At the Child Abuse Recognition, Research, and Education Translation (CARRET) Conference, national child abuse experts representing different disciplines discussed and developed new strategies that would address the barriers to reporting suspected child abuse and improve the protection of children. This article describes the experts' analysis of the barriers to and strategies for improving the outcome for abused children, in addition to the steps planned to facilitate continued action.
A generation after the introduction of mandated reporting and the development of the child protection systems by the states, there are still major problems in effective communication and collaboration. These structural issues frustrated all of the conference participants: doctors, social workers, advocates, and families. As the articles and discussions presented in this journal supplement clearly illustrate, conference participants felt that improvements in these collaborations could save the lives of children and minimize the severe long-term consequences of maltreatment for many more children.
To translate these sentiments into action, conference participants, in facilitated small groups, discussed and debated the strategies presented by the speakers and panelists. Using a structured discussion format, they assessed feasibility and the potential impact of suggested systems changes and reforms. When the groups reconvened, key points were identified and prioritized.
The final panel focused on ways to improve relationships between reporters and state child protective services (CPS). Using a consensus approach in which participants revisited each strategy and then ranked them, the participants then determined their final priorities stemming from the conference, which formed the core of an action plan. The participants then planned potential mechanisms for implementing these recommendations. Specifically, they considered the organizations responsible for implementation, their roles, the actions needed to implement the strategy, and the logistics and other needed information. Finally, the conference closed with discussion about immediate and medium-term action steps.
In this manner, the various disparate groups were able to achieve agreement on high-impact priority areas for policy change and development, which are summarized below.
The following 5 barriers to effective protection of children and the strategies for addressing them (Table 1) were prioritized for implementation:
Barrier: Hospitals have varying interpretations of how the Health Insurance Portability and Accountability Act (HIPAA) applies in child abuse cases, which limits hospital-based personnel's ability to discuss cases with CPS. CPS regulations and practices vary according to locality, often preventing them from providing even the most basic feedback to mandated reporters concerning the outcome of their reports.
Strategy: Clarify and expand confidentiality regulations to improve communication and collaboration between CPS workers and other professionals.
Barrier: Research has produced much new knowledge about the identification and management of child maltreatment. The expanding knowledge base has resulted in the development of a new subspecialty: child abuse pediatrics. In addition, because this expertise is needed, some hospitals have developed centers of excellence following guidelines published by the National Association of Children's Hospitals and Related Institutions (NACHRI).1 The American Academy of Pediatrics (AAP) has developed the Health Child Abuse Research, Education, and Service (CARES) Network proposal, which would provide federal support for centers of excellence.
Strategy: Develop and support multidisciplinary centers of excellence that would provide consultation, referrals to other services in the community, research, surveillance, and training to support and provide resources to reporters.
Barrier: Some areas of the country are sparsely populated and cannot effectively use a full-time specialized child abuse team.
Strategy: Develop more mobile methods and assemble regional service teams for assessment of possible child abuse and neglect.
Barrier: No standards specify the quantity or quality of education that medical students, pediatric residents, or other physicians should receive about child maltreatment.2 Many physicians indicate that they feel inadequately trained to identify and manage child maltreatment.
Strategy: Develop a comprehensive educational strategy that builds knowledge and experience from medical school and residency through continuing education once a clinician is in practice, including segments that describe prevention, identification, and interaction with the state CPS system. Training should include specific knowledge about CPS policies, services, and outcomes of intervention.
Barrier: Poor communication and collaboration between the professionals who evaluate, investigate, and adjudicate child maltreatment can lead to ineffective or inappropriate intervention. Poor communication may result from the lack of understanding of the roles of the other professionals. This misunderstanding often includes unrealistic expectations about the power and scope of the other professional's work.
Strategy: Clarify the roles of the different professionals who evaluate, investigate, and adjudicate child maltreatment. Encourage and facilitate collaboration between medical, law enforcement, and CPS by including the other professionals in the training to explain their respective roles. One example of how this strategy could be implemented is Pennsylvania's Educating Physicians in the Community (EPIC) program. In the EPIC training, CPS workers participate in physician training about child maltreatment.
A 2-pronged strategy was implemented to evaluate the conference. First, participants completed a paper-and-pencil evaluation survey on-site at the end of the conference. Second, an action group was convened via telephone in the spring after the conference to review the priority areas, finalize the next steps, and begin work on action steps after the call.
Conference attendees completed a brief survey developed by project staff and coinvestigators to determine the utility of each topical discussion; what perception/attitude/assumption changed because of the conference; their thoughts on the most important result/output of the conference and how it might influence their own organization's work; and what their preferred next steps were.
Many of the participants said that the conference had changed an assumption or a perception. They described a better appreciation of the problems confronting other professionals, particularly CPS (eg, “I never realized how downtrodden CPS felt”). Nonphysician participants were surprised to learn that not all physicians have received adequate training about child maltreatment. Most were surprised to learn that other professions were interested in improving the care and management of maltreated children.
The participants indicated that the most important results of the conference were the multidisciplinary collaboration, the consensus reached, and the strategies that were developed, including “concrete ideas for increasing multidisciplinary training and reaching community docs.” Many suggested that the conference had modeled the multidisciplinary approach that was needed.
Many of the participants had concrete ideas for how the conference would influence their own or their organization's work. Improving education and collaboration were the predominant themes. Some said that they planned to implement interdisciplinary training by using some of the models or ideas discussed at the conference.
When asked about the next steps they would like to see taken after the conference, many said that they wanted to see the results of the conference disseminated. Most wanted to see the process continued and have “a smaller group try to flesh out some ideas expressed in the conference” or a “follow-up conference to exchange ideas about what has or hasn't worked.”
Action-Group Conference Call
An action group comprising 8 members was formed to follow-up on the conference recommendations and continues to meet via conference call. The action group charged with following up on the conference evaluated each of the priority areas along the following domains:
Impact (in getting desired results)
Feasibility (barriers to implementation, resource availability, etc)
Support (priority/commitment from implementers and other stakeholders, political will, etc).
Several action steps have been taken to address some of the barriers that were identified. The American Professional Society on the Abuse of Children (APSAC) has developed guidelines describing the roles and responsibilities of each professional involved in the evaluation, investigation, and disposition of children who have been maltreated. The guidelines include sections related to law enforcement, child protection workers, forensic interviewers, district attorneys, health care professionals, mental health professionals, and juvenile court judges. The guidelines describe the information that professionals needs to complete their assessment, investigation, or intervention, the challenges they face, and the limitations of the scope of their work. These guidelines will be published soon.
The AAP Committee on Child Abuse and Neglect (COCAN) is in the process of developing a policy statement that discusses the issue of HIPAA, confidentiality, and child abuse. The National Association of Children's Hospitals and Related Institutions has expressed an interest in developing a policy related specifically to HIPAA regulations for hospitals, or they may work with the COCAN to incorporate language specifically related to hospitals in their policy if possible. In addition, for 2 years the AAP has been advocating aggressively in Congress for funding of the Health Child Abuse Research, Education, and Service Network proposal to address these issues in the medical field.
The Child Abuse Recognition, Research, and Education Translation (CARRET) Conference achieved its goals of developing a shared understanding of the current status of the interaction between health care providers and state agencies, developing partnerships with stakeholder organizations, and developing strategies to disseminate the results of the conference from a variety of disciplines. This conference was a small step in a very large process that is needed to improve the collaboration between all the professionals involved. It is encouraging that action has already been taken to overcome some of the barriers that prevent children who have been maltreated from receiving the most effective intervention and best outcome.
- Accepted May 28, 2008.
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Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵National Association of Children's Hospitals and Related Institutions. Defining the children's hospitals role in child maltreatment. Available at: www.childrenshospitals.net/AM/Template.cfm?Section=Child_Abuse2&Template=/CM/ContentDisplay.cfm&ContentID=11634. Accessed February 27, 2008
- ↵Christian CW. Professional education in child abuse and neglect. Pediatrics.2008;122 (3). Available at: www.pediatrics.org/cgi/content/full/122/3/S13
- Copyright © 2008 by the American Academy of Pediatrics