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

Surgeon General's Workshop Proceedings

Lister Hill Auditorium
National Institutes of Health
Bethesda, Maryland
March 30–31, 2005

United States Department of Health and Human Services
Office of Public Health and Science
Office of the Surgeon General

NOTE: This document summarizes the views and issues addressed by invited speakers and discussants at the Surgeon General's Workshop Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach. The views expressed in these Proceedings reflect the opinions of the individual participants at the Workshop and do not necessarily reflect the official position of the Office of the Surgeon General, the Department of the Health and Human Services or other federal entities.

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

Prologue

"I can think of no terror that could be more devastating than child maltreatment, violence, abuse, and neglect perpetrated by one human being upon another...I believe it is time for critical thinking to formulate a new national public health priority, preventing child maltreatment and promoting child well treatment."

(Surgeon General Richard H. Carmona, M.D., M.P.H.)

The 2005 Surgeon General's Workshop on Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach was convened to discover and elucidate 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 2005 Surgeon General's Workshop on Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach was uniquely structured to enable and encourage active exchange of ideas and debate among caring and committed colleagues from diverse backgrounds. Participants 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.

The 2005 Surgeon General's Workshop on Making Prevention of Child Maltreatment a National Priority: Implementing Innovations of a Public Health Approach was a part of the Surgeon General's 2005 Year of the Healthy Child Agenda examining issues surrounding the health and well being of children focusing efforts on the body, mind and spirit of the growing children throughout the Nation and the world.

In responding to the question - what is child maltreatment? Surgeon General Carmona replied, "It is unacceptable and it is preventable!"

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

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)

Surgeon General's Workshop Agenda
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

Wednesday, March 30, 2005

8:30 a.m.

Introduction and Welcome
RADM Woodie Kessel, M.D., M.P.H., Assistant Surgeon General
VADM Richard Carmona, M.D., M.P.H., FACS, U.S. Surgeon General

8:45 a.m.

Child Maltreatment in America
Cristina Beato, M.D., FAAFP, Acting Assistant Secretary for Health
Wade Horn, Ph.D., Assistant Secretary for Children and Families
RADM Kenneth Moritsugu, M.D., M.P.H., Deputy Surgeon General
Susan Orr, Ph.D., Associate Commissioner, Children's Bureau

9:00 a.m.

Family and Survivor Perspectives
Cici Porter, Singer/Songwriter/Survivor
George Lithco, J.D., Parent and Founder of the Skipper Initiative

9:30 a.m.

Fitness Break

DEFINING THE PUBLIC HEALTH APPROACH TO PREVENTING CHILD MALTREATMENT: KEY ELEMENTS

9:45 a.m.

Child Health and Development, and Public Health Systems Integration
Moderator: Carol Berkowitz, M.D., President, American Academy of Pediatrics
Expositeurs:
Neal Halfon, M.D., M.P.H., Professor, University of California at Los Angeles
Sharon Ramey, Ph.D., Professor, Georgetown University
Maria Gomez, R.N., M.P.H., Director, Mary's Center for Maternal and Child Care

10:15 a.m.

Discussion

11:15 a.m.

Parent, Family, Community, and Society: Influences Shaping Development
Moderator: Cindy Christian, M.D., Professor, Children's Hospital of Philadelphia
Expositeurs:
David Olds, Ph.D., Professor, Kempe Prevention Research Center, University of Colorado
Dorothy Marge, Ph.D., Assistant Professor, SUNY Upstate Medical University
Stacey Cunningham, M.S.W., National Black Child Development Institute

11:45 a.m.

Discussion

12:30 p.m.

Lunch

2:00 p.m.

Formative and Operational Systems Change
Moderator: Gary Knell, J.D., President, Sesame Workshop
Expositeurs:
Marc Cherna, Director, Department of Human Services Allegheny County
Michele Booth Cole, J.D., Executive Director, Safe Shores

2:30 p.m.

Discussion

3:30 p.m.

Fitness Break

3:45 p.m.

Summary of Key Elements of the Public Health Approach
Catherine Nolan, M.S.W., ACSW, Director, Office on Child Abuse and Neglect
Charles Wilson, M.S.W., Executive Director, Chadwick Center for Children and Families, San Diego Children's Hospital and Health Center

4:15 p.m.

Day Two Preview
Assistant Surgeon General Kessel

 

Thursday, March 31, 2005

8:30 a.m.

Review of Day One – Introduction to Day Two
Assistant Surgeon General Kessel

KEY ELEMENTS FOR ACHIEVING THE PUBLIC HEALTH APPROACH TO PREVENTING CHILD MALTREATMENT

8:45 a.m.

Parent and Family Innovations and Opportunities for Prevention
Moderator: Katherine Gottlieb, M.B.A., President/CEO, Southcentral Foundation
Expositeurs:
Cindy Lederman, J.D., Presiding Judge, Miami-Dade County Juvenile Court
Terry Cross, M.S.W., ACSW, LCSW, Executive Director, National Indian Child Welfare Association
Rob Clyman, M.D., American Academy of Child and Adolescent Psychiatry

9:15 a.m.

Discussion

10:15 a.m.

Fitness Break

10:30 a.m.

Community and Society Innovations and Opportunities for Prevention
Moderator: Jim Bueermann, M.B.A., Chief of Police, Redlands California
Expositeurs:
Maxine Hayes, M.D., Washington State Health Officer
Michelle Pierce, Principal, Harriet Tubman Charter School
Bill Isler, President, Family Communications

11:00 a.m.

Discussion

12:00 p.m.

Lunch

1:30 p.m.

Critical Thinking for a New National Public Health Priority
Moderator: Kevin Dinnin, CEO, Baptist Child and Family Services
Expositeurs:
Ed Schor, M.D., Vice President, The Commonwealth Fund
Calvin Johnson, M.D., M.P.H., Secretary of Health, Commonwealth of Pennsylvania
Ellen Wartella, Ph.D., Executive Vice Chancellor/Provost, University of California-Riverside

2:00 p.m.

Discussion

3:00 p.m.

Fitness Break

3:15 p.m.

Summary of Key Steps for Achieving the Public Health Approach
Shay Bilchik, J.D., President/CEO, Child Welfare League of America

3:45 p.m.

Preventing Child Maltreatment and Promoting Child Well Treatment
U.S. Surgeon General Carmona

4:00 p.m.

Closing
Assistant Surgeon General Kessel



Surgeon General's Workshop Discussion
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

Wednesday, March 30, 2005

Introduction

RADM Woodie Kessel, M.D., M.P.H., Assistant Surgeon General and Deputy Director for Medicine and Science, Office of Disease Prevention and Health Promotion

Dr. Kessel opened the workshop by noting that individuals from 25 states and many disciplines were present. Because the meeting was broadcast over the Web, comments and questions were forwarded from the Web audience.

Dr. Kessel introduced U.S. Surgeon General Richard Carmona and provided some background on his work experience and medical career. He noted that Dr. Carmona brings to the job compassion, humanity, caring, and a commitment to families.

Welcome

VADM Richard Carmona, M.D., M.P.H., FACS, U.S. Surgeon General

Dr. Carmona noted that the workshop was about developinging a public health approach to child maltreatment. It is time for critical thinking to prevent child maltreatment and promote child well treatment. The workshop was a major part of an ambitious agenda for 2005: The Year of the Healthy Child. This theme focuses on promoting the holistic health of all children. Goals include highlighting ways to strengthen the bodies, minds, and spirits of children; discovering ways to incorporate child development and literacy; and enhancing systems and sustaining an inclusive public health framework.

As Dr. Carmona stated, April is Child Abuse Prevention Month. In 2002, approximately 900,000 children were victims of child maltreatment. He noted that, in March 2005, a joint press conference was held with Administration for Children and Families (ACF) Secretary Wade Horn announcing the convening of a Surgeon General's Workshop on the prevention of child maltreatment using a public health approach.

Dr. Carmona related that a variety of different fields were represented at the workshop and the agenda was designed to spark conversations among participants. The workshop was much like a senior staff meeting to discuss issues. The focus was on discovery: what is needed, what is working, what is not working, and what the opportunities are.

He said that the only question not to consider was: Why? He stated: "The answer is obvious…because these are our children. They are our legacy and our gift to the future. There is so much to do. We need to help close the gaps and move this issue forward so that every child has an opportunity to prosper."

Child Maltreatment in America

Susan Orr, Ph.D., Associate Commissioner, Children's Bureau (speaking for Wade Horn, Ph.D., Assistant Secretary for Children and Families)

Dr. Orr emphasized that the Children's Bureau cannot work alone to prevent child maltreatment and it welcomes the opportunity to talk with other sectors. Trends show an annual decrease in the number of children who are maltreated, but there are still too many children who are (2,400 each day; 1,400 dead from maltreatment in 2002). ACF's Children's Bureau works under the Child Abuse Prevention and Treatment Act (CAPTA), which provides broad guidelines and grants to states to operate programs. The program supports the development of networks. Discretionary dollars focus on systems of care grants, which are now in their second year of operation. Child welfare agencies need to do a better job of working with other agencies, especially in ensuring children's safety and protecting their well-being, as well as in providing a coordinated response to child abuse and neglect.

Dr. Orr discussed some of the resources available to the public. The National Child Abuse and Neglect Information Clearinghouse (NCCAN) has partnered with national prevention organizations to develop a packet of information and materials. NCCAN's Web site is being updated with features including literature reviews on "what works," a Web-based toolkit, and links to organizations.

In 2003, the Children's Bureau commissioned a follow-up to a report on emerging practices in the prevention of child abuse and neglect. The Children's Bureau funded eight projects for 5 years to replicate and evaluate the family connections and neglect prevention programs based at the University of Maryland at Baltimore. She noted that while there are other effective programs, there clearly is a gap. Dr. Orr discussed the details of the President's budget and noted that increased funding and flexibility are needed.

RADM Kenneth Moritsugu, M.D., M.P.H., U.S. Deputy Surgeon General (speaking for Cristina Beato, M.D., Acting Assistant Secretary for Health)

Dr. Moritsugu noted that child maltreatment, including all of its horrific dimensions, is uncomfortable. While there is a need to focus on data and science but we must also keep in the forefront the human face of child maltreatment. He introduced two courageous Americans present at the workshop to help participants explore the topic.

Family and Survivor Perspectives

Cici Porter, Director, Journey to Wholeness Project (Singer, Songwriter, Survivor)

Ms. Porter is an incest survivor. Her abuse started when she was in diapers, culminating in rape at age 5–6. She travels around the country, sharing music and stories to inspire people and help them understand abuse. Ms. Porter shared a song that she composed based on a male friend who experienced incest in his family.

Ms. Porter then related her own experiences growing up in an upper middle class family with a father and paternal grandmother who were perpetrators of child sexual abuse. She noted that most child molesters are uncles, fathers, grandmothers; they are close- they don't jump out of the bushes. She called for continuing research on treatment options. Ms. Porter closed her presentation with another song about being a "warrior."

George Lithco, J.D., Founder of the SKIPPER Initiative (Survivor Parent)

Mr. Lithco is the father of an 11-month-old boy who died after being shaken by a home day care provider in 2000. He founded the SKIPPER initiative, which provides information about Shaken Baby Syndrome (SBS). He commented on a New York State bill that requires hospitals to provide opportunities for new parents to watch a video on SBS. He stressed that people should never leave their child with someone they think is going to hurt the child. He added that those most likely to shake children are parents themselves. A North Carolina study found that 2.6 percent of parents have admitted to shaking a child. Annually, between 1,200 and 1,400 children are shaken enough to require medical attention, and a quarter of these children die.

About 300 children in the United States die each year as a result of being shaken. He commented that even though it is difficult, there is a need to have conversations with everyone who cares for children. The message has evolved from "Don't ever shake a baby" to "We want to help you protect your child from injury." The SKIPPER Initiative brochure contains information to share with providers so they will not lose control. The idea is not to communicate an us-versus-them scenario.

The SKIPPER Initiative program operates in a number of hospitals in New York State. There are approximately 10 programs across the country focusing on this issue.

One model program involves a short video titled, "Portrait of Promise," which was developed in 1998 by Mark Dias of Children's Hospital in Buffalo. The video educates parents on putting children to sleep and anger management. Marilyn Sandberg-Barr from the National Center has another video used in Utah.

It is important to educate people who are about to become and those who have just become parents. Mr. Lithco stated that there is a need to help people deal with frustration, anger, and an infant or child's crying. An America Online survey released on March 29, 2005, found that 60 percent of parents reported control over their child's behavior is most important to them. This is a social problem.

Dr. Kessel closed the session by noting that participants have seen the human face of child maltreatment. He mentioned a Masai tribal greeting-"Kesserian Ingera?"-that means "How are the children?" This greeting indicates the importance of children in the Masai society. It is a hopeful greeting focused upon the future. He noted that through caring, we will put Ms. Porter's and Mr. Lithco's stories into perspective and change the ending of their stories for all children.

DEFINING THE PUBLIC HEALTH APPROACH TO PREVENTING CHILD MALTREATMENT: KEY ELEMENTS

Child Health and Development, and Public Health Systems Integration

Dr. Kessel reviewed the structure of this interactive session. The moderator would make opening comments and "expositeurs" would provide initial comments/observations to stimulate participant exchange.

Moderator: Carol Berkowitz, M.D., President, American Academy of Pediatrics

Dr. Berkowitz shared three comments to start the discussion:

  1. Legislation in California designates the fourth Monday in April as a memorial day to remember children who have been killed.
  2. In discussing child health issues with a magazine editor in New York City, it was clear that child abuse is not really on the radar screen. Unless it is a dramatic front-page story, it is not really of interest.
  3. The American Academy of Pediatrics is involved in a child development initiative funded by the Doris Duke Foundation. The initiative will create toolkits for parents that can be used by pediatricians.

Expositeur: Neal Halfon, M.D., M.P.H., Professor of Pediatrics, Public Health and Public Policy, University of California Los Angeles Center for Healthier Children, Families and Communities

Dr. Halfon discussed "Service System Strategies To Optimize Child Health and Development and Minimize Maltreatment." He noted that health and development are inextricably linked. The Institute of Medicine/National Research Council report, "Children's Health, The Nation's Wealth" is significant, marking the "third era" in redefining health. Dr. Halfon explained that this new definition says that "children's health is the extent to which an individual child or group of children is able or enabled to develop and realize his or her potential, satisfy his or her needs, and develop the capacities that allow the child to interact successfully with his or her biological, physical, and social environments". This is not a deficit-based definition. This developmentally focused definition looks at how to optimize the capacities of children over their life course.

Dr. Halfon explained that early trauma influences a cascade of developments and interactions, which can manifest immediately or decades later. While poverty and lack of health services are examples of negative influences, protective factors can influence children positively. He commented that it is necessary to think about how to optimize the positive and minimize the negative influences.

He provided statistics on the number of children at risk under this definition (2 percent to 4 percent of children with disabilities; 2 percent to 4 percent of children cycling through child protective services; 10 percent to 14 percent of children with special health needs; and 30 percent to 40 percent of children functioning suboptimally because they are impaired). A higher proportion of low-income children are vulnerable. Approaches include trying to identify children and move them out of the vulnerability area; targeting a shift of the entire population out of the vulnerable range and into the positive area; and moving the whole curve forward to get all children out of harm's way.

Dr. Halfon said that it is necessary to link the four systems that deal with children- clinical services, public health, universal interventions, and civic society-in a more comprehensive way. He provided a list of strategic issues, noting that the new mantra must be not just prevention but also optimization of all children's healthy development.

Expositeur: Sharon Ramey, Ph.D., Director, Georgetown Center on Health and Education, Georgetown University

Dr. Ramey explained how new technologies are allowing researchers to study child maltreatment. For example, in one study, cell phones were used as tools to find out where mothers and babies were and what their interactions were. This observational study found that mothers of all ages and income levels liked to use the cell phones and they relayed information to researchers. A quarter of the participants thought this was an intervention (it was not). It caused mothers to notice things about their children, and mothers said it made them become better mothers. The study also detected urgent conditions reflecting the most common cause of neglect-neglect due to ignorance. In four cities, it commonly was found that not everyone knew about health, safety, or cognition.

Television programs are being used to help promote positive parenting. Dr. Ramey commented on a national public television series funded by a foundation and based on books authored by Dr. Ramey and her husband. Often the didactic educational approach is not the best way to provide information. Literacy is an issue, and new ways must be found to disseminate information about evidence-based practices.

On another point, Dr. Ramey stressed the importance of listening to children. There is a need to explore techniques that do not involve asking children direct questions. There is a strong culture of silence in our society. It also is necessary to talk about whether adequate tools exist to translate research and discoveries into real-world practice.

Expositeur: Marie Gomez, R.N., M.P.H., President and CEO, Mary's Center for Maternal and Child Care, Inc., Washington, DC

Mary's Center was started 20 years ago at the time of the Central American conflict. The organization borrowed from a public health approach and was designed to stabilize and support families. Today, the center still works with immigrant families. It is important to stabilize families and also to create opportunities for the next generation. The literacy program targets parents so they can learn skills. The center promotes a safe and comfortable family environment. Ms. Gomez related that it is necessary to target goals so that children are healthy, supported, and ready to learn. This is an example of "shifting the curve."

The home-visiting strategy incorporates six Healthy Families America core program components: intensive (meet with families individually on a regular basis); comprehensive (address a range of issues); long term (at least 3 to 5 years); flexible; culturally appropriate (determine cultural norms based on family strengths and values); and cost-effective ($3,500 per family a year).

DISCUSSION

David Olds, Ph.D., University of Colorado Health Sciences Center, asked what systems approaches can produce? What is the added value of systems above individual programs?

Dr. Halfon responded that there are no good evaluation data on major systems. England's Sure Start program has some data from which participants can learn. The program is designed to end poverty and provide early childhood intervention. Approximately 500 to 600 communities are enrolled now, and evaluations of the impact on individual families and communities are under way. There have been discussions about looking again at the Infant Health and Development Project (IHDP). There are no data on what happens to individuals when multiple approaches are brought into communities.

Maxine Hayes, M.D., Washington State Department of Health, noted that the public health approach focuses on prevention; many systems could be involved in preventing child maltreatment, but they are failing. This is not because we do not know what to do. One big factor to consider is whether a pregnancy is intended or not. In Washington, resources have been linked to access reproductive health services before a child is born. The state brings resources together (child care, courts, health care) to help ensure each child coming into the world is intended. We must focus on things that we know work and take positive actions across systems.

Desmond Runyan, M.D., DrPH, University of North Carolina, noted a court case at which he testified and stated that we need an "OnStar button" for child maltreatment emergencies. Joy Osofsky, Ph.D., ZERO TO THREE and Louisiana State University, said that coordination across systems is important, but so is the idea of listening to different voices. If we cannot raise awareness about abuse and neglect, we will not be able to make progress. The media must help raise awareness. Otherwise, we just keep talking to one another as we have done with other public health approaches.

Ronald Prinz, Ph.D., University of South Carolina, noted that in trying to design a national strategy, an implicit tension between perspectives is important. Services must be intensive, but it is not possible to deliver intensive services to most families needing to be engaged in the preventive process. What are the minimum sufficient interventions needed to impact children and families favorably (curve shift approach)? We must start with the population frame-not the one-family-at-a-time perspective.

Margaret Giannini, M.D., FAAP, Office on Disability, Office of the Secretary, said that it is good that disabilities have been delineated. But there are barriers to access, and they are not identified by whether they are in the maltreatment population. There are no statistics on that population or numbers broken out by facilities. All children with disabilities must be included in whatever strategy we propose.

Randy Alexander, M.D., Ph.D., University of Florida, remarked that he was impressed with the notion of life, liberty, and the pursuit of happiness-but this has not expanded to children. Virtually all children are vulnerable. How do we do curve shifting? More must be done legislatively, but more important is a change in societal outlook. It is difficult to get society to change when the media portrays children in provocative ways. We need to consider mass society approaches. The child development point of view is key.

Howard Dubowitz, M.D., M.S., University of Maryland School of Medicine, noted that for a long time, collaboration and integration have been important buzzwords. Noting Dr. Halfon's example of England's early development program, he said that there is a need for strong leadership in the United States from the community level up to the President.

Tom Birch, J.D., National Child Abuse Coalition, noted new provisions in the 2003 amendment to CAPTA promoting collaborations among child welfare services, public health services, mental health, and developmental services. The law mandates referral of substantiated cases of abuse and neglect of children under age 3 to the Individuals with Disabilities Education Act (IDEA) Part C program; there are opportunities for child victims to get treatment and attention.

David Chadwick, M.D., Ph.D. University of Utah, remarked that the only way to deliver prevention services is via people who are already in touch with families, such as personal health providers. But how do we get that to happen? That group needs to step up.

Michael Marge asked about the perception of when maltreatment becomes negligence in legal terms.

Dr. Halfon pointed out that there are intentional and unintentional ways that children are neglected. He deferred to Judge Cindy Lederman, or Jim Bueermann, City of Redlands Chief of Police, in terms of operationalizing maltreatment from a judicial or law enforcement standpoint. At a societal level, he suggested considering the consequences of labor practices, trends in marriage, and marketing and the media.

Marilyn Sandberg-Barr, National Center on Shaken Baby Syndrome, said that the challenge is finding a method of identifying families most in need of services without making false assumptions based on race and poverty. She noted a mapping project undertaken by Clyde Hertzman in Vancouver, Canada, and asked whether there were similar projects in the United States.

Dr. Halfon explained that Dr. Hertzman is using a 5-year-old early development inventory that examines cognitive, social, and emotional development, and then mapping at a school level to show how that relates to the services that are in that neighborhood (libraries, preschools, other services that children use). He is then showing the buffering effect and curve-shifting effect of those services on children in communities. Dr. Halfon did not know of anything similar to this mapping project in the United States.

Parent, Family, Community, and Society: Influences Shaping Child Development

Moderator: Cindy Christian, M.D., Co-Director, Safe Place: The Center for Child Protection and Health, The Children's Hospital of Philadelphia

Dr. Christian explained that the center focuses on issues of primary and secondary prevention for children. The center has developed programs for doctors around the state on child maltreatment. According to Dr. Christian, older male physicians have been reported to be less eager to report child maltreatment.

Expositeur: David Olds, Ph.D., Director, Kempe Prevention Research Center for Family and Child Health, University of Colorado, Health Sciences Center

Dr. Olds discussed the Nurse-Family Partnership Program, a program for low-income mothers having their first babies. The program started in 1977 and has been tested and refined since then. It was first tested in Elmira, New York, and then in other communities. The program has been found to have consistent effects, including reductions in prenatal health problems, fewer injuries, and significant improvements in school readiness. The program has had an impact on child abuse and injury rates. Findings from studies have been corroborated by reports in the medical record of injuries from parents.

The Washington State Institute for Public Policy (http://www.wsipp.wa.gov/) recently evaluated home-visiting and child welfare programs. The report is now available.

According to Dr. Olds, several years ago, the Office on Juvenile Justice and Delinquency Prevention suggested putting the program into high-crime neighborhoods.

A Web-based program allows monitoring of the Nurse-Family Partnership Program in all States. Public officials must invest in intervention-based programs.

Expositeur: Dorothy Marge, Ph.D., Research Assistant Professor, Department of Physical Medicine and Rehabilitation, State University of New York Upstate Medical University

Dr. Marge co-authored a book titled, A Call to Action: Ending Crimes of Violence Against Children and Adults With Disabilities. It is available on the Web at www.upstate.edu/pmr.

The book's focus is abuse and neglect of children with disabilities. This is a unique challenge that should capture people's attention. The book details crimes that are punishable by law and advocates treating perpetrators as criminals. The public health and legal communities must work together.

Six million children in the United States have disabilities-should they be treated inclusively or segmented for primary prevention? Children with disabilities are more vulnerable than their peers without disabilities. Dr. Marge listed factors related to vulnerability and proposed action steps that should be included in the Surgeon General's national plan to prevent acts of violence against children with disabilities.

Dr. Marge's proposed action steps include the following:

  • Inform expecting parents about special needs and disabilities.
  • Provide respite care to families and caregivers to help reduce stress.
  • Train children and parents in ways to reduce risk and exposure.
  • Educate children with disabilities about healthy sexuality.
  • Train caregivers and teachers about special needs to prevent victimization of children with disabilities.
  • Institute a national public awareness campaign about violence, abuse, and neglect perpetrated against children with disabilities.
  • Implement effective community antidiscrimination programs.

Expositeur: Stacy Cunningham, M.S.W., Senior Program Associate, National Black Child Development Institute (for Evelyn Moore)

The National Black Child Development Institute (NBCDI) works with communities to reduce the number of African American children languishing in the system. The organization does not advocate any specific approach. Ms. Cunningham discussed three national studies that provide useful information (Abecedarian study http://www.balancedreading.com/assessment/abecedarian.html, High Scope, Healthy Families America). Investing in quality early learning and preschool on the front end is key; when children complete school, they are more likely to stay out of trouble. Shaping healthy child development is a function of many systems. Family development is critical.

Ms. Cunningham discussed two model prevention programs. The Parent Empowerment Project is a premier education tool. It promotes positive parenting and healthy child development, and helps parents take an active role. SPARK: Supporting Partnerships to Assure Ready Kids is another promising project. The Washington, DC, public schools and District of Columbia Department of Public Health are involved in SPARK DC (http://www.nbcdi.org/programs/spark/sparkdc.asp).

There also is a need to focus on language and speech development. Children may suffer from abuse if they cannot hear their parents due to poor development. It is important to help parents track the health of their children.

Ms. Cunningham summarized the following three recommendations:

  • Provide universal pre-kindergarten education to all 3- and 4-year-olds. Every child deserves the right to a healthy start.
  • Make early childhood development a priority and fully fund it.
  • Provide access to health services, resources, and information. Culturally relevant services are vital.

Moderator Dr. Christian referred to a JAMA-published study conducted in Philadelphia of young children with common injuries (Lane et al, 2002). It found that young minority children who came in with accidental trauma were five times more likely to be evaluated for suspected child abuse and neglect and more than three times more likely than Caucasian children to be reported for suspected child abuse and neglect. There are segments of the population who avoid health care because they fear the child welfare system.

DISCUSSION

Judge Lederman reported that some families do not know how to access health care and children do not have doctors. Children's health often improves when they are in foster care. Public will is key: How do we bridge the chasm between practice and research? According to Judge Lederman, research can be used to make policy, but often there is no access to the research.

Ms. Gomez noted that individuals feel disempowered; schools are failing, and there is no adult education. Families are overstressed, and parents have no chance to succeed at parenting. Lack of income reduces opportunities they can provide for their children.

Dr. Christian noted that there is resistance to thinking about child abuse and neglect. More money is invested to treat and support diseases that people think can happen to anyone. How do we treat this topic so people do not glaze over it or lose interest?

Jerry Silverman, M.S.W., U.S. Department of Health and Human Services (HHS), noted that many children are in homes where a parent is subject to violence. Support is needed to prevent domestic violence. There is a need to persuade pediatricians to ask about domestic violence. The public health sector should collaborate with those who have expertise in this topic.

Megan Bair-Merritt, M.D., Children's Hospital of Philadelphia, noted her interest in the domestic violence–child abuse intersection. It is necessary to consider the abuse of women if child abuse is to be established as a national priority.

Dr. Olds pointed out that there are few evidence-based domestic violence prevention/treatment programs. (Eckenrode et al, 200; 2001; Fiscella et al, 1998; Olds et al 1986, 1995, 1997) The challenge is to develop effective interventions. There is the potential to do harm given the urgency around the issue.

Dr. Hayes was aware of the WIPP evaluation noted earlier. Despite the high return on investment, there is a reluctance to embrace this model because of cost at a time when state and local governments have little funding. We must be able to finance workable solutions; they will not be embraced or sustained without the funding.

Dr. Olds noted that public health officials in some communities are willing to identify and invest funds in budget areas where a program has an impact. Public officials are interested when they are shown evidence of a return on investment. Economic analyses and evidence are useful in persuading officials. It is necessary to first focus on research to devise effective interventions and test them so we do not come up with harmful interventions.

Elizabeth Edgerton, Agency for Healthcare Research and Quality, clarified that there is a gap in evidence regarding effective screening tools in domestic violence interventions. Are we focusing on treatment or prevention?

Elizabeth McCord, M.D., East Tennessee State University, stressed that the focus should not be solely on the victims. No one is talking to the men about how women are coming to be abused. There is a need for data on how to do this and how to access treatment when someone needs treatment. William Harris, Ph.D., Children's Research and Education Institute, commented on the need to create a narrative that says this problem exists and something can be done about it. There is a need to convince 535 members of Congress that the problem exists and that doing nothing hurts individuals and society. The participants' job is to create the narrative-the conspiracy of silence is their responsibility.

Andrew Hsi, M.D., M.P.H., University of New Mexico Health Sciences Center, asked Dr. Marge if she finds that elderly people are similarly placed in vulnerable situations in extended family systems-and whether there is a need to involve internists and geriatric specialists in this conversation and also examine how adult protective services systems are working in welfare systems.

Dr. Marge responded that it is necessary to consider the entire spectrum of age from birth to death of elderly people. During every phase of life, there are issues we must confront in terms of quality of life, health, and well-being.

Theresa Covington, M.P.H., National MCH Center for Child Death Review, commented that the discussion was complex and suggested looking at the embrace of the youth violence prevention cause in the mid-1980s as a successful model.

Byron Egeland, Ph.D., University of Minnesota, talked about implementation at the state and national levels and wondered how to address who the participants should be and how to keep those at risk involved.

Dr. Olds stated that we must address two issues: (1) Why would anyone want to be involved in a program? There must be a sense of vulnerability. (2) Do people believe that what is offered will reduce their vulnerability? Programs must be designed with these issues in mind.

Margaret "Bunny" Nicholson, M.S.W., Nicholson and Associates, said that child welfare system problems are rampant. She did not know of a state that has passed the standards. She directed a research project in the 1970s in which public health and child welfare merged via pediatric nurse practitioners. This worked and is a good model. Cross systems training between child protective services and domestic violence must take place. In terms of dealing with the media, one way is to volunteer to become more involved. For domestic violence screening, she suggested using a substance abuse research instrument. Many of those screened in Colorado for domestic violence have substance abuse issues (especially abuse of methamphetamines).

Katherine Gottlieb, M.B.A., Southcentral Foundation, asked where and how to empower adults to break the silence about their own harm? She commented on the need to include parents in prevention activities.

A comment sent in by e-mail noted that there is need of a new way to talk about child abuse prevention that focuses on child well-being and optimal development.

Formative and Operational Systems Change

Moderator: Gary Knell, J.D., President and CEO of Sesame Workshop

Mr. Knell emphasized that the media should play a major role in addressing the epidemic of child maltreatment. America does not own this problem. The statistics are mind boggling, but the story has not been told properly. Mr. Knell explained that Sesame Street was founded in 1969 as a way to use the power of television as a teacher to promote a positive influence on children. This summer, the Healthy Habits for Life program will launch an effort to deal with the child obesity crisis.

Sesame Workshop staff try to get into the minds of children as they plan programming. Sesame Workshop gives a voice to children that they can respect and adults can listen to. It works to bolster self-esteem in children; to model good communication (e.g., "You Can Ask" kits in three languages provided to children stressed by the events of September 11); to provide parenting tips on a level that both parents and children can understand; to humanize stories and deliver powerful messages in a developmentally appropriate way; and to break the culture of silence (e.g., Tami is a character who talks about HIV/AIDS in South Africa and coping with it as a problem of stigmatism and alienation).

Mr. Knell commented on the need to reach parents though the media: cell phones, television, DVDs, I-Pods. There is a need to connect with the American public around victims of this problem. The media is just one tool, but it is an important one to use in striving to help all children reach their potential.

Expositeur: Marc Cherna, Director, Allegheny County Pennsylvania Department of Human Services

Mr. Cherna described child abuse prevention efforts in Allegheny County, Pennsylvania, the 28th largest county in the country. The system is state supervised. There are 2,100 children in care. During the last 21 months, there have been no child abuse-related deaths. In 2004, there were 250 substantiated child abuse investigations. It is extremely difficult work. According to Mr. Cherna, the county could be doing better but has done many good things. It is helpful to remember that there will be people doing bad things, but they are in the minority.

He commented on the need to impact the areas of poverty, mental illness, and diseases of addiction. 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 protect children. There is a need to educate and engage the public. Community efforts in Allegheny County that are working include a holiday project in which the corporate sector provides gifts to children; Project Prom dress donations; an annual music festival; "Maxfest" (named after a local judge); and Little League. These efforts bring in money, engage people, and put a positive spin on activities. There also is a need to be open and inclusive. Allegheny County has open courts. The county has a complaint line and encourages people to use it. The county cannot be defensive and tries to fix a problem if it is a system issue. Families need to have a voice, and the county does a lot of family decision-making. It has built a network of supports and assistance; there are 33 family support centers in the county, as well as parent support groups, parent drop-in centers, visiting programs, and substance abuse supports. Staff also do visitations in family support centers for the families outside of the system.

An integrated Department of Human Services is advantageous, because it is easier to coordinate the multiple services that children need. The focus is on holistic care, and the department tries to invest on the front end. Federal dollars do not go far when divided among 2,600 entities doing child protective services.

Expositeur: Michele Booth Cole, J.D., Executive Director, Safe Shores-The D.C. Children's Advocacy Center

Ms. Cole opened by noting that the D.C. Children's Advocacy Center has photos of the staff as children posted on the wall-sometimes little things help in relating to children. Ms. Cole explained that she has worked at the policy level, for a judge, administering mentoring programs, and lobbying. She has seen a huge disconnect between research and practice. Staff try to think about their work, but often there is no time to ruminate. She encourages pulling different people to come together at the table. She commented on the need to spend time on the public will piece too. Raising money for this issue is tough, and there is a need to look at why people are so disconnected from the issue.

People are more accepting of a multidisciplinary approach and understand that agencies must talk and work together. While reducing trauma, healthy outcomes, and more efficient government are all good, the silo-and-turf approach is not helpful to child victims. Public health facilitates access to services. The ability to take this model to scale and replicate it exists. If more of a public health focus is placed on the how, maybe the direct service providers will not have to fight the battle again and again. The focus on children's healthy development must be as important as the focus on making money in this country. Dollars follow priorities. Ways must be found to bridge practice, policy, and research and ensure that research gets to the community level.

DISCUSSION

Dr. Osofsky noted that some people involved in research and policy are also service providers. There is a need for cross training of child protective services, law enforcement, the judicial branch, early intervention, mental health, and others. Mr. Cherna's program provides a good example of cross training. The model is good; it includes communicating across systems and giving children and parents a voice. Can this work in other areas?

Mr. Cherna said that it is possible to transfer the model elsewhere if one has the will and continuity. But building community trust and institutionalizing the model take time and are not easy. He clarified that his program does not do a lot of cross training, but it does do a lot of cross communicating. The issue is difficult due to staff turnover.

Dr. Alexander clarified some statistics, noting that 2,000 deaths per year is not a complete count. He encouraged participants not to use numbers as gospel. There are three to four times as many cases that are not captured. There is a need to be careful because the numbers are wrong; however, they are the best that are available. There also is a need to be careful about which type of abuse they are talking about. He said that he was not aware that child sexual abuse is related to poverty, as other types of abuse are.

Robert (Bob) Johnson, M.D., University of Medicine and Dentistry of New Jersey, noted that two years ago New Jersey took on the job of revamping its child welfare system. He suggested that it would be easier to do what participants had been discussing if there were no "system." There is a need to change existing systems and bring in practices that work based on research. This must be done in communities at the local level.

A Web participant, Nancy Duncan, St. Louis Children's Hospital, asked: How can interventions cause harm?

Maxine Stein, Stop it Now!, said that there is a need to focus on intervening before a child is harmed, but also to put responsibility on adults to take action and speak to people when they are concerned about behaviors that do not seem right. Work must be done through collaboration. One gets at true prevention via primary prevention.

Dr. Berkowitz noted that the American Academy of Pediatrics is concerned about the increase in domestic violence in the sector of troops returning from combat to civil life. This is a risk group that needs to be included in this discussion.

Mr. Knell commented that the Sesame Workshop is about to launch an outreach effort targeting these families.

Dr. Harris noted that money alone will not solve the problem. There are many serious issues to grapple with, such as poverty; yet people cannot continue to deny that child maltreatment is a huge issue. The need for resources that exists must be acknowledged. Money will not do it alone, but there is a need for the money.

Mr. Knell said that money follows ideas, and money follows the narrative. The political reality is that this issue has not yet been properly "sold." Political will and a strategy are needed.

Shay Bilchik, J.D., Child Welfare League of America, said that Allegheny County is a lesson learned regarding renovating a dysfunctional system.

Mr. Cherna noted that in addition to the county's hard work and efforts to gain public will, the county integrated all financial assistance into five program offices. It integrated data systems and public information systems as well. While there was initial resistance at the state level, the secretary is now fully supportive. Mr. Cherna explained in fuller detail Allegheny County's $740 million budget.

Marilyn Peterson, M.S.W., CAARE Diagnostic and Treatment Center, University of California Davis Children's Hospital, suggested pairing the researchers and the funding wizards to learn how to maximize the resources available and understand how to utilize funding streams.

John Holton, Ph.D., Prevent Child Abuse America, said that one can tell people what to do, but families might not have the wherewithal to do it. The Surgeon General should figure out how to maximize time from this meeting. There are several services models, including Healthy Families America.

Dr. Prinz noted that the role of prevention is to take stress off of formal systems. There are strategies that do not have to boil up from within one system. One example of this is the Wyoming Parenting Initiative. This initiative is funded by Department of Family Services, but it is open to all systems in which parents are involved. It is possible to have public health population-level approaches that destigmatize parenting improvement.

Diana English, Ph.D., Washington State Department of Social and Health Services, asked whether particpants were talking about primary, secondary, or tertiary prevention. There is a need to address specific age groups; adolescents are the next parents. She suggested discussing strategies that can help set a direction in the immediate future while building a base for long-term evidence. When one asks families what they want, they indicate they want different services from what they are offered (not that they do not want services).

Patricia Sullivan, Ph.D., Center for Abused Children With Disabilities, Creighton University School of Medicine, commented that the institutional abuse that takes place cannot be ignored.

Ms. Covington said that there are not many good primary prevention systems. Public health systems know little about social services. She stated that the foundation of their efforts must be to determine a way to make state public health and social services systems work together. Help building models for primary prevention is needed as well.

Mr. Knell commented on the need to focus on getting America to own this issue and stated that a powerful coalition can be built on behalf of children who do not have the political clout in this country. Dr. Kessel asked participants to pull their thoughts together and distill their ideas. While problem identification is the first priority, one homogenous solution will not work.

Summary of Key Elements of the Public Health Approach

Catherine Nolan, M.S.W., ACSW, Director, Office on Child Abuse and Neglect, Children's Bureau

Ms. Nolan commented that every April is Child Abuse Prevention Month. A community resource packet was distributed to communities in February both in English and Spanish. The packet and related resources are available on the NCCAN Web site at http://nccanch.acf.hhs.gov.

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

Mr. Wilson summarized the themes of the day and noted that participants must remember the children, the stories, and what motivates them. He remembered the moment in 1972 in Florida when he decided to do something about child abuse. It was after viewing a television advertisement showing babies crawling toward him and a voiceover that said: "Who Would Hurt a Little Child?" This is testament to the power of a single ad. Child abuse reporting in Florida skyrocketed after the placement of this ad. Mr. Wilson also shared a personal story, noting communication from his daughter's school about paddling. He said that children cannot comprehend that adults would hurt kids.

Mr. Wilson said that an underappreciated crisis exists. It is a public health crisis, the full scale of which is masked by secrecy and denial. It also is a social welfare crisis, a criminal justice crisis, an educational crisis. No one system or discipline has the answers. But there is synergy in our collective wisdom. It is necessary to learn from the public health model and the public health framework, and to look at what has been done before. It is necessary to first measure the problem. There is a need to create environments that reduce toxicity for children; programs must be accountable and measure outcomes. Targeted programs must be based on sound theory and a conceptual model. They must include adequate dosage and be culturally and developmentally appropriate.

How can maltreatment be prevented? One way is to invest in research to develop the knowledge base; there must be widespread adoption of evidence-based practices. There also is a need to identify related supports, such as funding, community resources, and organizational change.

He commented on the need to engage clients, institutionalize processes over time, think about strategies that impact on all systems, and create the public will to demand change at the national level. A campaign named National Call to Action: A Movement to End Child Abuse provides some lessons learned. For example, participants must speak with one voice and build a narrative; they must expand "collaboration and coordination"; there is a need for authentic voices that will empower adults to break the silence; they need shared leadership; and they must create a social movement that will demand change.

Mr. Wilson also discussed the need to find the right message-the words "child abuse" make people uncomfortable. How can the message be framed in a new way? It is necessary to make child abuse socially unacceptable. There is a need to take the long view: things that seem impossible do change in the blink of an eye. There are many problems in the system, but one cannot just turn off the system. There are children who are dependent upon the system, and there is a need to fix it. It may be worth revisiting past activities that have worked.

Mr. Wilson concluded that financing best practices and investing on the front end require money-and there is little of it. It is possible to invest public funds in programs that have evidentiary support, but it is necessary to be aware of unintended consequences. A good idea should not be applied in the real world in a way that makes no sense. Moving to an evidence-supported practice world is complicated.

DISCUSSION

Mr. Wilson asked for comments that inform action planning by the government.

Dr. Prinz said that it is necessary to define the guiding principles of prevention.

Barbara Bonner, M.Ed., Ph.D., University of Oklahoma Health Sciences Center, noted the need to clarify the public health role and the role of the Centers for Disease Control and Prevention (CDC).

Dr. Runyan said that public health has largely ignored child abuse and neglect, as well as injury. Public health agencies must be encouraged to be part of the discussion.

Dr. Chadwick commented that a major change and immediate role at a low cost could be achieved by having the public health sector move into the measurement area for child maltreatment and measure health harms.

Mr. Marge said that guidance from the Surgeon General is needed on the level of prevention to focus on. In terms of a plan, are participants considering recommendations within the context of constraints imposed by resources? Or are they looking at something more ideal, such as what is right for the country?

Ms. Gottlieb commented on the need to describe what family wellness is and redefine it with true cultural norms.

Dr. Osofsky remarked that from a public health perspective, generally the focus would be on primary prevention. But there is a compelling reason to focus on secondary and tertiary as well in an effort to stop the intergenerational cycle of violence. To prevent abuse and violence, it is necessary to stop the intergenerational cycle.

Dr. Halfon suggested moving beyond primary, secondary, and tertiary models to think more broadly. He pointed to the success of the One Child Health Initiative funded by the Robert Wood Johnson Foundation. He said that Federal agencies' rules often make it impossible to have meshed services (due primarily to cost accounting principles). He suggested looking at what is going on in England, Canada, and Australia for models of children's agendas. Participants can learn from what they are doing instead of reinventing the wheel.

Mark Chaffin, Ph.D., University of Oklahoma Health Sciences Center, said that the Surgeon General might be uniquely suited to promote positive parenting.

Dr. Ramey suggested collecting innovative and creative ideas. She noted that there is public evidence of other groups making inroads (i.e., the Business Roundtable for Education). The city of Seattle has an innovative program to reach families by providing information through grocery stores.

Dr. Hayes said that the Surgeon General could use the bully pulpit to underscore what communities can do. The measurement piece is the most important contribution that public health can make. The Department of Public Health in Washington State documented that children were dying and polled the public about their views. There is a need to clarify more accurately what people will react to. County commissioners are the decisionmakers in many communities, and it is clear that many local communities are not yet ready to move forward. They must be motivated to want to act. The child maltreatment message must be balanced with that of optimal healthy child development.

Mr. Wilson stated that the fundamental issue is that this is a public health crisis, and there is a need to learn from past public health experiences.

Dr. Kessel commented that the real sign of a good meeting is that it does not end on time because people are sharing ideas and thoughts.

Dr. Moritsugu concluded the first day of the workshop by noting that the sign of a good meeting is when time runs out before the ideas do. He summarized that the focus of Day One was on data, evidence, and the human face. Some participants raised questions about guidance from the Surgeon General. The Surgeon General and the Office of Surgeon General staff were present to listen and learn, but not to react or respond. In highlighting the gap areas, he asked participants to keep in mind that this workshop is not the end of a process but part of a process. He asked for participants' best recommendations to the Surgeon General and asked them to think about how to parse and prioritize resources.


Thursday, March 31, 2005

Review of Day One and Introduction to Day Two

RADM Woodie Kessel, M.D., M.P.H., Assistant Surgeon General and Deputy Director for Medicine and Science, Office of Disease Prevention and Health Promotion

Dr. Kessel opened the second day of the meeting by highlighting the issues discussed during Day One of the workshop.

He reported that presentations and discussions focused on data and the proper collection of information; creating and disseminating messages; adding specificity to clarify dimensions of the problem; the importance of primary, secondary, and tertiary prevention; the opportunity to create the next (third) revolution in public health (health promotion); the need for systems integration; the importance of resources along with the realization that it is possible to do some things with the resources that are available; the importance of education across the continuum; the impact of cross training; differentiating notions of "at risk" versus "high risk" versus "no risk" related to interventions to enhance the well-being of families and children; the importance of screening, follow-up, and follow-through; and system touch-points. He reminded participants of the importance of the community and household levels in addition to county, state, and national levels. Most important, participants discussed making sure their focus stays family- and child-centric.

Dr. Kessel stressed that the goal of Day Two was to look at what participants need to do next. What are the key elements for successful implementation? Who must be on board, and how can they accomplish key next steps?

He showed participants an image of the Stop Family Violence stamp (known as a "semi-postal") and pointed out that the stamp is not selling well. Dr. Kessel said that in his view, the stamp captures hope. It was created by 6-year-old Monique Macpherson Blais of Santa Barbara, California. Funds from the stamps will support programs such as the Safe and Bright Futures Program designed to stop the cycle of violence from children's exposure to domestic violence.

Dr. Kessel concluded by noting that the Surgeon General believes in action-he wants to focus on this issue and implement effective actions.

ACHIEVING THE PUBLIC HEALTH APPROACH TO PREVENTING CHILD MALTREATMENT: KEY STEPS

Parent and Family Innovations and Opportunities for Prevention

Dr. Kessel introduced Katherine Gottlieb, M.B.A., Southcentral Foundation, as an example of someone who has changed the focus of her organization to extend beyond primary care to a holistic program.

Moderator: Katherine Gottlieb, M.B.A., President and CEO, Southcentral Foundation, Anchorage, AK

Ms. Gottlieb related that domestic violence, child abuse, and child neglect occur in the whole population in Alaska. The Family Wellness Warriors Initiative involves men to address these issues. Through this project, Alaskans are breaking the silence and telling their stories publicly.

Expositeur: Cindy Lederman, J.D., Presiding Judge, Miami-Dade County Juvenile Court

Judge Lederman led the team that created the Dade County Domestic Violence Court, has been a member of the National Research Council's Committee on Family Violence Interventions, and served on the Council's Board of Children, Youth, and Families and Juvenile Crime Panel.

Judge Lederman discussed how juvenile courts can play a role in prevention efforts. By the time juveniles come into the system, if the courts cannot help them, no one can. Juvenile court is a place where cumulative disadvantage, impoverishment, and deprivation are everywhere. To be successful, it is necessary to modify human behavior. There needs to be a marriage of law and science in juvenile courts across America. If the courts understood the research, they would know better how to intervene. Judge Lederman said that one could define what the juvenile courts do as doing clinical work in a legal setting. This is why that work has to be interdisciplinary. One way the Miami court system has chosen to engage in prevention is to start with the youngest children in the child welfare system.

Dr. Osofsky, ZERO TO THREE, (http://www.zerotothree.org/)is part of the interdisciplinary team, and provides training on the cognitive and developmental functioning of infants. Judge Lederman said that the courts try to bring infants and toddlers to the forefront, changing the culture from being ignored to being the focus. The hope is that if they can intervene successfully, they can help children be ready to learn by the time they go to school instead of the children going to school, acting out, having problems, and finally having someone at the school diagnose those undetected problems.

The difficult part is stopping the intergenerational transmission of abuse. Judge Lederman added that parenting classes in this country are ineffective and do not deal with the level of parents' problems.

With the help of Dr. Osofsky, Judge Lederman's court developed a 25-week dyadic therapy program for mothers and babies. After 4 years of data, the program has been able to demonstrate promising improvements in the relationship between parents and babies.

Expositeur: Terry Cross, M.S.W., ACSW, LCSW, Executive Director, National Indian Child Welfare Association

Mr. Cross said that it is important to have tribal leaders at the table for discussion of this topic. Due to limited funding, child abuse prevention efforts are nonexistent in Indian Country. Of the 560 tribes across the country, all provide some form of child welfare services; most have their own tribal courts, their own child abuse codes, and their own child welfare programs. Most are doing child protection services.

In 1998, the National Indian Child Welfare Association and the National Clearinghouse on Child Abuse and Neglect conducted an exploratory study on child abuse prevention efforts in Indian Country. The study revealed that less than 1 percent of tribes had any ongoing prevention efforts at that time. Last year, a follow-up study found that just one of those tribes that had been providing prevention services in 1998 was able to continue doing so in 2004.

Mr. Cross noted that data show that child abuse rates among Indians have increased (it is unclear whether the increase is an actual figure or due to increasing numbers of tribes providing their own services, resulting in a higher count). Mr. Cross noted that passage of the Indian Child Protection and Family Violence Prevention Act in 1991 was a result of the disclosure of the number of child sexual abuse cases perpetrated by employees of the Bureau of Indian Affairs (BIA) and the BIA boarding schools. No funding has been appropriated for implementation of the law. He discussed various funding streams, such as entitlement funds and block grant funds, that do not reach tribal communities.

Mr. Cross discussed the cultural strengths model, which focuses on tapping into the strength of a culture to find its resiliency factors. He noted that a project is under way to gather information on resilience to isolate the items that represent cultural strengths. This work is being funded by the Children's Bureau through a grant that helps examine how to develop a better system for tribal communities to report child abuse and neglect data into the National Child Abuse and Neglect Data System database.

He concluded with a cautionary note about evidence-based practices, stating that no methodology has been able to reduce societal issues and complex human behavior associated with this issue. He noted that evidence-based practice is becoming the next wave of oppression-imposed outside solutions derived from Western models and Western thinking.

Expositeur: Robert Clyman, M.D., Executive Director, American Academy of Child and Adolescent Psychiatry, University of Colorado Health Sciences Center

Dr. Clyman discussed new opportunities to improve outcomes for maltreated children. He explained that there is growing evidence of the importance of genes in influencing outcomes and treatment. The risk for maltreating children may be genetically influenced. Nearly half of all children entering foster care are under age 3. This gap in age between age 3 and adolescence represents the best opportunity to make a difference. In partnership with the Denver Department of Human Services, his program reaches out and enrolls every baby under age 6 months who goes into foster care in Denver.

Empirical information is one way to potentially help improve major child welfare practice and policy.

Dr. Clyman called for three items to move forward on child maltreatment prevention efforts: (1) leadership that stands up and makes this a national priority; (2) grassroots support; and (3) scientific advances to innovate, test, and implement in the next generation of interventions.

DISCUSSION

William Harris, Ph.D., Children's Research and Education Institute, asked what happens to failing systems and programs-why are they not shut down? Is there any legal recourse?

Judge Lederman responded that the answer is yes, but it falls on us to take responsibility for this and to complain. Litigation is costly. Many states are on the verge of privatization.

Dr. Berkowitz asked about Judge Lederman's view of the adversarial relationship in juvenile court.

Judge Lederman replied that this is troubling; it is necessary to work as a team. Being adversarial just to be adversarial will not help anyone. In addition, with the Adoption and Safe Families Act, there is a very short time to deal with these families, and there is a need to work on solving the problem rather than legal maneuvering.

Ms. Nicholson noted that in Colorado, there is a movement by legislators toward a mandatory requirement of termination of parental rights at time of birth if there is any evidence (in the baby) of substance abuse by a parent. This is drastic and provides no leeway for judges. Judge Lederman pointed out that this is an example of the legislature intervening in the judicial role based on politics, not science, which is a major problem. There is a need to understand the research and have respect for it to help craft laws that make sense.

Dr. Ramey noted a program in Washington State-WAMI (Washington, Alaska, Montana, Idaho) in which Washington State provides medical education as a way to engage individuals from rural states where there is no state medical school. She echoed Mr. Cross' point about the Positive Indian Parenting Program and other local initiatives that are culturally grounded and accepted, and in which people see first-hand benefits-these programs do not get studied. Dr. Ramey called for more efforts to connect to scientific evaluations.

Ms. Gottlieb noted that there are foundations such as Robert Wood Johnson that fund measurement efforts.

Dr. Hsi said that the emphasis on toxicology screens has become overemphasized. He asked how communities are looking at that and wondered what potential community and legal responses might be.

Dr. Marge noted that Florida has an effective advocate for disabled persons, so that when situations reach the court, there is no adversarial relationship.

Dr. Prinz asked whether any of the parent and family innovations have been applied to the population level. If not, is there a specific model or recommendations about how to do that?

Dr. Clyman responded that the answer depends on the population. He was not aware that it is going on at the full population level.

Mr. Cross commented that there is a growing movement in tribal communities to define issues and prevention strategies culturally, but there are no resources to support this.

Brooke McClintic Griese, Ph.D., University of South Florida and the Judith Ann Griese Foundation, noted that there are some captive audiences that programs could target with prevention efforts (i.e., juvenile offenders). Hospital-based linkages to technology could be used, such as DVDs, to provide media that teach basic skills; schools could get out information to students.

Mr. Wilson noted that legitimate criticism is that this field does not have a tradition of applying good science to what it does. He encouraged the Surgeon General to focus efforts on building the science base and to test some child welfare prevention efforts to help sort out the "pearls of practice."

Judith Becker, Ph.D., University of Arizona, stated that there is no need to take a one-size-fits-all approach. There is a need to advocate for more evaluation of the effectiveness of a number of policies, particularly some of the mandated probation policies.

Mr. Marge asked Mr. Cross whether he has approached the Indian Health Service or BIA for funding.

Mr. Cross responded that he approached them and received some funding and offers of collaboration and support. But he said that the Federal Government is falling far short. Senator Smith from Oregon submitted a 4-E bill that would give tribes direct access to the 4-E provisions of the Social Security Act. This provision also has been included in the Welfare Reform Bill that recently came out of the Senate Finance Committee. This administration must step forward and say that it is time to pass that provision.

Mr. Cherna agreed that it is unconscionable that Indian tribes do not get Title 4-E funds. That is something the Surgeon General should hear and advocate for.

Dr. Osofsky said that in terms of the adversarial relationship in the courts, communication and partnerships are important so the judges recognize not only where expert witnesses are coming from, but also the experts recognize how much judges really value the expertise that helps them make better decisions related to the children. She added that cultural sensitivity is extremely important in trying to build strength within families and communities.

Dr. Chadwick commented that total information usually informs public policy, but it does not have to be this way. He described the continuous quality improvement (CQI) model.

Dr. (Randy) Alexander asked how the genetics angle might be used for interventions.

Dr. Clyman remarked that it is still early, but it is possible that the way psychosocial interventions are targeted will completely change based on genetic research.

Mr. Birch suggested that participants recommend to the Surgeon General that the Public Health Service aggressively promote prenatal care to underserved populations and communities all over the country.

Dr. Dubowitz stated that one strong, clear recommendation he would like to see is a commitment to building the knowledge base.

Dr. Ann Burgess, Boston College School of Nursing, commented on a study of abused children in which researchers looked at more than 800 children between the ages of 5 and 16 who were reported as sexually reactive children. The issue of multiple foster homes or multiple caregivers was found to be important.

Dr. Olds noted that collaboration and deep commitment are necessary to move the field forward. He noted that participants have an ethical responsibility to test and do their work more effectively.

Dr. Bair-Merritt added that participants must think about interventions and challenge themselves to ensure that they do not harm families.

Community and Society Innovations and Opportunities for Prevention

Dr. Kessel introduced the session by noting an article in the Washington Post Metro section on March 31, 2005, that highlighted the Sesame Street character Elmo and the Surgeon General talking about parenting. He reported that HHS is planning a National Children's Study to capture information on 100,000 children and families.

Moderator: Jim Bueermann, Chief of Police and Community Services, City of Redlands, California

Chief Bueermann discussed the roles and responsibilities of law enforcement, pointing out that most police activity is reactive. His discussion focused on prevention efforts. There is a movement today from primarily reactive orientation to community problem solving. There is a need to expand the knowledge base regarding how to better serve communities. Out in the field, it is the cops who have an opportunity to make a difference in the lives of families. This new model is called "risk-focused policing," and its genesis is in health care (see Hawkins and Catalano, University of Washington). Chief Bueermann presented maps related to risk-focused policing. He indicated that in individual neighborhood risk profiles, the darker the color, the higher the concentration of risk. He explained that where children live has something to do with the notion of risk. There is a need to look at a variety of connections like this in forming policy.

Expositeur: Maxine Hayes, M.D., Washington State Health Officer, Washington State Department of Health

Dr. Hayes stated that a clear articulation of the public health approach is needed. There is a need to promote optimal child health and use it as a construct. Dr. Hayes detailed the three core functions of public health via the 10 essential services of public health. Every grant proposal submitted to CDC and other Federal agencies needs to include these elements. She commented on the need for policy and environmental changes that can create conditions in which it is optimally possible to promote child health.

Dr. Hayes noted the need for surveillance systems that can provide a full picture. Community-based child death review teams are extremely helpful in providing information that can lead to systems change. Achieving the public health approach will not be possible unless data are pulled together across systems such as law enforcement, juvenile justice, the courts, clinics, hospital rooms, emergency rooms, mental health, drug abuse, and alcohol. One of the fundamental flaws is that information sharing across systems is difficult due to privacy and confidentiality. Once this problem is addressed, there is a need to standardize early intervention and early warning protocols around what to do when one discovers an issue.

Expositeur: Michele Pierce, Founder and Principal, Harriet Tubman Charter School

Ms. Pierce discussed the idea of community. If communities are an opportunity for intervention, it is necessary to reestablish communities and what they mean for people.

Expositeur: Bill Isler, President, Family Communications (Producer of Mister Rogers' Neighborhood)

Mr. Isler explained that the work of his organization is grounded in child development philosophy. The framework is based on working with the community. He noted that that Dr. Osofsky's work and research are used in all projects. Mr. Isler spoke about Family Communications products and initiatives that help people who work with young children. For example, the "Mad Feelings" project, a series of anger management programs and posters, is an initiative that was very well received in the community.

The Substance Abuse and Mental Health Services Administration grants that funded outreach in Iowa, Pennsylvania, Mississippi, and Ohio led to development of the Challenging Behaviors Workshop, which focuses on challenging children. Another workshop on relationship-based discipline targets parents and others who work with young children. The Safe Havens training program helps people working with children deal with the violence they see in their lives.

Collaboration with the Yale Studies Center (Steve Merritts) resulted in "One on One Connecting Cops and Kids." This initiative works with police officers to help them understand the child development literature. The focus is on partners in crisis, communication, and helping children who are in trouble. Mr. Isler reminded participants that they must carefully choose words and messages.

Finally, he detailed the "One Kind Word" project, which helps parents diffuse situations with their children. Much of the training is done by DVD.

DISCUSSION

Dr. Chaffin asked which elements in Dr. Hayes' presentation on the public health system she thought were the most important.

Dr. Hayes responded that key elements include assessing the size and magnitude of the problem, and getting to the data without barriers.

Theresa Covington, M.P.H., National MCH Center for Child Death Review, noted that the CDC funded five states to develop surveillance systems for child maltreatment (Michigan, Mississippi, California, Rhode Island, Minnesota). No one system captured all mortality and morbidity. It was found that they did a better job when they merged data systems. A report on this is coming out soon. The neglect categories were the ones missed.

Patricia (Trish) Sullivan, Ph.D., Creighton University School of Medicine, stated that there also is a need to look at disability review teams. Children have developed disabilities as a result of child abuse and neglect. There is a tendency to let parents off the hook sometimes, especially in relation to adolescents. In Nebraska, children go back and forth from the mental health system to the criminal justice system. There is a need to look at those pathways.

Ms. Cunningham stated that it is critical to support parents who have environmental stressors. This is especially true for parents whose basic needs are not met. Schools are critical-how can participants help them play a major role in what many in society think of as a private issue?

Dr. Christian noted the need for data and added that this is an enormous problem. One-third of all children are not doing well. The public thinks that it is an urban, rural, or minority problem; it is necessary to get the public to embrace this as a serious public health problem. This can be done by highlighting the impact on adults and stressing how much money is required to address related issues. A focus group may be needed to look at how the issue resonates with the public.

Dr. Edgerton commented on the need for community participatory research to bring partners to the table and keep the focus on messaging.

Clarice Walker, Howard University, The D.C. Children's Advocacy Center, stated that a lot is learned from child death reviews and wondered how to get systems to implement recommendations coming out of those reviews. What about confidentially issues or getting community buy-in?

Dr. Hayes said that funding has been reduced, and there is a need for resources for this. There are structural barriers to information sharing, and these barriers could be addressed in some cases without money. Dr. Hayes said that she did not know the role of the Federal Government because there is a lot of resistance to disclosing information.

Katherine Beckman, HHS Emerging Leader, suggested that participants look to partners they do not usually think of such as childcare providers. The American Academy of Pediatrics is working on a plan to form linkages between childcare providers, parents, and children. The National Center for Birth Defects also is working on this issue. The California Children and Families Commission uses tobacco money to develop New Parent Toolkits that include videos on child development and safety, and offers home visiting to talk about child well treatment.

Susan Royer, Sesame Workshop (for Gary Knell), said that building communication skills is key. She urged participants to think of the media as a potential partner in public health. Mr. Isler said that everything is based on partnerships. Schools must share in the responsibility, and it is important not to give up on the media. The social messaging concept is slowly emerging from corporations. There is a need for participants to follow up on initiatives that work in their own communities.

Dr. Hsi noted a disconnect around funding issues. He pointed out that government agencies play a game of funding projects in short cycles, limiting the funding, then saying the project is not a priority and eliminating it.

Dr. Olds explored the issue of how much the public is aware of child abuse and neglect. Prevent Child Abuse America has shown that the public is aware. He said that the public is aware but feels helpless and does not believe the government can do anything. He commented on the need to develop and test effective programs and share these with the public.

John Lutzker, Ph.D., CDC, said that the latest ICIRUS 3.0 survey includes questions on the public's willingness to pay to prevent a case of child maltreatment. This survey, for the first time ever, will allow formal and full cost-benefit analyses.

Mr. Lithco commented that it is important for participants to realize what they are communicating and to whom they are communicating. He concluded with a question to all the parents: When dealing with your child, how much of what you do is evidence-based practice?

Dr. Ramey remarked that parents are vital but warned against focusing on parents alone. Others perpetrate abuse and neglect: childcare providers, healthcare providers, boyfriends, and extended kin. The public is more likely to accept a national campaign if the focus is not all on parents.

Ms. Nicholson said that she has not experienced that people do not want to hear the message. The Surgeon General should develop a comprehensive strategy for how to address the press, fraternal organizations, and the clergy. There is a need to develop models or protocols that are not necessarily evidence based.

Chief Bueermann suggested engaging police departments in this debate, noting that 99 percent of police chiefs are parents themselves.

Dr. Kessel concluded the session by noting that the neighborhood policing concept is important. He commented that things that used to be important seem not to be included in the schools anymore (e.g., nutrition, physical activity).

Critical Thinking for a New National Public Health Priority

Moderator: Kevin Dinnin, Executive Director and CEO, Baptist Child and Family Services, San Antonio, Texas

Mr. Dinnin shared a story about young girls asking for money on the streets and how no one in the community wanted to take responsibility for this problem. He said that the United States has a fabric that many countries do not have. Our fabric might be like gauze-with holes throughout-but there is a need just to tighten it up a bit.

Expositeur: Ed Schor, M.D., Assistant Vice President, Child Development and Preventative Care Program, The Commonwealth Fund, New York City

The United States is one of two countries that has not signed the United Nations Convention on the Rights of the Child. Dr. Schor said that families have been changing over the past decades. It is necessary to ensure that families do well to achieve better outcomes for children.

Relationships are the key to early development (as discussed in From Neurons to Neighborhoods). Yet family relationships are strained. He did not think that child development should be taught in high school but said that positive skills can be reinforced via relationship education.

Early brain development research shows that parents play a big role in shaping development, but they do not know how to do it very well. We do not know all the answers, and we do not know what we do not know. Public health needs to place more emphasis on promoting families' early development. He called for a system of universal parent education in this country.

Child abuse is a reflection of families being unable to cope. Surveys of parents indicate a lot of stress. There is a need to help parents get the resources they need to cope. A model initiative is "Help Me Grow" in Connecticut, which provides a 1-800 number for doctors or parents to call if they have a concern. Calls come in to short-term care organizers who link people to services. The project is not expensive because it piggybacks on existing 800 numbers.

Public health could partner with private medicine. And public health needs to help people in communities build supportive relationships. Dr. Schor mentioned a book titled Better Together that discusses the notion of social capital.

Expositeur: Calvin Johnson, M.D., M.P.H., Pennsylvania Department of Health

Dr. Johnson's first job in public health was in New York City. He said that he could not remember his first experiences dealing with child abuse as a professional because there have been far too many and such a wide range of them.

In Pennsylvania, 36 children died of abuse in 2003. The state has spent $44 million to investigate child maltreatment-that is far too much to spend on something that is wholly preventable.

Dr. Johnson discussed taking "AIM" at child maltreatment. "A" is for Awareness; "I" is for Intervention; and "M" is for Monitoring and Maintenance.

Dr. Johnson discussed the state perspective and stated that there is no national standard for defining and collecting data. The Pennsylvania Child Death Review program needs to be implemented elsewhere. The Department of Public Welfare houses this program in Pennsylvania and works with the Department of Public Health. The program operates in 48 of 67 counties and will be extended to all counties.

There is a need to understand more and coordinate better to solve this issue. There also is need for a broader standard curriculum for healthcare workers to train them to recognize and deal with child abuse and neglect issues. One model is the EPI-SCAN program (from the Pennsylvania chapter of the American Academy of Pediatrics).

There also is a need to target parents. The Nurse-Family Partnership Program is an example of a good home visitation program. It is necessary to show a return on investment for programs when requesting money.

Ellen Wartella, Ph.D., Executive Vice President and Provost, University of California-Riverside

Dr. Wartella discussed historical change in the use of media in public health campaigns. She noted that adaptation of commercial marketing technologies and social marketing has swept through public health campaigns. Campaigns have a customer-driven focus on desired behavior (e.g., antismoking and heart healthy campaigns). Mass media are not good at impacting individual behavior.

Community-levels programs are a little more effective, but are dwarfed by other messages (e.g., Stanford Tri-City project; Minnesota Heart Health project). The institution level is where there is a need to galvanize public will. Approaches include media advocacy and entertainment education. Larry Wallick has developed kits on the media advocacy approach. Entertainment education puts public health messages into mainstream shows, including the use of dramatic portrayals.

Dr. Wartella recommended that participants use the media advocacy toolkits to galvanize local media. She suggested establishing a coalition of groups to set up an organization that will constantly keep the issue in front of the media. She stated that the Surgeon General should serve as a spokesperson around a summit for the media on this issue. Groups that are engaged in trying to create good programming for children, such as Sesame Workshop, Nickelodeon channel, Disney channel, ABC Family channel, could be pulled together to discuss ways to bring these messages into their programming. In terms of entertainment education, specific issues could be written into television shows (Sonny Cox holds an annual workshop on this topic).

DISCUSSION

Dr. Berkowitz asked about the role of grandparents.

Dr. Schor reflected that a fair number of children are being raised by grandparents, but that group has not been studied much.

Charlie LaVallee, Highmark Caring Foundation, Pittsburgh, commented on the need to quantify financial impacts and argue the case from a financial perspective. Participants must take the data to the media.

Nancy Siegel, M.S.W., NBS Associates, noted that media awards are given to programs or news outlets for making positive connections on this topic.

Dr. Wartella suggested bringing public relations experts in social marketing together to analyze where people are on this issue. The Surgeon General or another highly placed official could bring together media groups for discussions.

Bettina Richardson, Bexar County District Attorney's Office, stated that family is the best place to reach out to children. She noted that there are currently 15 family justice centers being established throughout the nation under the same prototype as the Children's Advocacy Centers.

Wanda Jones, DrPH, Office on Women's Health, HHS, said that Federal Agencies are not seen or rewarded for breaking down barriers. It is difficult to reach out and establish connections. Government agencies are part of the solution, not the problem. She cited the example of HHS and the Department of Justice collaborating on the Greenbook Project.

Theresa Costello, National Resource Center on Child Protective Services, ACTION for Child Protection, Inc., said that public agencies are not the problem. Many states have implemented alternative responses so that every family does not get the same response. The child welfare system would welcome any level of prevention. In terms of the CQI concept mentioned earlier, every agency in the child family service review process is required to have a quality assurance system in place. She added that the public system needs help, support, and partners to make the effort on child abuse prevention successful.

Dr. Egeland noted the need for somebody like the Surgeon General to speak out and say that this is a national crisis. He cited a Federal Reserve member in Minneapolis who accomplished a lot on the issue of early childhood development with just one speech.

Call-in comment read from a social worker on dealing first with poverty.

Dr. Prinz commented on the need for positive parenting programs that model positive parenting and are evidence-based.

Dr. Christian called on participants to work behind the scenes; there is need for a spokesperson and a message that resonate with the American public.

Mr. Lithco stated that it would be helpful if there were a mechanism to continue commenting on this issue.

Lauren Raskin Ramos, M.P.H., Association of State and Territorial Health Officials, asked for thoughts on how to approach the legislature or the governor to frame the issue and to get resources for working on child maltreatment.

Dr. Calvin Johnson responded that when a person feels ownership of a problem, he or she is more likely to do something about it. One constituent can cause a ripple effect by getting the attention of a legislator. Data and information matter. Growth and development and health are what drive an economy. The economic message has not been effective. There are many competing issues and agendas.

Call-in comment from Molly Schultz about cost-benefit analysis.

Mr. LaVallee commented on the need to deal with economic costs.

Mr. Dinnin noted that last year Texas eliminated prevention programs, but the public was able to get them restored. He wondered if participants would be interested in an effort to do national polling of the public to get the messaging right. He was not sure the government would fund this effort but offered to secure funding for it. He asked participants to see him during the scheduled break if interested. He suggested convening a meeting in Texas.

Summary of Key Steps for Achieving the Public Health Approach

Shay Bilchik, J.D., President and CEO, Child Welfare League of America

Mr. Bilchik provided a summary of what he heard during the workshop, especially during Day Two. He thanked participants for contributing and sharing their personal stories. He said that he thought everyone believed in action and suggested staying connected to the Surgeon General and others while moving forward on this issue.

In thinking about what the Surgeon General should do to move the issue forward, he stated that it is necessary to keep in mind that the Surgeon General and public health model bring rigor to the issue and provide a template for how to attack this problem in its entirety. But it does not bring ownership of the problem by the American public. There is a need to first define prevention: is it primary, secondary or tertiary? Mr. Bilchik's assumption was that participants were talking about all three levels.

Mr. Bilchik noted that there is a need to assess the problem. It is necessary to identify each relevant data source, including those not reported into formal systems and recorded (i.e., emergency rooms, schools, doctors' offices, upper class households that do not report). Multisystems assessment centers must be used as well as methodologies known to be effective based upon a certain high level of rigor and those thought to be effective but based perhaps on a little less rigor.

There is a need to educate the public about the problem and their ability to address it. Participants must demand action on a public policy level. Child maltreatment now is either someone else's problem or too uncomfortable to deal with. He noted that the problem is not owned on tribal reservations, in low-income areas, or in upper-income areas. There is a need for strong, visible leaders who are willing to educate and lead. There is a need for the Surgeon General, the President, the First Lady, Secretary Leavitt, Congressman Delay, Senator Clinton as well as sports and television stars to use a public health model. The media also must be used effectively. This is not a short-term task-it could take 10 years or longer.

Participants must look to social marketing; strategic, committed and sustained efforts; new technologies; and viral marketing. The Surgeon General must help mobilize communities and promote partnerships.

Mr. Bilchik related that it is important to complete a rigorous matching of each dimension of the problem (risk factors matched with protective factors). He added that eventually participants must move their efforts to full-scale implementation and adopt a strategic plan based upon a public health model to prevent child maltreatment in America.

This is possible with adequate resources. Mr. Bilchik shared his vision of the Surgeon General working with HHS to look at Child and Family Services (CFS) Reviews and of HHS and the Office of Management and Budget "arm wrestling" over resources.

He noted that systems integration and collaboration are good things to talk about as long as they are not code words for doing more with less. He warned that struggles over turf, control, and building trust will likely factor into moving forward on this issue.

He pointed out that participants can learn from "systems of care" work about systems integration, such as through the Safe Schools, Healthy Students Initiative. He suggested using evidence-based practices but not getting stuck on the mantra of evidence-based practice. He could imagine creating a grid charting levels of rigor in terms of research and levels of effectiveness. In talking about evidence-based research, he commented that if something cannot be demonstrated, they will not get funding for it; even if they can demonstrate it, this does not guarantee funding.

He concluded that the Surgeon General was uniquely qualified to work with the National Institutes of Health and others on building the capacity needed to implement through this model an effective attack on child maltreatment. Mr. Bilchik said that he hoped to leave participants with a sense of urgency, noting that each day that goes by, four children will die from child abuse and neglect. There is not a day to spare in moving the agenda forward.

Preventing Child Maltreatment and Promoting Child Well Treatment

Richard Carmona, M.D., M.P.H., FACS, U.S. Surgeon General, Vice Admiral

Dr. Carmona stated that one of the things the Surgeon General does best is to bring excellent people together to study issues and issue reports. The Office of the Surgeon General has credibility. It is difficult to move things forward in Washington, DC. Everyone has the same goals at the workshop, and they need to figure out how to bring the pieces together and align the stakeholders to move forward seamlessly. The enormity of his position (its visibility and credibility) includes immense responsibility. The most important part of the Surgeon General's role is to protect the integrity of the office. As Dr. Carmona stated, if he does not, he will have no credibility in the position. Dr. Carmona reflected that persistence, tenacity, and staying in the game win the game-and not necessarily a superior intellect. He revealed that he knows what it is like to be hungry, homeless, part of an immigrant family, from an unstable environment, and lacking access to health care. The need to make the world safer for kids and help vulnerable populations is at his core.

The need to promote child health and wellness is important, but it does not get at the issue of child maltreatment. There is no one-size-fits-all approach. There is no one message. What is the brand participants are trying to create? They want something that will capture the public's imagination. Dr. Carmona related that he has access to an extraordinary cadre of experts, yet he does not have the translational element necessary to change the behaviors of thousands of complex communities. The translational element is going to challenge participants most in developing the messaging and branding. The power is with them. The real solution is in the communities, in establishing credibility, and in working through faith-based organizations and with police and fire departments. Everyone who works with children must be involved.

What must not happen is just one press conference. A sustained effort is needed. Participants must figure out a way to ensure that their messaging is culturally competent and that it also embraces the issue of health literacy. There is a need to make sure that each mom, dad, and child understands what the message means.

Dr. Carmona commented that he accepts the responsibility given to him to stand at the bully pulpit and speak for all the disciplines and diversities represented. He added that when he looks over his shoulder, he wants to see a big army behind him, all speaking the same voice. He concluded that participants need to speak as one and come together as a community and keep a bright light on this issue every single day.

Closing

Dr. Kessel noted that Dr. Carmona is a caring, compassionate leader who will carry forth the message. He asked for a round of applause for Federal staff who organized the workshop. He commented that the meeting format worked well and provided a rich discussion.

Dr. Kessel added that he hoped participants will be able to respond to the Masai greeting-Kasserian Ingera? (How are the children?) with the answer that "the children are well, child maltreatment is no longer." He concluded, "There is hope in this room… with all of you, and we will translate that hope into action."


Surgeon General's Workshop Participant List

Making Prevention of Child Maltreatment a National Priority:
Implementing Innovations of a Public Health Approach
Lister Hill Auditorium, NIH, Bethesda, Maryland
March 30–31, 2005

Randy Alexander, M.D., Ph.D.
Chief
Division of Child Protection and Forensic Pediatrics
University of Florida
1650 Prudential Drive, Suite 100
Jacksonville, FL 32207
Phone: (904) 265-4900
Email: ralexander@abusenet.org

Sharon Amatetti, M.P.H.
Senior Public Health Analyst
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road, Room 5-1-039
Rockville, MD 20850
Phone: (240) 276-1694
Email: haron.amatetti@samhsa.hhs.gov

Lisa Bain
Executive Editor
Parenting Magazine
Parenting Group
530 Fifth Avenue
New York, NY 10036
Phone: (212) 522-8518
Email: lisa_bain@timeinc.com

Megan Bair-Merritt, M.D.
General Pediatric Fellow
Department of Pediatrics
Children's Hospital of Philadelphia
3535 Market Street, Office 1550
Philadelphia, PA 19104
Phone: (215) 590-2174
Email: merritt@email.chop.edu

Kirsten Bechtel, M.D.
Assistant Professor of Pediatric Emergency Medicine
Department of Pediatrics
Yale University
333 Cedar Street
New Haven, CT 06520-8064
Phone: (203) 688-4936
Email: kirsten.bechtel@yale.edu

Judith Becker, Ph.D.
Professor
Department of Psychology
University of Arizona
1503 East University
P.O. Box 210068
Tucson, AZ 85721
Phone: (520) 621-7455
Email: jvbecker@u.arizona.edu

Katherine Beckmann
Emerging Leader
National Institute of Child Health and Human Development
National Institutes of Health
Phone: (301) 435-3458
Email: katherine.beckmann@hhs.gov

Carol Berkowitz, M.D.
President
American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007
Phone: (847) 434-4000
Email: carolb@pol.net

Shay Bilchik, J.D.
President/CEO
Child Welfare League of America
440 First Street, N.W., 3rd Floor
Washington, DC 20001-2085
Phone: (202) 638-2952
Email: sbilchik@cwla.org

Thomas Birch, J.D.
Legislative Counsel
National Child Abuse Coalition
733 15th Street, N.W., Suite 938
Washington, DC 20005
Phone: (202) 347-3666
Email: tbirch@elinkisp.com

Barbara Bonner, Ph.D., M.Ed.
Director of the Center on Child Abuse and Neglect
Department of Pediatrics
University of Oklahoma Health Sciences Center
940 N.E. 13th Street
Oklahoma City, OK 73104
Phone: (405) 271-4401
Email: barbara-bonner@ouhsc.edu

Cheryl Boyce, Ph.D.
Program Chief
Child Abuse and Neglect Program
National Institute of Mental Health
National Institutes of Health
6001 Executive Boulevard, Room 6300
Bethesda, MD 20892
Phone: (301) 443-0848
Email: cboyce@mail.nih.gov

CAPT Stephanie Bryn, M.P.H.
Health Resources and Services Administration
5600 Fishers Lane
Parklawn Building, Room 18A-38
Rockville, MD 20857
Phone: (301) 443-6091
Email: sbryn@hrsa.gov

Jim Bueermann, M.B.A.
Chief of Police and Community Services
City of Redlands
35 Cajon Street
Redlands, CA 92373
Phone: (909) 798-7661
Email: jbueermann@aol.com

Ann Burgess, Ph.D., R.N., FAAN
Professor of Psychiatric Mental Health Nursing
School of Nursing
Boston College
140 Commonwealth Avenue
Chestnut Hill, MA 02467
Phone: (617) 552-6133
Email: burges@bc.edu

VADM Richard Carmona, M.D., M.P.H., FACS
U.S. Surgeon General
Office of the Surgeon General
5600 Fishers Lane
Parklawn Building, Room 18-67
Rockville, MD 20857
Phone: (301) 443-4000

Dana Carr, M.P.H.
Program Specialist
Office of Safe and Drug-Free Schools
U.S. Department of Education
400 Maryland Avenue, SW FB 6
Washington, DC 20202
Phone: (202) 260-3954
Email: dana.carr@ed.gov

David Chadwick, M.D., Ph.D.
Professor
Department of Pediatrics
University of Utah
30 North 1900 East
Salt Lake City, Utah 84132
Phone: (801) 588-2360
Email: dlchadwick1@earthlink.net

Mark Chaffin, Ph.D.
Professor of Pediatrics
University of Oklahoma Health Sciences Center
P.O. Box 26901, CSC 225
Oklahoma City, OK 73190
Phone: (405) 271-8858
Email: mark-chaffin@ouhsc.edu

Marc Cherna
Director
Department of Human Services
Allegheny County Department of Human Services
933 Penn Avenue, 5th Floor
Pittsburgh, PA 15222-3872
Phone: (412) 350-5701
Email: mcherna@dhs.county.allegheny.pa.us

Cindy Christian, M.D.
Co-Director
Safe Place: The Center for Child Protection and Health
The Children's Hospital of Philadelphia
34th Street and Civic Center Boulevard
Philadelphia, PA 19104-4399
Phone: (215) 590-2058
Email: christian@email.chop.edu

Robert Clyman, M.D.
American Academy of Child and Adolescent Psychiatry
University of Colorado Health Sciences Center
4200 East 9th Avenue
Denver, CO 80262
Phone: (303) 864-5255
Email: clyman.rob@tchden.org

Michele Booth Cole, J.D.
Executive Director
Safe Shores
The D.C. Children's Advocacy Center
300 E Street, N.W.
Washington, DC 20001
Phone: (202) 638-2575
Email: mboothcole@safeshores.org

Angela Corbin
Family and Children's Health Programs Group
Center for Medicare & Medicaid Services
7500 Security Boulevard
Mailstop S2-01-16
Baltimore, MD 21244
Phone: (410) 786-1285
Email: acorbin@cms.hhs.gov

Theresa Costello
Director
National Resource Center on Child Protective Services
ACTION for Child Protection, Inc.
925 #4 Sixth Street, N.W. Albuquerque, NM 87102
Phone: (505) 345-2444
Email: theresa.costello@actionchildprotection.org

Theresa Covington, M.P.H.
Director
National MCH Center for Child Death Review
2438 Woodlake Circle, Suite 240
Okemos, MI 48864
Phone: (800) 656-2434
Email: tcovingt@mphi.org

Terry Cross, M.S.W., ACSW, LCSW
Executive Director
National Indian Child Welfare Association
5100 Southwest Macadam Avenue, Suite 300
Portland, OR 92739
Phone: (503) 222-4044
Email: tlcross@nicwa.org

Stacey D. Cunningham, M.S.W.
Senior Program Associate
National Black Child Development Institute
1101 15th Street, N.W., Suite 900
Washington, DC 20005
Phone: (202) 833-2220, ext. 129
Email: scunningham@nbcdi.org

Lonna Davis
Family Violence Prevention Fund
685 Centre Street
Jamaica Plain, MA 02130
Phone: (617) 522-2770
Email: lonna@endabuse.org

Diane DePanfilis, Ph.D.
Associate Professor and Co-Director Center for Families
University of Maryland
525 West Redwood Street
Baltimore, MD 21201
Phone: (410) 706-3609
Email: ddepanfi@ssw.umaryland.edu

Kevin Dinnin
Executive Director/CEO
Baptist Child and Family Services
909 Northeast Loop 410, Suite 800
San Antonio, TX 78209-1311
Phone: (210) 832-5000
Email: kdinnin@bcfs.net

Howard Dubowitz, M.D., M.S.
Co-Director, Center for Families
University of Maryland School of Medicine
22 South Greene Street
1 George Gray Hall
Baltimore, MD 21201
Phone: (410) 328-8919
Email: hdubowitz@peds.umaryland.edu

John Eckenrode, Ph.D.
Family Life Development Center
Cornell University
21 Renwick Heights Road
Ithaca, NY 14853
Phone: (607) 255-0834
Email: jje1@cornell.edu

Byron Egeland, Ph.D.
Irving B. Harris Professor of Child Development
University of Minnesota
230 Child Development
51 East River Road
Minneapolis, MN 55455-0345
Phone: (612) 624-5273
Email: egela001@umn.edu

Eileen Elias, M.Ed.
Deputy Director
Office on Disability
Office of the Secretary
200 Independence Avenue, S.W., Room 637D
Washington, DC 20201
Phone: (202) 205-1104
Email: eileen.elias@hhs.gov

Diana English, Ph.D.
Washington State Department of Social and Health Services
101 Israel Road, S.E.
Olympia, WA 98504-7890
Phone: (206) 933-3535
Email: endi300@dshs.wa.gov

Anna Falkenstern
Health Resources and Services Administration
5600 Fishers Lane
Parklawn Building
Rockville, MD 20857
Phone: (301) 443-2243
Email:  

Sarah Foster, M.P.H.
Acting Associate Director for Policy, Planning, and Evaluation
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
4770 Buford Highway, N.E., MS K-61
Atlanta, GA 30341
Phone: (770) 488-1316
Email: sjf4@cdc.gov

Reem Ghandour, M.P.A.
Office of Women's Health
Health Resources and Services Administration
5600 Fishers Lane
Parklawn Building, Room 18A-44
Rockville, MD 20857
Phone: (301) 443-3786
Email: rghandour@hrsa.gov

Margaret Giannini, M.D., FAAP
Director
Office on Disability
Office of the Secretary
200 Independence Avenue, S.W., Room 637D
Washington, DC 20201
Phone: (202) 205-1016
Email: margaret.giannini@hhs.gov

Maria Gomez, R.N., M.P.H.
President/CEO
Mary's Center for Maternal and Child Care, Inc.
2333 Ontario Road, N.W.
Washington, DC 20009
Phone: (202) 483-8319, ext. 328
Email: info@maryscenter.org

Katherine Gottlieb, M.B.A.
President/CEO
Southcentral Foundation
4501 Diplomacy Drive
Anchorage, AK 99508
Phone: (907) 729-4955
Email: katherineg@scf.scc

Kathi Grasso, J.D.
Senior Juvenile Justice Policy and Legal Advisor
Office of Juvenile Justice and Delinquency Prevention
U.S. Department of Justice 810 7th Street, N.W.
Washington, DC 20531
Phone: (202) 616-7567
Email: kathi.grasso@usdoj.gov

Brook McClintic Griese, Ph.D.
Research Director
Judith Ann Griese Foundation
1600 Downing Street, Suite 200
Denver, CO 80218
Phone: (813) 974-8545
Email: brookmcclintic@hotmail.com

Neil Guterman, Ph.D., M.S.W.
School of Social Work
Columbia University
1255 Amsterdam Avenue
New York, NY 10027
Phone: (212) 851-2385
Email: nbg2@columbia.edu

Neal Halfon, M.D., M.P.H.
Professor of Pediatrics,
Public Health and Public Policy
UCLA Center for Healthier Children, Families and Communities
1100 Glendon, Suite 850
Los Angeles, CA 90024
Phone: (310) 794-0967
Email: nhalfon@ucla.edu

Isadora Hare, M.S.W., LCSW
Public Health Analyst
Division of Child, Adolescent, and Family Health
Health Resources and Services Administration
5600 Fishers Lane
Parklawn Building, Room 18A-39
Rockville, MD 20857
Phone: (301) 443-6392
Email: isadore.hare@hhs.hrsa.gov

William Harris, Ph.D.
Chair
Children's Research and Education Institute
2 Brighton Street
Belmont, MA 02478
Phone: (617) 201-7564
Email: kidspac@mindspring.com

Betty Lee Hawks, M.A.
Special Assistant to the Director
Office of Minority Health
Office of Public Health and Science
1101 Wootton Parkway, Suite 600
Rockville, MD 20852
Phone: (301) 443-5084
Email: bhawks@osophs.dhhs.gov

Maxine Hayes, M.D.
Washington State Health Officer
Washington State Department of Health
101 Israel Road, S.E.
Olympia, WA 98504-7890
Phone: (360) 236-4018
Email: maxine.hayes@doh.wa.gov

CAPT Karen Hench, R.N., M.S.
Public Health Advisor
Health Resources and Services Administration
5600 Fishers Lane
Parklawn Building, Room 10C-16
Rockville, MD 20857
Phone: (301) 443-9708
Email: khench@hrsa.gov

Diedra Henry-Spires, M.P.H.
Office on Women's Health
Office of Public Health and Science
U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 718-F
Washington, DC 20201
Phone: (202) 401-9582
Email: dhenry@osophs.dhhs.gov

Karen Seaver Hill
Associate Director for Child Advocacy
National Association of Children's Hospitals and Related Institutions
401 Wythe Street
Alexandria, VA 22315
Phone: (703) 797-6035
Email: khill@nachri.org

John Holton, Ph.D.
President
Prevent Child Abuse America
200 South Michigan Avenue, 17th Floor
Chicago, IL 60604-2404
Phone: (312) 663-3520
Email: jholton@preventchildabuse.org

Andrew Hsi, M.D., M.P.H.
Director
Division of General Pediatrics
University of New Mexico Health Sciences Center
1 University of New Mexico
Albuquerque, NM 87131-5001
Phone: (505) 272-6843
Email: ahsi@salud.unm.edu

Bill Isler
President
Family Communications, Inc.
4802 Fifth Avenue
Pittsburgh, PA 15213
Phone: (412) 687-2990, ext. 222
Email: isler@fci.org

Annette Jacobi, J.D.
Director
Office of Child Abuse and Neglect
Oklahoma State Department of Health
2500 North Lincoln Boulevard
Oklahoma City, OK 73105-4599
Phone: (405) 271-9444
Email: annettej@health.ok.gov

Calvin Johnson, M.D., M.P.H.
Secretary of Health
Commonwealth of Pennsylvania
7th and Forster Streets
Harrisburg, PA 17120
Phone: (717) 787-6436
Email: calvjohnso@state.pa.us

Robert L. Johnson, M.D.
Professor of Pediatrics and Psychiatry
University of Medicine and Dentistry of New Jersey
Medical Science Building, Room F-540
185 South Orange Avenue
Newark, NJ 07101-1709
Phone: (973) 972-5277
Email: rjohnson@umdnj.edu

Barbara Jones, M.S.W., MSPH
DHHS Emerging Leader
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
1101 Wootton Parkway, Suite LL100

Rockville, MD 20852
Phone: (240) 453-8271
Email: bjones2@osophs.dhhs.gov

Wanda Jones, DrPH
Deputy Assistant Secretary for Health
Office on Women's Health
U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 712-E
Washington, DC 20201
Phone: (202) 690-7650
Email: wjones@osophs.dhhs.gov

RADM Woodie Kessel, M.D., M.P.H.
Assistant Surgeon General
Deputy Director for Medicine and Science
Office of Disease Prevention and Health Promotion
1101 Wootton Parkway, Suite LL100
Rockville, MD 20852
Phone: (240) 453-8280
Email: wkessel@osophs.dhhs.gov

Gillian Kimura, M.P.H.
Office on Women's Health
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
Phone: (202) 401-1170
Email: ghkimura@osophs.dhhs.gov

Gary Knell, J.D.
President/CEO
Sesame Workshop
One Lincoln Plaza
New York, NY 10023
Phone: (212) 875-6876
Email: gary.knell@sesameworkshop.org

David Kolko, Ph.D.
Professor of Psychiatry
University of Pittsburgh Medical Center
541 Bellefield Towers
Pittsburgh, PA 15213
Phone: (412) 624-2096
Email: kolkodj@msx.upmc.edu

Charles LaVallee
Vice President
Highmark Caring Foundation
Pittsburgh Center for Grieving Children
620 Stanwix Street
Pittsburgh, PA 15222
Phone: (412) 544-1689
Email: charles.lavallee@highmark.com

Cindy Lederman, J.D.
Presiding Judge
Miami-Dade Juvenile Court
3300 N.W. 27th Avenue, Room 201
Miami, FL 33142
Phone: (305) 638-6087
Email: clederman@jud11.flcourts.org

Dawn Levinson, M.S.W.
Policy Advisor on Children and Families
Office of Policy, Planning, and Budget
Office of the Administrator
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road, Room 8-1062
Rockville, MD 20857
Phone: (240) 276-2015
Email: dawn.levinson@samhsa.hhs.gov

George Lithco, J.D.
The Skipper Initiative
Jacobowitz & Gubits, LLP
158 Orange Avenue
P.O. Box 367
Walden, NY 12586
Phone: (845) 778-2121, ext. 272
Email: gwl@jacobowitz.com

John Lutzker, Ph.D.
Chief, Prevention Development and Evaluation Branch
Division of Violence Prevention
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
4770 Buford Highway, N.E., MS K-60
Atlanta, GA 30333
Phone: (770) 488-1557
Email: jlutzker@cdc.gov

Yvonne T. Maddox, Ph.D.
Deputy Director
National Institute of Child Health and Human Development
National Institutes of Health
1 Center Drive
Bethesda, MD 20892
Phone: (301) 496-1848
Email: ym16x@nih.gov

Valerie Maholmes, Ph.D.
Program Officer
Child Development and Behavior Branch
National Institute of Child Health and Human Development
National Institutes of Health
Room 4B05E, MSC 7510
6100 Executive Boulevard
Bethesda, MD 20892
Phone: (301) 496-1514
Email: maholmev@mail.nih.gov

Dorothy Marge, Ph.D.
Research Assistant Professor
Department of Physical Medicine and Rehabilitation
State University of New York Upstate Medical University
449 Old Orchard Circle
Millersville, MD 21108
Phone: (410) 729-9566
Email: dorothy.marge@comcast.net

Michael Marge, Ed.D.
Special Assistant
Office on Disability
Office of the Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 637D
Washington, DC 20201
Phone: 202-401-5844
Email: michael.marge@HHS.GOV

Sue Martone, M.P.A.
Assistant Deputy Director
Office of Behavioral Health
Allegheny County Department of Human Services
304 Wood Street
Pittsburgh, PA 15222
Phone: (412) 350-7399
Email: smartone@dhs.county.allegheny.pa.us

Elizabeth McCord, M.D.
Department of Family Medicine
East Tennessee State University
Box 70621
Johnson City, TN 37614
Phone: (423) 915-0117
Email: mailto:mccord@mail.etsu.edu

RADM Kenneth Moritsugu, M.D., M.P.H.
U.S. Deputy Surgeon General
Office of the Surgeon General
5600 Fishers Lane
Parklawn Building, Room 18-67
Phone: (301) 443-4000

Susan Moskosky, M.S., R.N.C.
Director
Office of Family Planning
Office of Population Affairs
1101 Wootton Parkway, Suite 700
Rockville, MD 20852
Phone: (301) 594-4004
Email: smoskosky@osophs.dhhs.gov

Charlotte Mullican, M.P.H.
Senior Advisor for Mental Health Research
Center for Primary Care, Prevention, and Clinical Partnerships
Agency for Healthcare Research and Quality
540 Gaither Road, Suite 6129
Rockville, MD 20850
Phone: (301) 427-1495
Email: mailto:cmullica@ahrq.gov

Johanna Nestor, M.P.H.
Public Health Analyst
Office of Adolescent Pregnancy Programs
Office of Population Affairs
1101 Wootton Parkway, Suite 700
Rockville, MD 20852
Phone: (301) 594-4004
Email: jnestor@osophs.dhhs.gov

Bunny Nicholson, M.S.W.
President
Nicholson and Associates
2368 South Fillmore Street
Denver, CO 80210
Phone: (303) 758-0799
Email: nicholsonspencer@msn.com

Catherine Nolan, M.S.W., ACSW
Director
Children's Bureau
Office on Child Abuse and Neglect
Administration for Children and Families
330 C Street, S.W.
Washington, DC 20447
Phone: (202) 260-5140
Email: cnolan@acf.hhs.gov

Emmeline Ochiai, J.D., M.P.H.
Office of Disease Prevention and Health Promotion
1101 Wootton Parkway, Suite LL100
Rockville, MD 20852
Phone: (240) 453-8259
Email: eochiai@osophs.dhhs.gov

David Olds, Ph.D.
Director
Kempe Prevention Research Center for Family and Child Health
University of Colorado Health Sciences Center
4200 East Ninth Avenue
Denver, CO 80262
Phone: (303) 864-5205
Email: olds.david@tchden.org

Susan Orr, Ph.D.
Associate Commissioner
Children's Bureau
Office on Child Abuse and Neglect
Administration for Children and Families
330 C Street, S.W.
Switzer Building, Room 2318
Washington, DC 20447
Phone: (202) 205-8618
Email: dorr@acf.hhs.gov

Joy Osofsky, Ph.D.
President
ZERO TO THREE
2000 M Street, N.W., Suite 200
Washington, DC 20036
Phone: (202) 638-1144
Email: josofs@lsuhsc.edu

Elaine Parry, M.S.
Immediate Office of the Administrator
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road, Room 7-1111
Rockville, MD 20857
Phone: (240) 276-2018
Email: elaine.parry@samhsa.hhs.gov

Marilyn Peterson, M.S.W.
Director
CAARE Diagnostic and Treatment Center
University of California Davis Children's Hospital
3300 Stockton Boulevard
Sacramento, CA 95820
Phone: (916) 734-7615
Email: marilyn.peterson@ucdmc.ucdavis.edu

Molly Petersen, M.S.W., M.P.P.
Child Welfare Policy Analyst
Administration for Children and Families
901 D Street, S.W.
ashington, DC 20447
Phone: (202) 401-4733
Email: mpeterson@acf.hhs.gov

Michele Pierce
Principal
Harriet Tubman Charter School
3565 Third Avenue
Bronx, NY 10456
Phone: (718) 537-9912
Email: mipierce@verizon.net

Cici Porter
Director
Journey to Wholeness Project
1726 South Clementine Street
Oceanside, CA 92054
Phone: (760) 433-6536
Email: cicipg@cox.net

Terracita A. Powell
Psychologist
National Institute of Mental Health
National Institutes of Health
3317 Sir Thomas Drive
Silver Spring, MD 20914
Phone: (301) 402-4798
Email: terracitapowell@mail.nih.gov

Deborah Price
Deputy Undersecretary
Office of Safe and Drug-Free Schools
U.S. Department of Education
400 Maryland Avenue, SW FB 6
Washington, DC 20202
Phone: (202) 205-4169
Email: deborah.price@ed.gov

Ronald Prinz, Ph.D.
Department of Psychology
University of South Carolina
Columbia, SC 29208
Phone: (803) 777-7143
Email: prinz@sc.edu

Sharon Ramey, Ph.D.
Director
Georgetown Center on Health and Education
Georgetown University
3700 Reservoir Road, N.W.
Box 571107
Washington, DC 20057-1017
Phone: (202) 687-1389
Email: sr222@georgetown.edu

Lauren Raskin Ramos, M.P.H.
Senior Director
Maternal and Child Health Policy
Association of State and Territorial Health Officials
1275 K Street, N.W., Suite 800
Washington, DC 20005-4006
Phone: (202) 371-9090, ext. 1622
Email: lraskin@astho.org

Bettina Richardson
Bexar County District Attorney's Office
Family Justice Center
300 Dolorosa, 5th Floor
San Antonio, TX 78205-3030
Phone: (210) 335-2954
Email: brichardson@co.bexar.tx.us

Lydia Rochfort
Program Director
Indian Child Social Services
Southern Indian Health Council
4058 Williams Road
Alpine, CA 91903-2128
Phone: (619) 445-1188
Email: lrochfort@sihc.org

CAPT Penelope Royall, P.T., M.S.W.
Deputy Assistant Secretary for Health
Office of Disease Prevention and Health Promotion
1101 Wootton Parkway, Suite LL100
Rockville, MD 20852
Phone: (240) 453-8280
Email: proyall@osophs.dhhs.gov

Susan Royer
Sesame Workshop
One Lincoln Plaza
New York, NY 10023
Phone: (212) 875-6876
Email: susan.royer@sesameWorkshop.org

Desmond Runyan, M.D., DrPH
Professor and Chair of Social Medicine
The University of North Carolina
CB #7240
Chapel Hill, NC 27599
Phone: (919) 843-8261
Email: drunyan@unc.edu

Marilyn Sandberg-Barr
Founder and Executive Director
National Center on Shaken Baby Syndrome
2955 Harrison Boulevard, Suite 102
Ogden, UT 84403
Phone: (801) 627-3399
Email: mail@dontshake.com

Ben Saunders, M.D.
Director
National Crime Victims Research and Treatment Center
Medical University of South Carolina
165 Cannon Street
Charleston, SC 29425
Phone: (843) 792-2945
Email: saunders@musc.edu

Katherine Darke Schmitt, M.P.P.
Social Policy Analyst
Office of Juvenile Justice and Delinquency Prevention
Office of Justice Program
U.S. Department of Justice
810 7th Street, N.W.
Washington, DC 20202
Phone: (202) 616-7373
Email: katherine.darke.schmitt@usdoj.gov

Edward Schor, M.D.
Vice President
The Commonwealth Fund
1 East 75th Street
New York, NY 10021
Phone: (212) 606-3800
Email: els@cmwf.org

Patrick Sheeran, D.P.A.
Director
Office of Adolescent Pregnancy Programs
Office of Population Affairs
1101 Wootton Parkway, Suite 700
Rockville, MD 20852
Phone: (301) 594-4004
Email: psheeran@osophs.dhhs.gov

Nancy Siegel, M.S.W.
Consultant
NBS Associates
10141 Cape Ann Drive
Columbia, MD 21046
Phone: (410) 730-2278
Email: nbs979@comcast.net

Jerry Silverman, M.S.W.
Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 21202
Phone: (202) 690-5654
Email: jerry.silverman@hhs.gov

Maxine Stein
President/CEO
Stop It Now!
351 Pleasant Street, Suite B319
Northampton, MA 01060
Phone: (413) 587-3500
Email: mstein@stopitnow.org

Patricia Sullivan, Ph.D.
Director
Center for Abused Children with Disabilities
Creighton University School of Medicine
2400 California Place
Omaha, NE 68131
Phone: (402) 498-1656
Email: tsullivan@creighton.edu

Susan Swedo, M.D.
Associate Director for Child and Adolescent Research and
Director, Division of Pediatric Translational Research and Treatment
National Institute of Mental Health
National Institutes of Health
6001 Executive Boulevard
Room 6196, MSC 9617
Rockville, MD 20852
Phone: (301) 443-5944
Email: swedos@mail.nih.gov

CAPT Judith Thierry, D.O.
Director, Maternal Child Health
Indian Health Service
12300 Twinbrook Parkway
Twinbrook Metro Plaza, Suite 450
Rockville, MD 20852
Phone: (301) 443-5070
Email: jthierry@na.ihs.gov

Clarice Walker
Board President, Safe Shores
The DC Children's Advocacy Center
300 E Street, N.W.
Washington, DC 20001
Phone: (202) 638-2575
Email: claricedwalker@aol.com

Ellen Wartella, Ph.D.
Executive Vice President and Provost
University of California - Riverside
900 University Avenue
Riverside, CA 92521
Phone: (951) 827-5034
Email: wartella@admin.ucr.edu

Ramona Williams
Social Work Consultant
Indian Health Service
12300 Twinbrook Parkway
Twinbrook Metro Place, Suite 605
Rockville, MD 20852
Phone: (301) 443-1539
Email: ramona.williams@ns.ihs.gov

RADM Robert Williams, P.E., D.E.E.
Chief of Staff
Office of the Surgeon General
5600 Fishers Lane
Parklawn Building, Room 18067
Rockville, MD 20857
Phone: (301) 443-4000

Charles Wilson, M.S.W.
San Diego Children's Hospital and Center
3020 Children's Way
San Diego, CA 92123
Phone: (858) 966-5911
Email: cwilson@chsd.org

Brian Wyant
Director
Division of Health Risk Reduction
Pennsylvania Department of Health
7th and Forster Streets
Harrisburg, PA 17120
Phone: (717) 787-5900
Email: bwyant@state.pa.us

Joan Yengo Vice President
Mary's Center for Maternal and Child Care, Inc.
2333 Ontario Road, N.W.
Washington, DC 20009
Phone: 202-483-8319, ext. 321
Email: jyengo@maryscenter.org

 



REFERENCES

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Eckenrode J, Zielinski D, Smith E, Marcynyszyn LA, Henderson CR Jr, Kitzman H, Cole R, Powers J, Olds DL. Child maltreatment and the early onset of problem behaviors: can a program of nurse home visitation break the link? Dev Psychopathol. 2001 Fall;13(4):873-90.

Fiscella K, Kitzman HJ, Cole RE, Sidora KJ, Olds D. Does child abuse predict adolescent pregnancy? Pediatrics. 1998 Apr;101(4 Pt 1):620-4.

Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for child abuse. JAMA, 2002;288:1603-09.

National Research Council, Institute of Medicine (JP Shonkoff and D Phillips (Eds)): From Neurons to Neighborhoods. Washington, DC: National Academy Press, 2000.

Olds DL, Eckenrode J, Henderson CR Jr, Kitzman H, Powers J, Cole R, Sidora K. Morris P, Pettitt LM, Luckey D. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA. 1997 Aug 27;278(8):637-43.

Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics. 1986 Jul;78(1):65-78.

Olds DL, Henderson CR Jr, Kitzman HJ, Cole RE. Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment. Pediatrics. 1995 Mar;95(3):365-72.