset of child maltreatment by identifying and treating known risk factors when present; and, tertiary prevention - preventing the untoward sequelae of child maltreatment by treatment and management to restore the highest function possible, minimize the negative effects of maltreatment, and prevent disease-related complications - (The U.S. Preventative Services Task Forces' Guide to Clinical Preventive Services; 2d edition, 1996) was cited as essential for creating a comprehensive systems continuum to "prevent intergenerational cycles of violence."

Participants noted that health and child development are inextricably linked. They are systems assets that support child and family well-being. Childhood trauma of any type-physical or emotional-can be disruptive to the child's dynamic system development. Childhood trauma can influence a cascade of problematic consequences immediately or decades later. "We must think about how we optimize the positive and minimize the negative…and link the four systems that deal with children-clinical services, public health, universal interventions, and civic society, in a more comprehensive way." (Neal Halfon, M.D., M.P.H., Professor of Pediatrics, Public Health, and Public Policy, UCLA Center for Healthier Children, Families and Communities)

Workshop participants conveyed information on innovative programs, including intensive home visitation strategies that are comprehensive, often long term, flexible, culturally appropriate, and ultimately cost-effective. Working together, human services agencies, schools, faith-based groups, health care facilities, businesses, and other agencies and organizations that have a stake in helping to prevent child abuse and neglect can combine resources to prevent physical and emotional harm to children, build strong families, and help communities thrive.

Finding a method of identifying families most in need of services poses a number of challenges. Care must be taken to not make false assumptions based on race and/or poverty. The goal must be to design a national strategy that manages to create a balance that both provide intensive services for the few and preventive services for the majority.

Participants emphasized that there is a need to clarify the elements associated with each prevention level. The goal is to gain a better understanding of the essential program characteristics to be included in a comprehensive public health approach to combating child maltreatment. Participants recommended a review of successful domestic and international programs and best practices be investigated. Given the evidence of positive outcomes, the British Sure Start System was one example mentioned (http://www.surestart.gov.uk/). Other suggestions centered on reviewing the U.S. Children's Bureau emergency care system and the integration of public health and child welfare approaches that took place in the 1970s.

Child Well Treatment Education and Early Skill-Building for Parents

Promoting "child wellness" should be grounded in the principles of child development. These principles were posed as a way to enhance a child's potential as well as create a positive and receptive message for prevention of child maltreatment. Providers should reinforce parents for positive and effective parenting. The importance of family development was also cited because it helps parents take an active role. All persons providing childcare, whether family or not, should be included in education efforts to understand the strengths and vulnerabilities of children, especially young children. Participants also noted that children with disabilities are more vulnerable than those without disabilities. Children with disabilities require a special focus.

Media's Role To Achieve Public Ownership of the Problem and the Solution

"It is clear that child abuse is not really on the radar screen. Unless it's a dramatic front-page story, it's not really of interest." (Carol Berkowitz, M.D., President, American Academy of Pediatrics) The workshop addressed the potential of the media to help raise public awareness as well as to facilitate educational outreach and skill building. Participants stated that well-formulated media campaigns would be helpful in educating the public about maltreatment and its victims enough to take ownership of the problem and work towards prevention. Among the media efforts that should be considered are: the Ad Council's public service ads, corporate cause marketing, and paid advertising.

"Sesame Street" and "Mister Rogers' Neighborhood" are recognized as powerful icons in children's media and among children and families because they are grounded in child development science while engaging the child. "The framework is based on working with the community." (Bill Isler, President, Family Communications) As such, these programs were identified as excellent potential resources for addressing child maltreatment. These are programs that parents and children can watch together. These programs are unique in that they are able to (1) communicate the child's perspective, (2) bolster self-esteem, (3) model healthy conversation, and (4) battle stigmatization. Supportive learning is especially critical in reducing maltreatment in children at risk, such as children with special needs and disabilities.

Another significant point that was emphasized was the importance of promoting messages that children are not at fault for causing maltreatment. "Because they are taught to believe it is their fault for letting bad things happen to them, children are often afraid to come forward, unknowingly allowing the maltreatment to continue." (Gary Knell, President and CEO, Sesame Workshop)

Many participants suggested having local news organizations tailor messages for their own community. This may help achieve public ownership and create the political determination necessary to drive effective actions. "However, mass media are not good at impacting individual behavior." (Ellen Wartella, Ph.D., Executive Vice President and Provost, University of California–Riverside) Other aspects of the discussion focused on the need for local support, the importance of continuity of leadership, and the stability of available resources.

Social Acceptance and Responsibility to Intervene and Ask for Help

There was discussion on the need for strategies on how to act or intervene when abuse or neglect is witnessed or suspected.. "We need to make the focus on children's healthy development as important as the focus on making money in this country." (Michele Booth Cole, J.D., Executive Director, Safe Shores-The D.C. Children's Advocacy Center) This situation with child maltreatment was likened to the social acceptability of smoking. As a result of antismoking campaigns, the social acceptability of smoking has changed over the past 10 years. It was hypothesized that with similar campaigns, people involved in aspects of a child's life would be able to prevent child maltreatment. "People know that it takes a village, but they don't know what the heck their role is in the village." (Michele Pierce, Principal of the Harriet Tubman Charter School, Bronx, NY) Experts and professionals must provide the community with the knowledge and skills to support families and protect children. It is important to promote the social acceptability of being helpful and asking for help.

It is necessary to mobilize communities and create community partnerships to help promote the understanding of and commitment to this issue. "Child maltreatment is a community issue and the community has responsibility. It is a fallacy to think that government can protect children. Family members, clergy, and neighbors: they protect children. We need to educate and engage the public." (Marc Cherna, Director, Allegheny County Department of Human Services) Effective child maltreatment prevention programs must address the roots the problem, including poverty, mental illness, and diseases of addiction. Participants cautioned about well-intentioned, but (potentially) misguided intrusions upon individual and family rights. It is critical not to over generalize. For example, sexual abuse is not necessarily linked to poverty.

Sustainable and Continuing Programmatic Efforts

Sustainability requires that programs be built on evidence-based models. These models should be administered over a defined period of time to document longitudinal effectiveness. Programming also should be flexible and adaptable to withstand the impact of inevitable changes in such areas as funding and leadership. Programs should be community based to maximize program effectiveness.

There was a discussion on the use of technology in programming. Two examples were the use of cell phones and the internet. One included using cell phones to provide young mothers with an immediate source of information about parenting and child health. This could be used "in real time" when the need and opportunity were the greatest. The Internet was also discussed as a powerful tool for dissemination of information.

Participants suggested that all relevant existing reports be reviewed and summarized. Other informal sources of information -schools, emergency departments, and faith-based organizations-should be explored. Another topic discussed was the difficulty of assessing the depth of child maltreatment across the socioeconomic spectrum and among children with special needs.

Systems Integration and Systems Change

There was strong support for a child- and family-centered systems approach. Systems integration would be best achieved through trust, transparency, respect, and shared resources. Accordingly, significant new provisions in the CAPTA promote collaborations between and among child welfare, public health, mental health, and developmental services. A successful example of systems integration was drawn from the human services model in Allegheny County, Pennsylvania. "The county integrated all financial assistance into five program offices. It integrated data systems and public information systems as well. Our focus is on holistic care, and we try to invest on the front end." (Marc Cherna, Director, Allegheny County Department of Human Services) Also recommended was incorporating mandatory family health and parenting education in juvenile correctional facilities. This suggestion reflected the consensus that educating parents early is the best way to prevent child maltreatment.

Shaping healthy child development is a function of many systems. The importance of quality early learning and preschool, as well as elementary, middle, and high school, was cited as "vital." Successful completion of school is related to staying out of trouble. Reassessment of child welfare and juvenile justice agencies, health and human services agencies, disability-based organizations, foster care providers, law enforcement agencies, and public health departments is needed to determine which areas are effective It is in the best interest of children to assess the quality of child welfare, juvenile justice, and foster care services. If this is not done, unintentional harm could arise. Two examples were offered: 1) prolonged delays for children in juvenile detention centers to receive mental health services; and 2) children being placed in multiple foster care environments with only brief stays in each. To achieve systems change, public awareness and system accountability are essential.

Cultivation of trust, respect, transparency, and fair allocation of resources are important elements to overcome system barriers. There was a discussion on performance measures and Federal leadership to achieve effective systems integration. This is especially critical in attempting to secure adequate funding.

Cooperation Between and Among Organizations and Disciplines

Cooperation within public health departments is critical, particularly around sharing information in a timely fashion. One example of this is sharing findings from child death reviews. The value of systematically linking data, linking families with other needed health and human services in the community, and matching the needs of families with the appropriate professional services was stressed. "Achieving the public health approach won't be possible unless we pull together data across systems such as law enforcement, juvenile justice, the courts, clinics, hospital rooms, emergency rooms, mental health, drug abuse, and alcohol." (Maxine Hayes, M.D., Washington State Health Officer) Nurses might be more effective than social workers if the families' prior experiences with nurses were positive and familiar. The importance of systems modification for police was raised. It is crucial to outfit officers with skill sets for community problem-solving and child maltreatment. Nontraditional partners can enhance system efficacy and efficiency. It was recognized that, although promising, it would take time for diverse workforces to become acquainted, engage in cross-training, and break down institutional barriers. "Engaging police departments in this debate would be important, since 99 percent of police chiefs are parents themselves." (Jim Bueermann, Chief of Police and Community Services, City of Redlands, California) Successful systems change requires streamlining and coordination, while preserving individuality and maintaining credibility.

Local Administration and Evaluation

Individual communities are best situated to determine their own specific needs. Identifying unique community-based assets and barriers is an important method for engaging families living in these neighborhoods. Local administration and evaluation offer direct accountability as well as opportunities for more immediate and responsive system improvements. However, creating partners at all levels may have the greatest impact on prevention of child maltreatment.

Full Access to Culturally Competent and Evidence-Based Prevention

Prevention and intervention programs should be widely available and easily accessible. Comprehensive approaches provide the best method for prevention as they are broad in scope. They provide the best opportunity to observe early signs and symptoms that may be more easily remedied before serious maltreatment occurs. Support for the entire family is needed to ensure that all family members are healthy and functioning optimally. In addition, intervention programs should be culturally competent. "The cultural strengths model focuses on tapping into the strength of a culture to find its resiliency factors." (Terry Cross, M.S.W., ACSW, LCSW, Executive Director, National Indian Child Welfare Association)

"Scientific advances to innovate, test, and implement the next generation of treatments are essential to move forward on child maltreatment prevention." (Robert Clyman, M.D., Executive Director, American Academy of Child and Adolescent Psychiatry, University of Colorado Health Sciences Center) It was noted that evidenced-based prevention programs can help in two important ways: (1) by diminishing the use of harmful interventions and (2) by directing efforts based upon proven effectiveness. Several areas of research were cited as needing an expanded evidence base for prevention efforts targeted at the following:

  • Abuse by caretakers (parents and others serving in a caretaker role)
  • Abuse by teachers, coaches, counselors, clergy, and childcare workers
  • Instances of abusive head trauma (formerly shaken baby syndrome)
  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Neglect (the most pervasive form of maltreatment)
  • Maltreatment co-occurring with domestic violence
  • Maltreatment taking place in urban/suburban, rural, and tribal communities
  • Maltreatment taking place in poor, middle, and upper income households
  • Maltreatment taking place in all families
  • Child well treatment and health promotion.

It is important to maintain ethical dimensions of programs. For example, when children are in need of medical attention, low-income parents may avoid healthcare settings due to fear of child welfare systems, whether their fear is justified or not. In addition, addressing racial disparities is an important part of public health programs aimed at decreasing the prevalence of child maltreatment. The importance of establishing programs that focus on outreach to men and fathers, was also discussed.

Combating child maltreatment among children with special needs and disabilities was stressed. Participants suggested the following:

  • Help parents of children with disabilities understand their children's limitations. Provide the parents with information and continuing support;
  • Provide respite care for families and other caregivers to help reduce stress;
  • Provide children with disabilities with education about healthy sexuality;
  • Train caregivers and teachers about special needs and interventions to help prevent victimization of children with disabilities; and
  • At the community level, offer information and continued support for effective antidiscrimination programs.

Summary

The Surgeon General's Workshop, "Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach," focused on defining and achieving the public health approach to preventing child maltreatment. The workshop assembly discussed an array of issues related to a comprehensive public health model. These included implementing a public health approach, preparing proposals for evaluation, and developing ideas for modifying the public health approach. Several key themes emerged from the debate, emphasizing the following:

  • The "human face" of child maltreatment
  • Comprehensive primary, secondary, and tertiary care systems
  • Child well-treatment education and early skill-building for parents
  • Media's role in achieving ownership of the problem and the solution
  • Social acceptance and responsibility to intervene and ask for help
  • Sustainable and continuing programmatic efforts
  • Systems integration and basic systems change
  • Cooperation between and among organizations and disciplines
  • Local administration and evaluation
  • Full access to culturally competent and evidence-based prevention.

The workshop enabled experts and representatives from many public and private organizations to meet and discuss ways in which their offices could collaborate to form a united front against child maltreatment. Physicians, nurses, social service providers, media experts, public health officials, educators, psychologists, researchers, program administrators, judges, lawyers, CEOs, and police chiefs spent two days focused solely on the prevention of child maltreatment. Suggestions were made that will undoubtedly help transform relationships. It is no longer acceptable to put this population in the midst of a system in which no part is able to work effectively. This workshop was an important initial step. The workshop puts into action an all-encompassing public health approach to preventing child maltreatment.

The public health model calls for assessment and epidemiologic analysis, development of a plan and policy for reducing the problem, assurance that action occurs, and evaluation of the action to insure it produced the desired results. Workshop participants addressed the full spectrum of primary, secondary, and tertiary prevention efforts and the broader context of health optimization. Approaches were discussed, including the conduct of a community needs assessment; better identification of children suffering from emotional neglect; and new methods for identifying and reporting maltreatment to school officials, emergency departments, private physicians, clergy members, and youth workers in after-school programs.

The Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institutes of Health, the Centers for Disease Control and Prevention, the Administration for Children and Families, and other Federal agencies that focus on child maltreatment should help to expand the current knowledge base on the causes of maltreatment and on effective prevention methodologies. The causes and prevention methodologies should be studied using sound scientific methods. Next steps and successful interventions to confront the problem should be developed and evaluated.

There are a number of systems of care initiatives supported by SAMHSA. In addition, there are Safe Schools/Healthy Students programs in dozens of communities across the country. There should be a systematic examination of these. Furthermore, agencies should be aware of the provisions in CAPTA, in the Juvenile Justice and Delinquency Prevention Act, and other legislation that directs work on the Federal level. In turn, these efforts will translate into benefits for local practitioners and the children and families they serve.

"The Surgeon General and public health model bring rigor to the child maltreatment issue and provide a template for how to attack this problem in its entirety." (Shay Bilchik, J.D., President and CEO of Child Welfare League of America) The assembly agreed that by virtue of the scientific legacy and integrity, the Surgeon General of the United States is in a unique and powerful position both to improve visibility and to move the issue to the forefront with a sense of urgency.

"Child maltreatment has traditionally been thought of as a criminal justice issue. It is also very much a public health issue....The wrenching mental and physical health effects of child maltreatment continue for the child and the family long after he or she has been placed in a safe environment. And the frequency with which child maltreatment occurs in our society compels us to be aggressive in developing ways to stop it. It is my hope that together we will help shine a bright light on this problem and help find ways to end this scourge in our society."

(Surgeon General Carmona)

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