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The concept of Child Protective Services (CPS) was idealistic when it first came into being in the early 1970s. Following the lead of Henry Kempe and colleagues at the University of Colorado, pediatric centers began putting together multidisciplinary teams to evaluate infants and children with suspected inflicted injuries. Initially the task of identifying nonaccidental trauma was relatively straightforward because it was the classic “battered child” that was among most frequent diagnoses. (That is, the classic picture was an infant or child with multiple fractures incurred at varying ages, often coexisting with failure to thrive, and a mother who was depressed. It would be 1 or more decades before other forms of maltreatment like sexual abuse, Munchausen by proxy, and intimate-partner violence were “discovered.”)
Management after the diagnosis was confirmed, however, was quite another matter. Few police personnel were capable of investigating a hitherto unknown entity, and social workers did not possess the power to ask questions of persons who did not want to speak to them—hence, the appearance of a new breed of professional with the legal power to investigate, combined with the skills to provide support for the child and family. The supportive role was deemed important because it was assumed that the majority of children involved with CPS would either remain in or return to their homes. As Paulsen said:
Protective services aim at effecting constructive change within the family in which there has been child neglect or abuse so that the child's environment may be improved.1 (p157)
The number of CPS workers escalated following passage of mandated reporting laws in the states and the federal Child Abuse Prevention and Treatment of Act of 19742 that provided the funds to pay for them.
Much has changed in the child welfare field over the past 40 years, notably the types of child maltreatment seen and the explosive growth of the foster care system. Substantiated physical abuse has declined 52% from 1992 to 2007; substantiated sexual abuse has declined 53% in the same period.3 Two important reasons are the increase in public and professional awareness and the decrease in the number of recurrent instances of abuse. The classic “battered child” is now rarely seen. Much credit for these accomplishments must go to the CPS system. A high proportion of long-term abusers have been identified and separated from their child victims. But while the number of reported cases of physical and sexual abuse has fallen, the number of neglect cases has remained relatively level and now constitutes almost three-quarters of cases reported to CPS. The types of substantiated maltreatment in 758 289 children reported in 2008 were neglect, 73%; physical abuse, 16%; psychological maltreatment, 7%; sexual abuse, 9%; and other, 9%.4 (The percentages exceed 100% because some victims experienced more than 1 type of maltreatment.)
How has CPS responded to these changed responsibilities? Not well, according to the study by Campbell and colleagues5 in this issue of the Archives. They looked at 595 children between the ages of 4 and 8 years judged to be at risk for abuse and neglect. Differences in 7 modifiable risk factors were compared in the 164 children (28%) who experienced a CPS investigation for suspected maltreatment vs the rest of the cohort (72%) who were not involved with CPS. Their findings:
At age 8 years, investigated subjects were not perceptibly different than noninvestigated subjects in social support, family functioning, poverty, maternal education, or child behavior problems after adjusting for baseline risk factors.
As Campbell and colleagues point out, the results are not surprising. Who expects CPS to affect such basic factors as poverty, family functioning, and social support? Perhaps child welfare officials who continue to recruit battalions of CPS workers to fight battles for which they are ill prepared. A Government Accounting Office study in 2003 found that only 28% of child welfare staff hold either a bachelor's degree (15%) or master's degree in social work (13%) and that the average tenure of child welfare workers is less than 2 years.6 In these days of fiscal distress, the situation must be worse.
Child Protective Services has outlived its usefulness; it is time the responsibilities of these programs be reallocated as follows:
Investigation of abuse: Assault of a child is a crime and should be treated as such. Allegations of physical or sexual abuse should be investigated by law enforcement personnel. The expense of dual investigations that currently take place cannot be justified. Just as physicians had to be educated about maltreatment, so were law enforcement staff. Most major police agencies now have staff with the knowledge and sensitivity to appropriately deal with child maltreatment.
Child neglect and family support: Public health nurses should be the first-line responders when concerns of child neglect are raised. More importantly, public health nursing services should be provided to at-risk families before the occurrence of abuse or neglect. Public health nurses possess skills to assess child and family functioning and are more apt to be accepted in homes than CPS workers. The landmark studies of Olds and colleagues7 and Kitzman and colleagues8 have demonstrated how nurse home visits to families at risk result in improved family functioning and cost savings.
Social workers: Social workers with professional training should continue to have a major role in child protection, but not as crime investigators. They should continue to work with child protection teams and with the courts to assess appropriate living situations, provide family counseling and other kinds of clinical interventions, and work with families and child welfare agencies to help secure needed resources and services.
Unfortunately, it is illusory to believe that any of these recommendations will be adopted in the near future, because:
Addressing child neglect is not a popular action item for politicians or the public. Welfare policies are invariably guided by high-profile child deaths, with associated finger pointing, blue-ribbon committees, and new policies that stay in effect until the next child homicide.
However valuable the work of public health nurses on behalf of mothers and children, they constitute a dispirited, vanishing species in the United States. A report from the Quad Council of Public Health Nursing Organizations stated:
“The public health nursing shortage is complex and caused by numerous and varied factors such as inadequate salaries, aging of the current workforce, reduction of positions due to budget constraints, bureaucratic personnel and hiring systems, ineffective recruitment and retention strategies, inadequate political support and advocacy, and a critical shortage of adequately prepared faculty.9 ”
If child welfare agencies were not hiring trained social workers for child protection work in 2003, it is doubtful they will start doing so now.
This gloomy prognosis notwithstanding, the changed picture of child maltreatment in the United States demands, at the very least, that we begin a wide-ranging discussion and testing of alternative responses.
Correspondence: Dr Bergman, Department of Pediatrics, Harborview Medical Center (MS 359774), 325 9th Ave, Seattle, WA 98104 (oscarb@uw.edu).
Financial Disclosure: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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