discussion

P

R p

C a

b

a

A R A A

K M R C C U t

d i V

o

0 h

Child Abuse & Neglect 37 (2013) 93–101

Contents lists available at SciVerse ScienceDirect

Child Abuse & Neglect

ractical strategies

esilience in the context of child maltreatment: Connections to the ractice of mandatory reporting�

hristine Wekerle a,b,∗

McMaster University, Canada University of Toronto, Canada

r t i c l e i n f o

rticle history: eceived 13 November 2012 ccepted 23 November 2012 vailable online 9 January 2013

eywords: andatory reporting

esilience hild maltreatment hild abuse and neglect nited Nations Convention on the Rights of

he Child

a b s t r a c t

A human rights perspective places the care for children in the obligation sphere. The duty to protect from violence is an outcome of having a declaration confirming inalienable human rights. Nationally, rights may be reflected in constitutions, charters, and criminal codes. Transnationally, the United Nation’s (UN) Convention on the Rights of the Child (CRC) prioritizes a child’s basic human rights, given their dependent status. UN CRC signatory countries commit to implementing minimal standards of care for minors. Laws requiring professionals to report child maltreatment to authorities is one practical strategy to imple- ment minimal child protection and service standards. Mandatory reporting laws officially affirm the wrong of maltreatment and the right of children. Mandatory reporting can be conceptualized as part of a resilience process, where the law sets the stage for child safety and well-being planning. Although widely enacted law, sizeable research gaps exist in terms of statistics on mandatory reporting compliance in key settings; obstacles and processes in mandatory reporting; the provision of evidence-based training to support the duty to report; and the training-reporting-child outcomes relationship, this latter area being vir- tually non-existent. The fact that mandatory reporting is not presently evidence-based cannot be separated from this lack of research activity in mandatory reporting. Reporting is an intervention that requires substantial inter-professional investment in research to guide best practices, with methodological expectations of any clinical intervention. Child abuse reporting is consistent with a clinician’s other duties to report (i.e., suicidality, homicidal- ity), practice-based skills (e.g., delivering “bad” news, giving assessment feedback), and the pervasive professional principle of best interests of the child. Resilience requires the pres- ence of resources and, mandated reporting, is one such resource to the maltreated child. Practice strategies identified in the literature are discussed.

© 2012 Elsevier Ltd. All rights reserved.

We live in a world where we rarely speak out and when someone does, often nobody is there to listen. . .I know I’m not the only child to be hurt. . .there are still the families that look great on the outside, but if someone were to delve deeper they would discover horrors. . .. (Dugard, 2011, p. 2)

Some children live daily lives of horror, terror, shock, and injury; violence can be debilitating and deadly. Violence is

efined as having the features of: (1) the abuse of power (threatened or actual) and (2) a heightened likelihood of psycholog-

cal harm, maladaptation, injury, and death (Krug, Mercy, Dahlberg, & Zwi, 2002; World Health Organization (WHO), 2002). iolence to children and adolescents is high. It is estimated that 31,000 homicides are committed on children less than

� This work was supported by a Canadian Institutes of Health Research grant (International Resilience Project), as well as a grant from the Ontario Centre f Excellence in Child and Youth Mental Health (www.excellenceforchildandyouth.ca/) to C. Wekerle. ∗ Corresponding author address: McMaster University, Department of Pediatrics, 1280 Main St. W., Hamilton, Ontario, Canada L8N 3Z5.

145-2134/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. ttp://dx.doi.org/10.1016/j.chiabu.2012.11.005

94 C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101

15 years of age every year globally, with an estimated 2,400 due to child maltreatment in the United States alone (Sedlak et al., 2010; WHO, 2010). In 2008, 1,740 children were identified as having died due to child abuse and neglect in the United States, and this number has increased over the prior 5 years (US Department of Health and Human Services, 2010). The US national average of 43.8/1000 children referred to CPS for suspected maltreatment in 2010, representing 6 million children (USDHHS, 2010).

Children depend on adults for their survival, safety, and care. Children and adolescents are not in control over their environments and, therefore, cannot escape harmful situations effectively. Research shows a high degree of multiple victim- ization dangers for youths – in the home, neighborhood, school, and community (Finkelhor, 2008). Danger persists across the childhood years: adolescents reporting involvement in physical teen dating violence (6.4% of youths) are more likely to report caregiver maltreatment, sexual victimization, internet harassment, and gang/group physical assaults (Hamby, Finkelhor, & Turner, 2012). Laws, policies, and procedures are required to ensure children’s right to life and living in ade- quate standards to support their development. Rights have three functions, providing: (1) rules for a common understanding to implement strategies, identifying structures, policies, and legislation responsive to governmental resources; (2) priori- tization for resource distribution, focusing on interdependent rights (education, health, welfare) and limiting social power (i.e., parents do not have the right to cause serious injury to their child as part of their child management style); and (3) an indication of process, as in ensuring child participation, as appropriate, in decisions affecting their lives (Morrow & Pells, 2012).

There is an evidence basis to a governmental imperative to protect minors (Lee & Svevo-Cianci, 2011; Pietrantonio et al., 2013, Svevo-Cianci, Hart, & Rubinson, 2010). The negative consequences to the child victim, both in the short-term and across their lifespan is well-established (e.g., Wekerle, 2011), as it is well-recognized that the majority of maltreatment does not come to the attention of child protective services (e.g., MacMillan, Jamieson, & Walsh, 2003). Some victims are asymptomatic following disclosure, and many find ways to resolve and integrate their maltreatment (Wekerle, MacMillan, Leung, & Jamieson, 2008). Longitudinal research shows that victimization is associated with a cascade of developmental implications that can confer greater health risk (Alink, Cicchetti, Kim, & Rogosch, 2012; Currie & Tekin, 2012; Danese, Pariante, Caspi, Taylor, & Poulton, 2007; Jonson-Reid, Kohl, & Drake, 2012; Kim & Cicchetti, 2010; Kim, Cicchetti, Rogosch, & Manly, 2009; Nanni, Uher, & Dannese, 2012; Rogosch, Oshri, & Cicchetti, 2010; Scott, McLaughlin, Smith, & Ellis, 2012; Shin & Miller, 2012). For example, sexually abused females are more likely to have early menarche (before age 11); girls who menstruate early may be at greater risk for certain health problems, such as heart disease, metabolic dysfunction, cancer, and depression (Boynton-Jarrett, Rosenberg, Palmer, Boggs, & Wise, 2012). Sexually assaulted victims were over 3 times more likely to report physical (hit, slap) teen dating violence; one-third of youths experiencing physical teen dating violence, also experienced sexual assault by dating partners (Hamby et al., 2012). Females who were sexually assaulted by a family member are 10 times more likely than their non-sexually abused, demographically-matched counterparts to have their own children reported to CPS (Trickett, Noll, & Putnam, 2011). For boys, sexual abuse increases the likelihood of fathering, having multiple partners, and failing to use protection (Homma, Wang, Saewyc, & Kishor, 2012). A large-scale study reported that any abuse and neglect (physical, psychological, sexual abuse, and emotional neglect) had the highest disability weights (.057) among a number of childhood adversities, where disability reflects a measure of the severity of a disease or condition ranging from 0 (perfect health) to 1 (equivalent to death). Such findings indicate implications for adult role fulfillment and quality of life (Cuijpers et al., 2011). Maltreatment requires on-going adaptations; while functionality in one domain may be achieved, dysfunctionality in other domains may be present (Cicchetti & Blender, 2006). The right to be free of violence has substantive real-life implications, and rights affect actions.

International treaties supporting universal human rights have been adopted by the majority of the countries of the world, reflecting global community standards in an individual’s right to health, education, adequate standard of liv- ing, self-determination, and to be recognized without discrimination (e.g., International Bill of Human Rights: Universal Declaration of Human Rights: International Covenant on Economic, Social, and Cultural Rights; International Covenant on Civil and Political Rights; Convention on the Rights of the Child (CRC); http://treaties.un.org/Pages/ViewDetails. aspx?chapter=4&lang=en&mtdsg no=IV-3&src=TREATY; http://www.who.int/hhr/Economic social cultural.pdf). Universal rights reflect the right to family life, which includes the protection of children (e.g., Article 24, International Covenant on Civil and Political Rights), and the need for “special measures” to be taken to ensure minor’s protection (e.g., Article 10, International Covenant on Economic, Social and Cultural Rights). Child maltreatment relates to both a “negative right” (i.e., the right to not have something noxious and injurious applied to a child), as well as a “positive right” to dignity. The 2005 Guidelines on Justice in Matters Involving Child Victims and Witnesses of Crime points to professionals main- taining principles of best interests, dignity, nondiscrimination, protection, harmonious development, and participation (www.un.org/en/pseataskforce/docs/guidelines on justice in matters involving child victims and.pdf).

Professional ethics doctrines share a common principle of “best interests” of the client, and this is reflected in the range of professional duties to report (i.e., child abuse and neglect; suicidality; homicidality). Living a life free of violence from all sources (not only parents) is in the child’s and adolescent’s “best interest,” and is a basic right in the United Nation’s (UN) Convention of the Rights of the Child (http://www.unicef.org/crc/), with most countries in the world adopting and ratifying

the UN CRC (Melton, 2005a, 2011). The UN CRC provides clarity in that prevention of violence is first in line in protecting a child’s best interests. Second in line, then, is preventing re-victimizations. Finally, “physical and psychological recovery” of a child victim is protected, yielding an obligation to provide services to promote physical and psychosocial healing (Article 39, UN CRC). The UN CRC is consistent with the constitution of many countries. For example, Guggenheim (2006) notes that

c f

H l “ p o w o t o i a a p o n ( i a a d r

a G c s i r S M T C m H p p i t c

a c i m p t r

M

t ( d 4 ( o i

C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101 95

hildren have their privacy and liberty rights protected in the US Constitution, although constitutional rights to be protected rom harm are not covered, and is a benefit of the UN CRC (the US has adopted but not ratified it).

Countries without mandatory reporting legislation span across the economic spectrum (e.g., Germany, Kindler, 2008; ong Kong, Leunga, Wong, Tang, & Lee, 2010; Pakistan, Mathews & Kenny, 2008), as do those with mandatory reporting

aws (e.g., US, Canada, Turkey, Ghana; Pinheiro, 2006). Mandatory reporting laws exist in all US states. Some indicate universal permissive” reporting (i.e., any adult suspecting child abuse or neglect), while others emphasize “mandated” reporting for rofessionals, yielding it an area of potentially fruitful inter-disciplinary collaboration (Kim, Gostin, & Cole, 2012). In reflecting n the state of current empirical knowledge, Gilbert et al. (2009, p. 168) concluded: “For child maltreatment, we do not know hether the process from recognition to reporting and subsequent interventions by child protection agencies improves lives

f children overall.” Reporting laws may yield benefits in terms of: (1) official acknowledgment of the wrong of maltreatment o the child, the offending party(ies) and the non-offending caregiver; (2) the potential for violence prevention, where an fficial record may serve to protect the index child from re-victimization, as well as other children from victimization, ncluding siblings; and (3) the opportunity for service provision in case management, direct resource allocation youth in care, s well as family support and linkages that may contribute to minimizing family stress, maltreatment-related impairment, nd optimizing trajectories of healthy living. Other benefits (e.g., sets the stage for maltreatment database; “in good faith” rinciple protects professionals in fulfilling reporting) and disadvantages (e.g., open to “threshold” interpretations on degree f suspicion, harm, and risk) have been noted (Gilbert et al., 2009). A key concern is that a report or an investigation should ot be the sole intervention for a family in crisis or confronting significant challenges to ensuring child health and safety e.g., Leventhal & Krugman, 2012; Mathews & Bross, 2008; Melton, 2005b). Reporting laws are only the basis for subsequent mplementation protocols in accountability and service provision. The Institute of Medicine (IOM, 2012) highlights that: (1) ll children are ready to learn; (2) early environments and nurturing relationships are essential; and (3) society is changing nd the child needs are not being adequately addressed. As Mathews and Bross (2008) point out, children are atypically the irect source for CPS referral and parents are in the minority as reporters of their child’s maltreatment, and that mandatory eporting offers the opportunity for a system of case-finding.

Resilience has been defined in increasingly complex ways toward highlighting multi-level interactions with environments nd, especially, the importance of available and accessible resources supporting adaptation (Cicchetti & Blender, 2006; al, 2011; Supkoff, Puig, & Sroufe, 2012; Ungar, 2011). Mandatory reporting, and the effective interventions that follow, an be regarded as a context for resilience. This is because maltreatment is (a) deadly (including maltreatment fatalities, uicidality, early mortality due to lifestyle-related diseases), (b) impairing to health and well-being, and early intervention n the maltreatment trajectory can be corrective and, even, life-saving, and (c) co-morbid with other issues, and treatment ecommendations can be sensitive to variations in trauma history (e.g., Dozier, Albus, Fisher, & Sepulveda, 2002; Fisher, toolmiller, Mannering, & Chamberlain, 2011; Ippen, Harris, Van Horn, & Lieberman, 2011; Gilbert et al., 2009; Jaffee & aikovich-Fong, 2011; Leventhal & Krugman, 2012; Nemeroff et al., 2003; Romano, Bell, & Billette, 2011; Shonkoff, Garner, &

he Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent are, and the Section on Developmental and Behavioral Pediatrics, 2012). Mandatory reporting is an intervention in the altreatment trajectory and the engagement with service systems can promote the resilience process (Coohey, Renner, ua, Zang, & Whitney, 2011). In the context of maltreatment, capacity and support to navigate and negotiate resources is art of the resilience role of the child welfare caseworker, where it is acknowledged that disclosure is an on-going, dynamic rocess facilitated by protective adult relationships (Wekerle, Waechter, & Chung, 2011). Research in CPS settings can help

dentify processes promoting or hindering resilience. For example, Yampolskava, Armstrong, and King-Miller (2011) found hat faster re-entry into out-of-home care was associated with a CPS agency’s lower average expenditures/child for shelter osts, and greater out-sourcing of case management.

This paper considers research related to mandatory reporting and practice guidance in the area of child maltreatment, and dvances that reporting represents a key, early intervention opportunity in setting the stage for resilience processes in the hild victim. To examine the potential of mandatory reporting as a part of a resilience process, we will consider this research n terms of: (i) maltreatment risk, including re-reporting to child protective services; (ii) professional under-reporting of child

altreatment; and (iii) practical strategies supporting the process of professional decision-making. Research within different rofessions subjected to mandatory reporting laws is scarce, with the most work done with physicians and physicians-in- raining, and cross-discipline work is scarce. Given the widespread adoption of the UN CRC and the extent of mandatory eporting laws, this research gap is very stark.

andatory reporting and maltreatment risk

The broad body of developmental research anchors “best interests” of the child as having identifiable parameters based on he weight of the evidence, for example, as with an “early years” investment strategy, alongside school-attending children Melton, 2011). The emergency visit represents one entry to first care in a maltreatment-related health crisis, and early etection, especially in these early years, may prevent subsequent injury (Teeuw, Derkx, Koster, & van Rijn, 2012). About

,600 children in the US were hospitalized as a result of child maltreatment over a 1-year period in 2006, and 300 died Leventhal, Martin, & Gaither, 2012). The peak age in hospitalization for abusive head trauma was between 2 and 5 months f age (Parks, Sugarman, Xu, & Coronado, 2012). Recent research identifies that when an infant comes to care, all children n the home are at risk. In a prospective study of 20 US medical centers utilizing a common child abuse screening protocol,

96 C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101

evidence of abusive fracture was found among other children in the home (Lindberg et al., 2012). These authors note that some child cases were lost due to death, highlighting that early detection, including detection of more subtle injuries (e.g., any level of bruising in pre-mobile infant), is critical. Further, it is important to note that most children presenting to hospital where maltreatment is suspected are discharged to go home with their parents (75.6%), with the minority discharged to CPS (2.9%) or an intermediate care facility (15.8%) (Friedman, Sheppard, & Friedman, 2012). Very clearly, children need protection, and to have the opportunity to have maltreatment recognized.

Once maltreatment has occurred, the risk for re-victimization is high. A national review of child maltreatment inves- tigations in the US revealed that 40% of all closed investigations were re-referred to CPS within 3.75 years of the index maltreatment event (Connell, Bergeron, Katz, Saunders, & Tebes, 2007). About 67% of CPS families with a young child (4 years of age and under) substantiated for maltreatment were re-reported (Proctor et al., 2012). In this study, physical abuse in young children, in particular, was a risk factor for substantiated maltreatment recurrence. A prospective study of children reported to CPS found that 51% of those with substantiated initial reports of maltreatment, and 38% of those with unsub- stantiated reports, were victims of substantiated abuse within 5 years of the index maltreatment report (Dakil, Sakai, Lin, & Glenn, 2011). While physical injury supports detection, psychological maltreatment (PM) has been shown to be seriously impairing (see 2009 and 2011 special issues on emotional maltreatment, this journal), and clinician groups have confirmed the need for its assessment, alongside physical and sexual abuse and neglect (Hibbard, Barlow, MacMillan, & Committee on Child Abuse and Neglect and American Academy of Child and Adolescent Psychiatry, Child Maltreatment and Violence Committee, 2012). Data from the US National Child Abuse and Neglect Data System (NCANDS) identified a sample of first- time confirmed PM cases (over 11,000 children), and found that about 10% had PM re-confirmed over the next 5 years (Palusci & Ondersma, 2012). Taken together, these injury and re-reporting statistics speak to a broad-scale and persistent maltreatment problem in need of effective first responses.

Professional under-reporting of child maltreatment

Mandated reporting is the first step in promoting child safety and, hence, resilience, when maltreatment concerns are present, as righting processes from an adverse event requires the adverse event to end (Wekerle et al., 2011). It needs to be kept in mind that maltreatment is part of a differential diagnosis framework; it is the suspicion of abuse or neglect that prompts the mandatory reporting. Gilbert et al. (2009) rightly point out that the benefit-harm analysis of the impact of mandatory reporting law would need to consider the harm to the child of reporting to child protection, as well as the provision of effective therapeutic responses to any maltreatment-related impairment and child well-being and health promotion (prevention of violence re-victimization and on-going impairment). Leventhal and Krugman (2012), in their analysis of the 50 years since the Journal of the American Medical Association’s publication of Kempe, Silverman, Steele, Droegmuller, and Silver’s (1962) “The Battered Child Syndrome” article, articulate practice learning to date. The learning points include the need to direct attention to situations where the injury mechanism in absent or inconsistent with clinical presentation, key clinical findings consistent with maltreatment and, importantly, that parents and caregivers can be asked effectively and compassionately about their parenting behaviors. Caregiver vulnerabilities, such as poverty, low social support, adult intimate partner violence, and parental alcohol and other drug abuse, that are predictive of substantiation decisions (e.g., Wekerle, Wall, Leung, & Trocmé, 2007) indicate referral and resource linkage by the clinicians attending to the child. It is important to connect the dots across violence types (Asnes & Leventhal, 2010, 2011). The professional continues to advocate and care for the child post-reporting, to assist in assessing safety, as well as contribute to a treatment plan, as indicated. Areas for improvement include better collaborative models among legal, protection, school, and care authorities, and the availability of affordable care, including in the mental health arena.

Most research into under-reporting and reporting training has occurred with health professionals, especially physician groups (Christian, 2008; Feigelman, Dubowitz, Lane, Grube, & Kim, 2011; Flaherty et al., 2008; Gilbert et al., 2009; Sege et al., 2011; Vulliamy & Sullivan, 2000). In the US, all states identify the physician as a mandated reporter. In terms of CPS referrals, only 8.2% of reporters are “medical workers” (USDHHS, 2010). Similar findings (10% “health care professionals”) emerged in analyzing surveillance data on first-reports to CPS in Canada (Tonmyr, Li, Williams, Scott, & Jack, 2010). Public health nurses have a duty to report, but those providing home-visiting services report challenges with client fears that CPS involvement is equivalent to child removal from the home (Davidov, Jack, Frost, & Coben, 2012), even though permanent removal from the home is not a high frequency outcome among all CPS cases opened for service. In a study of primary health care physicians, 21% of injuries that experts considered reportable were not reported. The data in this study indicated that the physician’s decision to report to CPS did not reduce the frequency of primary care follow-up visits in the six months after the index visit, as impaired follow-up care is one of the clinical care concerns cited with reporting (Sege et al., 2011). The main obstacles to mandatory reporting practices are: recognizing and responding to maltreatment, sound measurement properties of checklists or screening tools, standardized training and its measured outcomes (Gilbert et al., 2009).

The non-negotiable, basic human rights to be free of violence are realized and validated at the local level (Morrow & Pells, 2012). CPS agencies substantiate the abuse and/or neglect, and the police pursue criminal charges, as indicated. Existing

research suggests that final resolution in the criminal justice system is an atypical outcome of parental or caregiver abuse and/or neglect of the child. Further, the information on the interface between CPS and police is an area of research need. Data suggests that criminal investigation is more likely in sexual abuse cases, and less likely in neglect cases, but more likely when CPS and police have a memorandum of agreement (Cross, Helton, & Chuang, 2012). In a meta-analysis (Cross, Walsh,

S a t h &

F

a I o o t o i c r

e 2 c & & ( p t s c b 2 F m s p r t

t c a r ( a s c h e t

2 K t a a L a d S w i

C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101 97

imone, & Jones, 2003), a wide range of case rates were accepted by the prosecution across studies, with most between 48% nd 76% of cases with charges laid. In terms of cases that moved forward to go to trial or plea, over 90% were convicted in the rial process, including where a guilty plea was entered, with a mean of 54% for incarceration outcomes. Police involvement as been linked to a range of services offered to CPS families, even when controlling for case characteristics (Cross, Finkelhor, Ormond, 2005). Thus, a legal route is not a barrier to receipt of services.

ostering resilience: Practical strategies supporting mandatory reporting

The reasonable practitioner, with reasonable knowledge about child maltreatment, makes a reasonable determination bout the child being at-risk for maltreatment. Thus, initiating a mandated report is part and parcel of good clinical practices. n a hospital setting, multiple professions are involved, each potentially obtaining unique information. In one large study f nurses (Fraser, Mathews, Walsh, Chen, & Dunne, 2010), training in child abuse and neglect was mandated and available n-line; close to 60% of the sample reported receiving formal training. Training was related to a higher likelihood of intent o report in neglect, as evaluated by vignettes approach. Longitudinal follow-up to assess reporting practices was not part f this study. Carter, Bannon, Limbert, Docherty, and Barlow (2006) suggest that various training approaches (didactic, nteractive, computer assisted) need to be examined in conjunction with various tools, such as checklists, flow charts, onsultation, and other sources of procedural guidance to adequately derive a standardized clinical approach to maltreatment isk.

While there is no gold standard diagnostic test for child abuse and neglect, there is a building practice knowl- dge on its assessment and identification, commensurate with the increasing recent research base (Asnes & Leventhal, 010; Piteau, Ward, Barrowaman, & Plint, 2012). Research assessing professional interpretations of “reasonable suspi- ion” suggests both variable and inconsistent applications, calling for a standardized training and evaluation (Crowell

Levi, 2012). The need for dedicated governmental dollars to train in mandatory reporting has been raised (Leventhal Krugman, 2012). Much of the recent research has occurred in the context of emergency services. Systematic review

6 studies) points to the use of maltreatment checklists and education used in hospital emergency departments as otentially promising, although no randomized trials were available (Newton et al., 2010). A review paper of sys- ematic reviews to date, and recent literature, emphasized the low quality of available studies, and the dearth of tudies evaluating potential child maltreatment detection strategies (Teeuw et al., 2012). These authors note that ommonly used child abuse and neglect checklists are yet in need of rigorous research (sensitivity, specificity). The urden to clinician and systems of high false-positive rates places an emphasis on clinical assessment (Gilbert et al., 009). Evidence-based recommendations for action in sexual and physical abuse is provided by Gilbert and colleagues. or example, in the case of unexplained bruising, epidemiological information is provided (expectable bruising infor- ation: “babies who cannot move independently <1%; infants starting to move independently 17%; toddlers 53%;

chool-aged children 80%,” p. 170). This epidemiological information is matched to maltreatment risk (e.g., “Unex- lained bruises in babies who are not independently mobile and bruises that carry the imprint of an implement should aise suspicion of physical abuse,” p. 170). Epidemiology provides a critical context for understanding clinical presenta- ion.

Rigorous research methods as randomization can be applied to hospital and CPS settings and, ideally, to the follow- hrough from physician reporting to maltreatment investigation. One randomized study by Louwers et al. (2012) had a legal hange such that child abuse and neglect screening was mandated for emergency departments (in the Netherlands). Using screening checklist, along with staff training and physician follow-up, systematic screening increased the abuse detection

ate 5-fold in a sample of over 100,000 cases (aged 18 or younger), from 7 hospitals, over a 22 month period. Louwers et al. 2012) study checklist approach contained 6 questions, where any positive response was seen to reflect maltreatment risk nd the need for more in-depth assessment. These were: (1) Is the history consistent? (2) Was there unnecessary delay in eeking medical help? (3) Does the onset of the injury fit with the developmental level of the child? (4) Is the behavior of the hild, caregivers and their interaction appropriate? (5) Are the findings of the top-to-toe examination in accordance with the istory? (6) Are there any other signals that make you doubt the safety of the child or other family members? The process ntailed the checklist completion of the emergency room nurses with subsequent physician evaluation, and physicians were he responsible party to take action if necessary (and to provide a diagnosis).

In other work, there is evidence suggesting that the amount of education is predictive of reporting (Lawrence & Brannen, 000), underscoring the need to consider training from pre-service to continuing education. The Safe Environment for Every id (SEEK) program shows promise in a low-income, urban population. Using a parenting screening measure, child mal-

reatment risk factors were addressed by a resident (specifically trained in maltreatment assessment) and social worker, nd resources (handouts) were provided. As compared to standard care, the SEEK care yielded improved immunization dherence, less harsh parenting (parental report), and fewer CPS reports (medical chart review) (Dubowitz, Feigelman, ane, & Kim, 2009; Dubowitz, Lane, Semiatin, & Magder, 2012; Feigelman et al., 2011). Common parent education needs re recognized, which include a psycho-educational need for normative child developmental contexts (e.g., crying, sleep

isruptions, toileting accidents, appetite fluctuations, normative child and adolescent oppositional behavior) (Flaherty, tirling, & Committee on Child Abuse and Neglect, 2010; see American Academy of Pediatrics’ Connected Kids program, ww.aap.org/connectedkids). Also, positive discipline options available widely to parents remains important as most phys-

cal abuse reported to CPS occurs in the context of discipline, and there is a danger of crossing the line from physical

98 C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101

punishment to physical abuse (Durrant & Ensom, 2012; Gonzalez, Durrant, Chabot, Trocmé, & Brown, 2008; see also Christian, Block, & Committee on Child Abuse and Neglect (2009). Beyond supportive education, skill practice and development in needed: evidence-based parenting skills programs are also available, with resources on home visiting programs widely available (www.childwelfare.gov/preventing/programs/types/homevisit.cfm).

Asnes and Leventhal (2010) provide some practical sequences. For example, they urge allowing a caregiver to tell their story of the mechanism of the injury or dysfunction without interruption, so as to not influence the nature of the information. Fortin and Jenny (2012) remind clinicians that delay between the onset of sexual abuse and disclosure is common, and that recantation does not rule out sexual abuse. Sexual abuse is important in the differential diagnosis when children exhibit sexualized behaviors, and maltreated children may present with non-specific complaints, in toi- leting, sleeping, abdominal pain, that may be reflective of overwhelming stress. Practical guidance identified by Hibbard et al. (2012) for pediatricians for psychological maltreatment assessment and follow-up are applicable more generally to maltreatment. These include: (1) maintaining an alertness for, and consideration of, maltreatment when assessing pedi- atric psychological and behavioral conditions; (2) obtain multiple informant information, and involve team members in sharing the information-gathering load from child care and education personnel; (3) interview all major caregivers for children of all ages individually to support inquiry regarding adult intimate partner violence, adult substance abuse, and other sensitive content areas; (4) in addition to the physical exam, interview the child alone, away from caregivers, and from a developmental standpoint, to inquire about his/her relationship with caregivers, experiences of discipline in the home, and feelings of safety, being loved, and self-view. Very young children speaking in sentences often can provide information about what the parent does “to let you know you did something not-so-good, bad or wrong;” and (5) consult with child maltreatment experts or a mental health professional to support completing an assessment and a follow-up or treatment plan. As part of the local procedure, a member of the health care team should be des- ignated to share information and convene a case conference. Case conferencing is a practical data-sharing strategy for coordinating case management. Early notification to CPS can assist in the efficient and effective data gathering pro- cess.

All mandated reporters, and the teams within which they work, need to be clear that their statements and actions may impact the CPS investigation. Communications to family members about hypotheses on the mechanisms of injury may impact parental behavior negatively, in the case where the child is exiting the facility (hospital, school) with the caregiver, as well as the CPS or criminal investigation. An Institute of Medicine’s commentary identifies a set of 6 standard communication behaviors (CICARE; “see-I-care”; Feinberg, Coye, & Washington, 2012) for interacting with all clients that supports relationship-building (Connect; Introduce yourself; Communicate procedures; Ask for patient concerns; Respond to questions with immediacy; Exit explaining what will come next). Particular attention to supporting the professional trainee is needed in teaching centers, including consultations with experienced professionals and CPS (anonymously if desired, at first). The primary objective is to secure the protection needs and best healthcare for the child and other children (Christian & Block, 2009).

The evidence-based approach to early childhood policy and practice across multiple sectors, including mandatory report- ing, could provide a compelling framework for securing children’s rights. The pediatrician or family doctor is a key clinician to monitor children’s healthy development, and advocate for the multiple needs of vulnerable families, including when maltreatment is present (Shonkoff et al., 2012). Beyond early intervention and referral to services, the physician’s office may be the site for coordinating promising interventions, while maintaining a protective social network. It is noted that the practice community sends urgent resource requests given the high caseloads experienced by CPS workers; providing a coherent, coordinated, and collaborative service plan that may be best realized within sustained inter-professional relation- ships (Asnes & Leventhal, 2011; Gilbert et al., 2009; Toth & Manly, 2011). Serious research consideration needs to be given to the development of core maltreatment curricula for mandated professionals, training evaluation, and the reporting-service delivery-child outcomes relationship. Mandatory reporting cannot be fairly assessed at present. Its potential as a resilience process cannot be realized. A slate of maltreatment education would seem necessary that spans pre-service to service and continuing education, with on-going consultation resources. A shared professional responsibility for learning about maltreatment, mandatory reporting laws and the process of reporting and clinical follow-through seems potentially more fruitful than an over-reliance on the more limited availability of maltreatment experts. The reality of time constraints in direct patient contact (Flaherty, Jones, Sege, & The Child Abuse Recognition Experience Study Research Group, 2004) argues for a model where more are aware and watchful of maltreatment signs, know what to ask and to look for, and what to do in the reporting process. The mandatory reporting laws apply to many, and many are thus responsible for caring for our children.

Resilience can begins with that first experience of adversity. Maltreatment is impairing and preventable, but that first call to CPS, reporting the suspicion of maltreatment, needs to happen. The human rights framework requires that special effort (and resources) be dedicated to minors. While the family is the unit of care, within this unit, the minor is accorded primacy. We do understand how to prevent maltreatment (see MacMillan et al., 2009), yet we still grapple with how best to support the maltreated child’s building resilience and freedom from violence and re-victimization. No reporting law, in and of itself, can ever lead to child well-being without actions reliably and consistently attached to supporting the duty to report. It is important to see mandatory reporting within the resource allocation context, understanding that “. . .investment

in children and adolescents yields high returns in terms of developmental potential realized, adult disorder prevented or less severe, and economic advantage for healthy individuals.” (Kieling et al., 2011, p. 1521).

A

P

R

A

A A B

C

C C

C

C

C

C C

C

C C

C D

D

D

D

D

D

D D

F

F F F

F

F

F

F F

F

G G

G

G

G H

C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101 99

cknowledgments

The authors thank Ronald Chung for the research assistance, and Drs. Anne Niec, Harriet MacMillan, and Anna-Marie ietrantonio for their comments on an earlier draft.

eferences

link, Cicchetti, D., Kim, J., & Rogosch, F. A. (2012). Longitudinal association among child maltreatment, social functioning, and cortisol regulation. Devel- opmental Psychology, 48, 224–236.

snes, A. A., & Leventhal, J. (2010). Managing child abuse: General principles. Pediatrics in Review, 31, 47–55. snes, A. A., & Leventhal, J. (2011). Connecting the dots in childhood and adolescent trauma. Archives of Pediatrics and Adolescent Medicine, 165, 87–89. oynton-Jarrett, R., Rosenberg, L., Palmer, J. R., Boggs, D. A., & Wise, L. A. (2012). Child and adolescent abuse in relation to obesity in adulthood: The black

women’s health study. Journal of the American Academy of Pediatrics, 130, 1–9. arter, Y. H., Bannon, M. J., Limbert, C., Docherty, A., & Barlow, J. (2006). Improving child protection: A systematic review of training and procedural

interventions. Archives of Disease in Childhood, 91, 740–743. hristian, C. W. (2008). Professional education in child abuse and neglect. Pediatrics, 122, S13–S17. hristian, C. W., Block, R., & Committee on Child Abuse, Neglect, American Academy of Pediatrics. (2009). Abusive head trauma in infants and children.

Pediatrics, 123, 1409–1411. icchetti, D., & Blender, J. A. (2006). A multiple-levels-of-analysis perspective on resilience: Implications for the developing brain, neural plasticity, and

preventive interventions. Annals of New York Academy of Science, 1094, 248–258. onnell, C. M., Bergeron, N., Katz, K. H., Saunders, L., & Tebes, J. K. (2007). Re-referral to child protective services: The influence of child, family, and case

characteristics on risk status. Child Abuse & Neglect, 31, 573–588. oohey, C., Renner, L. M., Hua, L., Zang, Y. J., & Whitney, S. D. (2011). Academic achievement despite child maltreatment: A longitudinal study. Child Abuse

& Neglect, 35, 688–699. ross, T. P., Finkelhor, D., & Ormrod, R. (2005). Police involvement in child protective services investigations. Child Maltreatment, 10, 224–244. ross, T. P., Helton, J. J., & Chuang, E. (2012). Concurrent criminal and child protective services investigations. Urbana, IL: Children and Family Research Center,

University of Illinois at Urbana-Champaign. ross, T. P., Walsh, W. A., Simone, M., & Jones, L. M. (2003). Prosecution of child abuse: A meta-analysis of rates of criminal justice decisions. Trauma, Violence

& Abuse, 4, 323–340. rowell, K., & Levi, B. H. (2012). Mandated reporting thresholds for community professionals. Child Welfare, 91, 35–53. uijpers, P., Smit, F., Unger, F., Stikkelbroek, Y., Ten Have, M., & de Graaf, R. (2011). The disease burden of childhood adversities in adults: A population-based

study. Child Abuse & Neglect, 35, 937–945. urrie, J., & Tekin, E. (2012). Understanding the cycle: Childhood maltreatment and future crime. Journal of Human Resources, 47, 509–549. akil, S. R., Sakai, C., Lin, H., & Glenn, F. (2011). Recidivism in the child protection system identifying children at greatest risk of re-abuse among those

remaining in the home. Archives of Pediatrics & Adolescent Medicine, 165, 1006–1012. anese, A., Pariante, C. M., Caspi, A., Taylor, A., & Poulton, R. (2007). Childhood maltreatment predicts adult inflammation in a life-course study. Proceedings

of the National Academy of Science, 104, 1319–1324. avidov, D. M., Jack, S. M., Frost, S. S., & Coben, J. H. (2012). Mandatory reporting in the context of home visitation programs: Intimate partner violence and

children’s exposure to intimate partner violence. Violence Against Women, 18, 595–610. ozier, M., Albus, K., Fisher, P. R., & Sepulveda, S. (2002). Interventions for foster parents: Implications for developmental theory. Development and

Psychopathology, 14, 843–860. ubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009). Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid

(SEEK) model. Pediatrics, 123, 856–864. ubowitz, H., Lane, W. G., Semiatin, J. N., & Magder, L. S. (2012). The SEEK model of pediatric primary care: Can child maltreatment be prevented in a

low-risk population. Academic Pediatrics, 12, 259–268. ugard, J. (2011). A stolen life: A memoir. New York: Luna Lee, Inc., p. 2 urrant, J. E., & Ensom, R. (2012). Physical punishment of children: Lessons from 20 years of research. Canadian Medical Association Journal,

http://dx.doi.org/10.1503/cmaj.101314 eigelman, S., Dubowitz, H., Lane, W., Grube, L., & Kim, J. (2011). Training pediatric residents in a primary care clinic to help address psychosocial problems

and prevent child maltreatment. Academic Pediatrics, 11, 474–480. einberg, D., Coye, M., & Washington, E. (2012). Commentary: Healing humankind one patient at a time. Washington, DC: Institute of Medicine. inkelhor, D. (2008). Childhood victimization: Violence, crime, and abuse in the lives of young people. New York: Oxford University Press. isher, P. A., Stoolmiller, M., Mannering, A. M., & Chamberlain, P. (2011). RCT intervention effects on foster placement disruptions associated with problem

behavior. Journal of Consulting and Clinical Psychology, 79, 481–487. laherty, E. G., Jones, R., Sege, R., & The Child Abuse Recognition Experience Study Research Group. (2004). Telling their stories: Primary care practitioners’

experience evaluating and reporting injuries caused by child abuse. Child Abuse & Neglect, 28, 939–945. laherty, E. G., Sege, R. D., Griffith, J., Price, L. L., Wasserman, R., Slora, E., Dhepyasuwan, N., Harris, D., Norton, D., Angelilli, M. L., Abney, D., & Binns, H. J.

(2008). From suspicion of physical child abuse to reporting: Primary care clinician decision-making. Journal of the American Academy of Pediatrics, 122, 611–619.

laherty, E. G., Stirling, J., & The Committee on Child Abuse, Neglect. (2010). The pediatrician’s role in child maltreatment prevention. Journal of the American Academy of Pediatrics, 126, 833–841.

ortin, K., & Jenny, C. (2012). Sexual abuse. Pediatrics in Review, 33, 19–32. raser, J. A., Mathews, B., Walsh, K., Chen, L., & Dunne, M. (2010). Factors influencing child abuse and neglect recognition and reporting by nurses: A

multivariate analysis. International Journal of Nursing, 47, 146–153. riedman, L. S., Sheppard, S., & Friedman, D. (2012). A retrospective cohort study of child maltreatment cases resulting in hospitalization. Injury, 43,

1881–1887. al, T. (2011). Child victims and restorative justice: A needs-rights model. New York: Oxford University Press. ilbert, R., Kemp, A., Thobum, J., Sidebotham, P., Radford, L., Glaser, D., & MacMillan, H. L. (2009). Recognising and responding to child maltreatment. Lancet,

373, 167–180. hosh Ippen, C. G., Harris, W. W., Van Horn, P., & Lieberman, A. F. (2011). Traumatic and stressful early events in childhood: Can treatment help those at

highest risk? Child Abuse & Neglect, 35, 504–513.

onzalez, M., Durrant, J. E., Chabot, M., Trocmê, N., & Brown, J. (2008). What predicts injury from physical punishment? A test of the typologies of violence

hypothesis. Child Abuse & Neglect, 32, 752–765. uggenheim, M. (2006). Ratify the U.N. Convention on the Rights of the Child, but don’t expect any miracles. Emory International Law Review, 20, 43–68. amby, S., Finkelhor, D., & Turner, H. (2012). Teen dating violence: Co-occurrence with other victimizations in the National Survey of Children’s Exposure

to Violence (NatSCEV). Psychology of Violence, 2, 111–124.

100 C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101

Hibbard, R., Barlow, J., MacMillan, H., & Committee on Child Abuse, Neglect, American Academy of child, adolescent psychiatry. (2012). Psychological maltreatment. Journal of the American Academy of Pediatrics, 130, 372–378.

Homma, Y., Wang, N., Saewyc, E., & Kishor, N. (2012). The relationship between sexual abuse and risky sexual behavior among adolescent boys: A meta- analysis. Journal of Adolescent Health, 51, 18–24.

IOM (Institute of Medicine). (2012). For the public’s health: Investing in a healthier future. Washington, DC: The National Academies Press. Jaffee, S., & Maikovich-Fong, A. (2011). Effects of cognitive maltreatment and timing on children’s behaviour and cognitive abilities. The Journal of Child

Psychology and Psychiatry, 52, 184–194. Jonson-Reid, M., Kohl, P. L., & Drake, B. (2012). Child and adult outcomes of chronic child maltreatment. Pediatrics, 129, 839–845. Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., Rohde, L. A., Srinath, S., Ulkuer, N., & Rahman, A. (2011). Child and adolescent

mental health worldwide: Evidence for action. Lancet, 378, 1515–1525. Kim, J., & Cicchetti, D. (2010). Longitudinal pathways linking child maltreatment, emotion regulation, peer relations, and psychopathology. Journal of Child

Psychology and Psychiatry, 51, 706–716. Kim, J., Cicchetti, D., Rogosch, F. A., & Manly, J. T. (2009). Child maltreatment and trajectories of personality and behavioral functioning: Implications for

the development of personality disorder. Development and Psychopathology, 21, 889–912. Kempe, C. H., Silverman, F. N., Steele, B. F., Droegmuller, W., & Silver, H. K. (1962). The battered-child syndrome. Journal of the American Medical Association,

181, 17–24. Kindler, H. (2008). Developing evidence-based child protection practice: A view from Germany. Research on Social Work Practice, 18, 319–324. Kim, S. C., Gostin, L. O., & Cole, T. B. (2012). Rethinking child protection. Journal of the American Medical Association, 308, 37–38. Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on violence and health. Lancet, 360, 1083–1088. Lawrence, L. L., & Brannen, S. J. (2000). The impact of physician training on child maltreatment reporting: A multi-specialty study. Military Medicine, 165,

607–611. Lee, Y., & Svevo-Cianci, K. (2011). General comment no. 13 to the convention on the rights of the child: The right of the child to freedom from all forms of

violence. Child Abuse & Neglect, 35, 967–969. Leunga, P. W., Wong, W. C., Tang, C. S., & Lee, A. (2010). Attitudes and child abuse reporting behaviours among Hong Kong GPs. Family Practice, 28, 195–201. Leventhal, J. M., & Krugman, R. D. (2012). The battered-child syndrome 50 years later: Much accomplished, much left to do. Journal of American Medical

Association, 308, 35–36. Leventhal, J. M., Martin, K. D., & Gaither, J. R. (2012). Using US data to estimate the incidence of serious physical abuse in children. Pediatrics, 129, 458–464. Lindberg, D. M., Shapiro, R. A., Laskey, A. L., Pallin, D. J., Blood, E. A., & Berger, R. P. (2012). Prevalence of abusive injuries in siblings and household contacts

of physically abused children. Journal of the American Academy of Pediatrics, 130, 193–201. Louwers, E. C. F. M., Korfage, I. J., Affourtit, M. J., Schweewe, D. J. H., van de Merwe, M. H., Vooijs-Moulaert, A., van den Elzen, A. P. M., Jongejan, M. H. T. M.,

Ruige, M., Manaï, B. H. A. N., Looman, C. W. N., Bosschaart, A. N., Teeuw, A. H., Moll, H. A., & de Koning, H. J. (2012). Effects of systematic screening and detection of child abuse in emergency departments. Pediatrics, 130, 457–464.

MacMillan, H. L., Jamieson, E., & Walsh, C. A. (2003). Reported contact with child protective services among those reporting child physical and sexual abuse: Results from a community survey. Child Abuse & Neglect, 27, 1397–1408.

MacMillan, H. L., Wathen, C. N., Barlow, J., Fergusson, D. M., Leventhal, J. M., & Taussig, H. N. (2009). Interventions to prevent child maltreatment and associated impairment. Lancet, 373, 250–266.

Mathews, B. P., & Bross, D. C. (2008). Mandated reporting is still a policy with reason: Empirical evidence and philosophical grounds. Child Abuse & Neglect, 32, 511–516.

Mathews, B., & Kenny, M. C. (2008). Mandatory reporting legislation in the United States, Canada and Australia: A cross-jurisdictional review of key features, differences and issues. Child Maltreatment, 13, 50–63.

Melton, G. B. (2005a). Building humane environments respectful of children: The significance of the convention on the rights of the child. American Psychologist, 80, 918–926.

Melton, G. B. (2005b). Mandated reporting: A policy without reason. Child Abuse & Neglect, 29, 9–18. Melton, G. B. (2011). Young children’s rights. In Encyclopedia on early child development. Centre for Excellence in Early Childhood Development. Available

from:. http://www.child-encyclopedia.com/documents/MeltonANGxp1.pdf Morrow, V., & Pells, K. (2012). Integrating children’s human rights and child poverty debates: Examples from Young Lives in Ethiopia and India. Sociology,

46, 906–920. Nanni, V., Uher, R., & Dannese, A. (2012). Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: A meta-

analysis. American Journal of Psychiatry, 169, 141–151. Nemeroff, C. B., Heim, C. M., Thase, M. E., Klein, D. N., Rush, A. J., Schatzberg, A. F., Ninan, P. T., McCullough, J. P., Jr., Weiss, P. M., Dunner, D. L., Rothbaum, B.

O., Kornstein, S., Keitner, G., & Keller, M. B. (2003). Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proceedings of the National Academy of Science, 100, 14293–14296.

Newton, A. S., Zou, B., Hamm, M. P., Curran, J., Gupta, S., Dumonceaux, C., & Lewis, M. (2010). Improving child protection in the emergency department: A systematic review of professional interventions for health care providers. Academy of Emergency Medicine, 17, 117–125.

Palusci, V., & Ondersma, S. J. (2012). Services and recurrence after psychological maltreatment confirmed by child protective services. Child Maltreatment, 17, 153–163.

Parks, S., Sugerman, D., Xu, L., & Coronado, V. (2012). Characteristics of non-fatal abusive head trauma among children in the USA, 2003–2008: Application of the CDC operational case definition to national hospital inpatient data. Injury Prevention, http://dx.doi.org/10.1136/injuryprev-2011-040234

Pietrantonio, A. M., Wright, E., Gibson, K. N., Alldred, T., Jacobson, D., & Niec, A. (2013). Mandatory reporting of child abuse and neglect: Crafting a positive process for health professionals and caregivers. Child Abuse & Neglect, 37, 102–109.

Pinheiro, P. S. (2006). World reprt on violence against children. Geneva: The United Nations Secretary-General’s Study on Violence aginst Children. Piteau, S. J., Ward, M. G. K., Barrowman, N. J., & Plint, A. C. (2012). Clinical and radiographic characteristics associated with abusive and non-abusive head

trauma: A systematic review. Journal of the American Academy of Pediatrics, 130, 315–323. Proctor, L. J., Aarons, G. A., Dubowitz, H., English, D. J., Lewis, T., Thompson, R., Hussey, J. M., Litrownik, A. J., & Roesch, S. C. (2012). Trajectories of maltreatment

re-reports from ages 4 to 12: Evidence for persistent risk after early exposure. Child Maltreatment, 17, 207–217. Rogosch, F. A., Oshri, A., & Cicchetti, D. (2010). From child maltreatment to adolescent cannabis abuse and dependence: A developmental cascade model.

Development and Psychopathology, 22, 883–897. Romano, E., Bell, T., & Billette, M. (2011). Prevalence and correlates of multiple victimisations in a nation-wide adolescent sample. Child Abuse & Neglect,

35, 468–479. Scott, K. M., McLaughlin, K. A., Smith, D. A. R., & Ellis, P. M. (2012). Childhood maltreatment and DSM-IV adult mental disorders: Comparison of prospective

and retrospective findings. The British Journal of Psychiatry, 200, 469–475. Sedlak, A. J., Mettenburg, J., Basena, M., Petta, I., McPherson, K., Greene, A., & Li, S. (2010). The Fourth National Incidence Study of Child Abuse and Neglect

(NIS-4): Report to congress. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families. Sege, R. D., Flaherty, E., Jones, R., Price, L. L., Harris, D., Slora, E., Abney, D., & Wasserman, R. (2011). To report or not to report: Examination of the initial

primary care management of suspicious childhood injuries. Academic Pediatrics, 11, 460–466. Shin, S. H., & Miller, D. P. (2012). A longitudinal examination of child maltreatment and adolescent obesity: Results from the National Longitudinal Study

of Adolescent Health (AddHealth) Study. Child Abuse & Neglect, 36, 84–94. Shonkoff, J. P., Garner, A. S., & The Committee on Psychosocial Aspects of Child, Family Health, Committee on Early Childhood, Adoption, Dependent Care, the

Section on Developmental, Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129, e232–e246.

S

S

T

T

T

T

U

U V W W

W

W

W W Y

C. Wekerle / Child Abuse & Neglect 37 (2013) 93–101 101

upkoff, L. M., Puig, J., & Sroufe, A. L. (2012). Situating resilience in developmental context. In M. Ungar (Ed.), The social ecology of resilience (pp. 127–142). New York, NY: Springer.

vevo-Cianci, K. A., Hart, S. N., & Rubinson, C. (2010). Protecting children from violence and maltreatment: A qualitative comparative analysis assessing the implementation of u.n. crc article 19. Child Abuse & Neglect, 34, 45–56.

eeuw, A. H., Derkx, B. H. F., Koster, W. A., & van Rijn, R. R. (2012). Detection of child abuse and neglect at the emergency room. European Journal of Pediatrics, 17, 877–885.

onmyr, L., Li, Y. A., Williams, G., Scott, D., & Jack, S. (2010). Patterns of reporting by health care and non-health care professionals to child protection services in Canada. Pediatrics & Child Health, 15, e25–e32.

oth, S., & Manly, J. (2011). Bridging research and practice: Challenges and successes in implementing evidence-based preventive intervention strategies for child maltreatment. Child Abuse & Neglect, 35, 633–636.

rickett, P. K., Noll, J., & Putnam, F. W. (2011). The impact of sexual abuse on female development: Lessons from a multigenerational, longitudinal research study. Development and Psychopathology, 23, 453–476.

.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2010). Child maltreatment 2009. Available from:. http://www.acf.hhs.gov/programs/cb/stats research/index.htm#can

ngar, M. (2011). The social ecology of resilience. New York: Springer. ulliamy, A. P., & Sullivan, R. (2000). Reporting child abuse: Pediatricians’ experiences with the child protection system. Child Abuse & Neglect, 24, 1461–1470. ekerle, C. (2011). The dollars and senselessness in failing to prioritize child maltreatment prevention. Child Abuse & Neglect, 35, 159–161. ekerle, C., MacMillan, H. L., Leung, E., & Jamieson, E. (2008). Childhood maltreatment. In M. Hersen, & A. M. Gross (Eds.), Children and adolescents Handbook

of clinical psychology (pp. 856–903). Hoboken, NJ: John Wiley & Sons. ekerle, C., Wall, A.-M., Leung, E., & Trocmé, N. (2007). Cumulative stress and substantiated maltreatment: The importance of caregiver vulnerability and

adult partner violence. Child Abuse & Neglect, 31, 427–443. ekerle, C., Waechter, R., & Chung, R. (2011). Contexts of vulnerability and resilience: Childhood maltreatment, adolescent cognitive functioning and close

relationships. In M. Ungar (Ed.), The social ecology of resilience (pp. 187–198). New York: Springer. orld Health Organization (WHO). (2002). World report on violence and health. Geneva: World Health Organization. orld Health Organization (WHO). (2010). Addressing violence against women and HIV/AIDS: What works? Geneva: World Health Organization.

ampolskava, S., Armstrong, M. I., & King-Miller, T. (2011). Contextual and individual-level predictors of abused children’s reentry into out-of-home care: A multilevel mixture survival analysis. Child Abuse & Neglect, 35, 670–679.