EXECUTIVE SUMARY

In Senate Report No. 104-368 the Committee on Appropriations requested that the NIH "convene a working group of its component organizations currently supporting research on child abuse and neglect. The Committee further encouraged the working group to hold a conference on child abuse and neglect to assess the state-of-the-science and make recommendations for a research agenda in this field, and include in this conference relevant outside organizations and experts in the field. The Committee requested that this working group be prepared to report on current NIH research efforts in this area, the accomplishments of that research, and on plans for future coordination efforts at NIH at the fiscal 1998 hearings." Accordingly, NIH established an NIH Child Abuse and Neglect Working Group consisting of the major research Institutes and offices supporting research in this area, as well as the Office of Behavioral and Social Science Research (OBSSR).

The Child Abuse and Neglect Working Group (CANWG) held regular meetings to review NIH research efforts in child abuse and neglect, clarify Institute responsibilities to differentiate areas of overlap, identify accomplishments and future research needs, coordinate child abuse-related research across NIH, and plan future activities. In addition, in order to establish relationships and coordinate its activities with other sectors of government, the CANWG has met with representatives of other federal agencies (Administration for Children and Families, National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, Department of Education, and the Department of Defense).

This review revealed that $33.7 million is currently devoted primarily to child abuse and neglect research, and another $48 million of additional research is relevant to understanding the precursors and consequences of abuse and neglect. Over the last decade, substantial progress has been made in identifying the precursors and sequela of child abuse and neglect, and in examining the service systems within which maltreated children are identified and provided mental health and social services. However, significant research and knowledge gaps remain in a number of critical areas, including the definition, identification, and assessment of child abuse; the determination of appropriate and effective interventions; and the transfer and application of research knowledge into "real world" settings. In addition, child neglect, the most commonly reported form of child maltreatment, has remained relatively understudied. Conducting research with maltreated youth is a very difficult process due to difficulties in recruiting samples and in navigating the ethical and legal reporting requirements in collecting information from families where abuse has occurred. New researchers who might be interested in conducting research in this field require considerable training in complex research design issues. There is only a small handful of experimental researchers with conceptual and methodological sophistication to provide such training.

To build the research capacity of this field, the CANWG will explore the development of a series of conferences and/or workshops to train and attract new investigators. Also, the CANWG will explore the utility of various funding mechanisms and announcements that might be used to encourage more research proposals in critical areas, and will work closely with other federal agencies to explore ways to increase knowledge transfer and research application to practice.


I. INTRODUCTION

Child maltreatment is a tragic problem afflicting more than one million children per year in the United States, and 2,000 children die each year as a consequence of child abuse or neglect. Direct health care costs have been estimated to exceed 500 million annually, and eventual costs on long-term productivity of persons who were abused as children have been estimated at $1.3 billion (National Research Council, 1993). Research has been difficult to do, and progress has been slow in developing a scientific understanding of child abuse and neglect. Slow progress in understanding child abuse and neglect stems from a variety of factors, including ethical issues and challenges in the conduct of such research, the lack of trained investigators, and the legal implications of identifying cases of abuse.

Yet the consequences of abuse and neglect can be profound, including physical injuries (e.g. central nervous system injury, fractures and severe burns), mental and behavior problems (i.e., depression, anxiety, post-traumatic stress disorder), delinquency, an increased risk for later substance abuse and alcoholism, and a greater likelihood of growing up to repeat the cycle as an abusive parent. Thus, child abuse and neglect should be understood first and foremost as a health issue, not only compromising the health of our nations' children, but also threatening their long-term physical and mental health outcomes over a lifetime, their parenting practices as future parents, and their economic productivity (through its health consequences) as eventual wage earners.

In 1990, the National Academy of Sciences received a contract from several Federal agencies to convene an expert panel to evaluate the current state of child abuse research and to draft a research agenda for Federal efforts in this area. The 1993 report noted that child maltreatment research across the federal government often proceeded in a "haphazard, piecemeal fashion" and that better national leadership was needed to organize and develop the research base. In addition, the report outlined 17 research priority areas where research was especially needed. These priority areas involved the need for (a) better understanding of the nature and scope of child maltreatment, (b) increased knowledge about the origins and consequences of abuse and neglect, (c) improving treatments and prevention interventions, and (d) developing a science policy for research on child maltreatment.

While many concerted efforts to address these priorities have taken place in the past through the Federal Interagency Task Force on Child Abuse and Neglect, spokespersons among the scientific, professional, and lay communities were concerned that even greater efforts were required. In response to Senate Report No. 104-368, NIH established an NIH Child Abuse and Neglect Working Group consisting of the major research Institutes and offices conducting child maltreatment research, principally the National Institute of Mental Health, the National Institute on Child Health and Human Development, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Nursing Research, and the Office on Behavioral and Social Science Research (OBSSR). This report outlines the activities and efforts to date of the NIH Child Abuse and Neglect Working Group (CANWG).


II. ACTIVITIES OF THE NIH CHILD ABUSE AND NEGLECT WORKING GROUP

The Child Abuse and Neglect Working Group (CANWG) holds regular meetings to review NIH research efforts in child abuse and neglect, clarify Institute responsibilities and areas of overlap, identify accomplishments and future research needs, coordinate child abuse-related research across NIH, and plan future activities. In addition, in order to establish relationships and coordinate its activities with other sectors of government, the CANWG has met with representatives of other federal agencies (Administration for Children and Families, National Institute of Justice Office of Juvenile Justice and Delinquency Prevention, Department of Education, and the Department of Defense).

Thus far, the CANWG reviewed the status of all current NIH research to determine the extent of research primarily focused on child abuse and neglect. Additional research was also reviewed if relevant to understanding the causes and consequences of abuse and neglect (e.g., parent-child relationships; teen parenting, unwanted pregnancies). This review revealed that $33.7 million is currently devoted primarily to child abuse and neglect research. Of this $33.7 million, $10 million is devoted exclusively to studying child abuse and neglect, while the remaining $23.7 million is focused on prevention of child abuse and neglect as one of several major objectives. Furthermore, $48 million of additional research is relevant to understanding the precursors and consequences of abuse and neglect, although not focused on child maltreatment per se. All together, NIH funded $82 million of research primarily or secondarily related to child abuse and neglect.

In addition, using the research priorities outlined in the 1993 National Research Council (NRC) report "Understanding Child Abuse and Neglect" as an initial point of reference, the CANWG coded all current NIH research according to the NRC-identified priorities to identify areas where there is significant research activity and where major research gaps still exist. Working with its NIH representatives, the CANWG identified a range of potential program-building activities that might be undertaken to increase efforts in child maltreatment research across the NIH Institutes and with other federal partners.

In the following sections, each of the NIH Institutes with substantial research interest in child maltreatment outlines its mission vis-a-vis child abuse research, describes its progress and efforts to date, and identifies areas where significant research opportunities exist within that institute's research mission. Subsequently, trans-NIH activities and future challenges and opportunities for NIH and the CANWG will be outlined.


III. PROGRAM HISTORY AND ACCOMPLISHMENTS

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

NIAAA conducts and supports biomedical and behavioral research, research training, and health information dissemination with respect to the prevention of alcohol abuse and alcoholism and provides a national focus for the Federal effort to increase knowledge and promote effective strategies to deal with health problems and issues associated with alcohol abuse and alcoholism. Research has found that child abuse is a risk factor for alcohol abuse, that parental alcohol abuse or dependence increases the risk of child maltreatment, and that abusive drinking during pregnancy may result in the birth of a child affected by fetal alcohol syndrome (FAS). Because of these associations of alcohol abuse with child maltreatment, NIAAA has an interest in supporting research that further explores these associations, factors that mediate and moderate these relationships, and ways to reduce the associations and their consequences. In addition, NIAAA supports biomedical and behavioral research that may have secondary relevance to understanding child abuse through examining neurobiological factors, family interactions, and other risk and protective factors at the individual, interpersonal, and community levels.

Child Abuse and Neglect Research at NIAAA

In recognizing a need for additional research efforts in this area, NIAAA issued a program announcement in 1992 calling for research on alcohol-related violence and its prevention. Among the studies that have been completed as part of that emerging program are two focused on the link between child abuse and alcohol abuse. A study at the Research Institute on the Addictions (Mother's Alcohol Problems and Children's Victimization), ending in May 1996, extended previous research on alcohol use, victimization, and family violence that involved 472 women from the five original samples. It examined the relative contribution of the mother's alcohol problems to her use of violence against her children and the impact of alcohol use on her level of protectiveness and children's victimization experiences. Another completed study funded to the State University of New York in Albany (Childhood Victimization and Risk for Alcohol Problems) contributed to an ongoing study of a large matched sample of abused and neglected children and a matched control sample by examining the hypothesis that childhood victimization is a significant risk factor for the development of alcohol problems and/or alcohol abuse. The PI reported that childhood maltreatment was a significant predictor of adult arrests for alcohol and/or drug-related offenses and was associated with the subsequent alcohol abuse in females but not males.

Current research includes the support of a fellowship (Victimization, Alcohol Abuse and High Risk Sex Behavior) evaluating a model of the interrelationships between childhood sexual abuse and adult victimization experiences, alcohol abuse and high risk sexual behavior and is identifying predictors of these adult outcomes including childhood sexual abuse as a predictor variable. Other NIAAA studies related to child abuse treat it as a risk factor for alcohol-related problems and/or examine the ongoing relationship between violent victimization (including child abuse) and alcohol abuse in particular populations (e.g., homeless adolescents, persons in alcohol treatment). Another study focuses on the interrelationships among genetic and environmental risk factors (including child abuse) and alcoholism in American Indians.

NIAAA research not focused directly on child abuse and neglect but relevant to understanding its causes and consequences, includes studies of comorbid alcohol abuse and depression, post-traumatic stress disorder (PTSD), and other psychiatric disorders; family dynamics and parent-child interactions, particularly in families of alcoholics and the family antecedents of adolescent alcohol risk factors; and the etiology of FAS, as well as the consequences of prenatal alcohol exposure for pediatric outcomes.

Areas of Future Research Opportunity

There are wide gaps in our knowledge of the complex associations between alcohol abuse and child abuse. One promising area for research with a potential payoff for both alcohol and child abuse intervention communities focuses on family dynamics. Both prevention and treatment research are needed to explore ways to reduce the associations between parental alcoholism, child maltreatment and subsequent alcohol abuse. In addition, alcoholism and child abuse may be secondary consequences of depression, PTSD, or other psychological disorders and these, in turn, may contribute to further adverse consequences for individuals and their offspring. The complex sequencing and interrelationships among child abuse, adult victimization and/or aggression, alcohol (and other substance) abuse, and high-risk sexual behaviors are ripe areas for additional research.

There is a growing literature on FAS and its effects on developmental and cognitive impairments. Although the issue of whether drinking by the pregnant woman constitutes "child abuse" is a legal or definitional question, scientific studies are needed to clarify which biological and environmental factors make a difference in how and how much the unborn child is affected and how to most effectively reach alcoholic women early in their pregnancy (or better yet, before they become pregnant) to get them to reduce their drinking, as well as address other factors that may affect pregnancy outcomes.

National Institute of Child Health and Human Development (NICHD)

NICHD conducts and supports biomedical and behavioral research and research training in maternal and child health and development, reproduction, population dynamics, developmental biology, clinical nutrition, perinatal and infant morbidity and mortality, family dynamics, parent-child relationships, learning disabilities, mental retardation and developmental disabilities, and adolescent and maternal AIDS. Generally, research in these areas consists of biological and/or behavioral studies of normal and abnormal conception, growth, development, and maturation, from conception through maturity.

Within this context, the NICHD has an interest in the study of factors (family structure, poverty, parenting attitudes, family satisfaction, spousal relationships) associated with child abuse and neglect, and the identification of the effects that domestic violence has on the emotional, physical, and social development of children. The NICHD also conducts and supports research that, while not directly targeted at child abuse, addresses critical issues related to child abuse, such as neurobiological factors, perinatal and early childhood variables, family structures, parental attitudes toward discipline, the relationships between children and mothers and fathers, the effects of child care, and interactions among these variables. The effects of child abuse on cognitive, emotional, and social development of children are also of interest.

Child Abuse and Neglect Research at NICHD

In l996, the NICHD supported a variety of research projects related to several aspects of child abuse. Studies examined relationships between parent variables, child factors, and home environment characteristics and the association among these factors and cognitive, behavioral, emotional, academic, and social development in children. In the main, these studies focus on questions that may relate to precursors and effects of child abuse and neglect, and provide essential information about how children develop within a wide range of environments, including those where abuse and neglect have been identified.

Specifically, NICHD supports a cooperative agreement headed by the University of North Carolina designed to study how family factors influence healthy child development in general, one component of which addresses the effects of child maltreatment on child development variables in particular. By capitalizing on an existing data set of the Longitudinal Studies in Child Abuse and Neglect (LONGSCAN), this project uses data related to the identification of children who are at-risk for child abuse in determining risk factors that influence the psychological and social outcomes in children. This project also focuses on the analysis of the effects of Social Service interventions on abused and neglected children, and the impact of family structure, poverty, parenting attitudes, family satisfaction, and spousal relationships on the effects of such social service interventions.

An internal NICHD search identified 38 studies that have secondary relevance to understanding child abuse and neglect, in terms of precursors, correlates, and consequences. These relevant studies encompassed a wide range, and span the following areas: (a) biological correlates of stress and stress-induced behavior; (b) family, parent, and child interactions and development; (c) child care and cognitive, emotional, and social development; and (d) cross-cultural studies of effects of family and childrearing processes on development. For example, a number of NICHD projects are exploring the biological correlates of stress and how stress interacts with emotional development, identity and self-concept, and school performance.

In another relevant study, Columbia University is examining how physiological processes and relationships with parents influence the emotional development and self-concept during middle-childhood and puberty. The data derived from this study may provide information about both behavioral and biological effects and outcomes of stressful parent-child relationships.

The NICHD has invested in research that is designed to better understand the effects of family variables such as family structure; ethnicity; parental beliefs and attitudes toward discipline; paternal and maternal education, occupation, and income; parental social, emotional, and cognitive characteristics; and how poverty interacts with child characteristics to influence child well-being. This research also is relevant to the study of antecedents of child abuse and their effects on the emotional/psychological, social, and cognitive welfare of youngsters. For example, in one Cooperative Agreement with Northwestern University, cross-country and cross-cultural longitudinal data relevant to family background variables, poverty and welfare experiences of children, parental characteristics, and child characteristics have been collected over a 25-year period and are being related to the social, psychological, and economic outcomes that children of poverty face. Given that a higher frequency of child abuse is related to socioeconomic variables, this research sheds light on the effects of economic and cultural factors related to child abuse.

For the last seven years the NICHD has supported a large, prospective longitudinal cooperative agreement (at 10 sites and a data center) which studied 1,247 children and their families and the effects alternate child care has on psychological, cognitive, and social development. A critical question examined in this study was how the effects of early child care are moderated by child characteristics and by experiences in the family and in school. Children were first enrolled in the study at one month of age and will be studied intensively through age seven. Child outcome assessments will focus on (a) social-emotional development, including the quality of children's relationships with their parents, friends, and teachers; (b) emotional adjustment, social competence, behavior problems, and self-perceptions; (c) cognitive development, including general intellectual functioning, academic achievement, cognitive processes, and language; and (d) health status, including physical growth. Context assessments will focus on (a) the alternate care environment including quality, quantity, type, onset age, and stability; (b) the home/family environment, including the quality of home life and parent and structuring characteristics; and (c) the school environment, including school climate, curricular features, and teacher behavior.

In two studies under the NICHD Intramural Research Program (IRP), different mother-child and parent-child interactions were studied to explore the differences in the developmental environments in Euro-American, Central-American, and Palestinian cultures due to parental beliefs, values, and practices, and to assess how differences in these domains affect children's development. The results of these studies indicate that a wide range of variables such as parental styles, beliefs regarding discipline, and parental psychological characteristics across cultures must be understood in context as potential predictors, precursors, and/or consequences of child abuse and neglect.

Areas of Future Research Opportunity

Identifying and understanding the factors associated with abuse is critical to the development of prevention programs and strategies to enhance the quality of ecological, social, and psychological factors within family and child-care contexts. A critical public health task that continues to confront the NICHD is to conduct research that can shed light on the tremendous complexity that characterizes child development. Given this complexity, several important questions require further study:

* Which antecedents (family structure, poverty, parenting attitudes toward discipline, family satisfaction, spousal relationships) are most associated with abuse of children, at which levels of severity, at which ages?
* Which types of measures or assessment protocols are most reliable and valid for the purpose of identifying critical antecedents in different cultures and at different ages?
* What factors within family, social and school contexts aid in mitigating the severity of outcomes associated with child abuse?

National Institute on Drug Abuse (NIDA)

NIDA supports over 85% of the world's research on the health aspects of drug abuse and addiction. NIDA-supported science addresses the most fundamental and essential questions about drug abuse, including the correlation between drug abuse and family violence. Research has shown child abuse to be a factor in the development of drug abuse problems in childhood, adolescence and adulthood. In fact, previous NIDA-supported research by the Medical University of South Carolina has shown that 73% of women in drug treatment had a history of child physical and or/sexual abuse. NIDA devotes a substantial portion of its resources to better understand this relationship of early child abuse and later substance abuse, as well as to other questions relating to the causes and consequences of addiction, child abuse and neglect.

The NIDA-sponsored research with a primary focus on child abuse and neglect has concentrated on three areas. The first area deals with the role of child abuse and neglect in the etiology and consequences of drug abuse. One study at the Institute on Addiction in Buffalo investigates the etiology of partner violence and drug use in terms of a woman's history of family violence (child abuse) and familial drug use. Another study at UCLA looks at the possible role of early child abuse and neglect and insecure family relationships in the development of drug abuse in samples of inner city women, including homeless women. A non-profit organization with expertise in the study of drug abusing populations, the National Development Research Institutes (NDRI), is collaborating with NIDA to examine the predisposing risk factor of child abuse and neglect in populations of drug abusing, violent, inC-CARerated males and in drug abusing, pregnant females involved in Juvenile Courts.

The role of drug abuse in the perpetration of child abuse, neglect and family violence is a second area of emphasis for NIDA. One studies, funded to NDRI entitled Addicts and Their Children, looks at trans-generational influences on substance abuse and deviant behaviors (such as child abuse) in a population of inC-CARerated female narcotic addicts. A study at Columbia University examines how the co-occurrence of depression and cocaine abuse and a history of child and/or spouse abuse in a population of women of lower socioeconomic status relates to the perpetration of child abuse.

The third area of research for NIDA where child abuse and neglect are the primary areas of focus is on intervention strategies to prevent child abuse and neglect and violence associated with substance abuse. The NDRI is evaluating the effectiveness of a unique comprehensive program for families where the mothers are in treatment for cocaine/crack addiction. The prevention of child abuse is one of the outcomes being monitored. Because maternal use of cocaine is associated with increased risk for child abuse and neglect, a number of NIDA studies follow in utero, drug-exposed infants and their mothers. In addition, NIDA studies the effects of cocaine and other drugs of abuse on pre-, peri-, and post-natal development, and beyond.

Additional areas of study at NIDA include the prevalence, nature and scope of child abuse and neglect in substance abusing households and neighborhoods; the natural history of drug abuse and predisposing risk and protective factors at individual, family, neighborhood and community levels; and treatment research on co-morbid substance abuse and psychiatric disorders, in particular, post-traumatic stress disorder (PTSD), a common consequence of child abuse.

NIDA convened an expert panel in April 1996 to address special issues concerning research on the role of childhood trauma in the etiology of drug abuse. Among the conclusions drawn from review of research in this area was that the characteristics of the trauma, the individual, and the environment interact to either buffer (lessen) the impact or to aggregate the impact and produce dysfunctional behavior such as drug abuse. Specifically, the greater the severity of child abuse (including degree of contact and severity of injury), the younger the victim at the time of abuse, the lower the educational attainment, combined with prior psychological distress or disorder, presence of family dysfunction, and a lack of adequate coping skills and social support after the abuse were shown to be associated with dysfunctional behaviors such as drug abuse. Other factors, such as gender, race/ethnicity, and biological make-up of the victim may also be important, but these findings are inconclusive to date.

Areas of Future Research Opportunity

From the review of the NIDA-funded research described above, it is difficult to separate child abuse and neglect from other problems such as substance abuse, family violence, delinquency, and teen pregnancy. Yet, NIDA is attempting to study these complex co-existing public healthphenomena as they exist in the "real world." This is a major challenge in biomedical and behavioral research, and for NIDA research in particular.

Despite increasing research related to child abuse and neglect, several gaps have been identified and are being addressed through NIDA's research portfolio, including:

* cross-training of researchers in different disciplines and fields such as drug abuse, child abuse and post-traumatic stress disorder research
* developing integrative models to examine the multi-factorial nature of the relation between childhood trauma and the etiology of drug abuse beyond cause and effect
* evaluating current options for prevention and treatment of substance abuse in light of child abuse and neglect
* examining environmental factors that have implications for prevention and primary treatment
* focusing on understanding the relationship of child abuse and neglect and substance abuse in nonclinical populations.

Do survivors of abuse have different drug preferences and patterns of abuse?Could early identification of and intervention with abuse survivors lead to the prevention of substance abuse?

What assessment tools yield valid, reliable, and clinically useful information and when in the course of substance abuse treatment should these assessments be administered?

Does a history of childhood abuse affect substance abuse treatment, retention, relapse, and other outcomes?


National Institute of Mental Health (NIMH)

The National Institute of Mental Health (NIMH) supports extramural and intramural research on the causes, prevention, treatment, consequences, and outcomes of mental health and mental disorders. Within this overall mission, a major NIMH priority targets research focused on the understanding and amelioration of mental health problems in children and adolescents. Relevant basic research provides information about the range of variation in children's cognitive, social-emotional, and biological development. Such research also provides scientific models that explain the means by which variations in individual (e.g., biological dispositions and vulnerabilities), interpersonal (e.g., parenting practices) and social (e.g., neighborhood characteristics and cultural practices) factors shape and interact with the development of the child or adolescent. Such knowledge is key to the development of appropriate and effective preventive and treatment interventions.

Clinical studies of the course and treatment of specific cognitive, emotional, or behavioral disorders in childhood or adolescence are emphasized and encouraged, and are highly relevant in understanding mental illness outcomes occurring with or resulting from maltreatment, or that may be pathological precursors of later abusive or violent behavior in maltreated children and youth. Applied studies, such as those that focus on how proven treatments are actually delivered in "real world" settings, and the costs and societal consequences of children's mental illness are also emphasized.

Child abuse and neglect studies are a cornerstone of NIMH's overall children's research agenda because childhood maltreatment experiences are associated with the development and exacerbation of significant mental health problems and disorders, and are precursors to the cycle of abuse in adulthood by persons who once were abused or neglected as children.

Child Abuse and Neglect Research in NIMH

NIMH-supported research with a principal focus on child abuse and neglect is extensive and currently addresses the following questions:

* How common are maltreatment experiences in children and adolescents and how do these experiences affect the development of mental health problems in children and adolescents? What are the associations between adult mental health and childhood maltreatment experiences?
* Why are some children severely damaged by their maltreatment experiences whereas others are able to adequately cope with their maltreatment? How are mental health outcomes determined by the interaction between maltreatment and other factors (such as other positive and negative childhood experiences), developmental stage of the child, family interpersonal processes, individual and family vulnerabilities and strengths, larger social contexts (such as community characteristics), and on the child's and the family's experiences with social service agency interventions (such as removal from the home)?
* What characteristics and experiences of perpetrators (such as psychopathology or their own childhood maltreatment) play a role in their maltreatment of children?
* What are the major mental health needs of maltreated children, what are the best ways of assessing such needs, and how well do current mental health, physical health, and child welfare systems provide services that address such needs?
* What types of treatment programs can help children, adolescents, and adults overcome the lasting negative mental health effects of maltreatment experiences?
* What types of approaches can effectively prevent the occurrence or recurrence of child maltreatment?

In addition to research that focuses directly on maltreatment, NIMH funds a great deal of research that contributes to understanding the precursors and mental health consequences of child maltreatment. Much of this related research focuses on the normal and psychopathological development of children and adolescents and on the behavioral, social, and biological contexts in which development occurs. These studies provide a background for understanding the individual and interpersonal contexts in which maltreatment occurs (e.g., how abusive parenting differs from supportive parenting) and the impact of maltreatment on normal and psychopathological development (e.g., why children abused early in childhood may have difficulty forming emotional attachment to others throughout life). Results from such studies can be used to develop prevention approaches that test models of the developmental impact of biological, psychological, and sociocultural factors by attempting to alter developmental outcomes in community or at-risk populations. To the extent that factors in these models overlap with and often contribute to maltreatment, such research is relevant to understanding and preventing maltreatment and its effects.
Similarly, clinical studies of the etiology and treatment of specific cognitive, emotional, or behavioral disorders in childhood or adolescence are relevant in understanding outcomes associated with or resulting from maltreatment or that may be pathological precursors of later abusive, antisocial, or violent behavior in maltreated children or youth. Thus, maltreated children have been observed to evidence significant problems with depression, anxiety, suicidal ideation and attempts, emotional attachment to others, maintaining attention to cognitive tasks, academic achievement, and aggressive and antisocial behavior. To the extent that child clinical research improves the identification and treatment of specific psychopathologies, maltreated children with these problems will benefit. Likewise, research on delivery of mental health services to children and adolescents is relevant to understanding how mental health services are organized, financed, and delivered and the impact of mental health service delivery on children with mental health problems, including maltreated children, in the community and in specialized settings, such as in the child welfare system or various forms of foster care.

Research-based knowledge of child abuse and neglect has increased in the past decade. Increasingly sophisticated research designs and methods are clarifying and extending previous research. NIMH-funded epidemiological studies have demonstrated a relatively high prevalence of different forms of child maltreatment in the general population and in individuals with mental health problems or disorders. One study at Beloit College (Past Abuse and Current Symptoms in Psychiatric Inpatients) found that a high proportion (approximately 80%) of psychiatric inpatients reported a history of physical or sexual abuse or both. It was also discovered that patients with a history of sexual abuse had predominant symptoms of depression, anxiety and dissociation, patients with a history of physical abuse had problems with anger and aggression, and patients who experienced both physical and sexual abuse were most impaired and experienced a wide variety of severe psychiatric symptoms, compared with patients without a history of abuse.

Studies of the mental health consequences of maltreatment are assessing the longitudinal course and the impact of maltreatment experiences in multiple domains. For example, a prospective longitudinal study by investigators of the NIMH Intramural Research Program (IRP) and the University of Southern California (Sexual Abuse of Females - Effects in the Pubertal Period) is following almost 200 sexually abused and comparative non-abused children and adolescents through adolescence into young adulthood. The study has found that a maltreatment history can have significant effects on the biological and psychosocial development of adolescence, including (a) dysregulation of biological systems (such as the hypothalamic-pituitary-adrenal system) that play an important role in the stress response of the body, metabolism of brain neurotransmitters, and immune responses; (b) decreased academic attainment and social competence in sexually abused girls; and (c) increased levels of psychopathology, including depression, suicidal ideation, dissociation, sexualized behaviors, and other psychiatric illnesses in the sexually abused girls.

Evaluations of multi-component interventions that address multiple factors that may be products of abuse or neglect have shown promise in improving the family management practices of low-income parents and in facilitating the cognitive and social development of children. There also is some evidence that multi-component early childhood interventions may promote prosocial behavior and prevent behavioral problems. Since these outcomes may also appear in maltreatment, these multi-component preventive intervention programs can serve as models to be tested as preventive intervention for child abuse and neglect. Investigators at the University of Denver are conducting a 13-year follow-up to track an innovative, previously successful, preventive intervention program for poor, unmarried, adolescent mothers and their first newborn in a semi-rural upstate New York county. The original intervention provided prenatal and infancy nurse home visitation aimed at improving (1) the outcomes of pregnancy, (2) the quality of care that the mothers provide to their children, and (3) the women's own development through education, employment, and subsequent family planning. These important goals were achieved through parent education, the involvement of other family members and friends in the pregnancy, birth, early care of the child, and in the support of the mother, and the linkage of the family with other health and human services. The intervention had several beneficial effects on the health and well-being of both the mothers and their infants, including (a) improved health practices, greater social support, and better use of childbirth education and a nutritional supplementation program by mothers; (b) fewer preterm deliveries and higher average birth weights; (c) better maternal employment histories and fewer pregnancies in the years following the birth; and (d) significantly less abuse or neglect and less emergency-room visits for injuries of the child. This research team is currently conducting a long-term follow-up of the enduring impact on the mothers' fertility, education, work, and reliance on welfare, as well as the children's intelligence, school achievement, behavior, and emotional adjustment.

Studies of the organization of children's services are being conducted by investigators at the University of Tennessee. The majority of these children are in custody for reasons of abuse or neglect and a high proportion demonstrate clinical levels of psychosocial functioning. Examination of the effects of organizational climate (e.g., employee job satisfaction, cooperation and personalization) has demonstrated that climate is the primary predictor of these children's improved psychosocial functioning. Further, improved organizational climate, rather than service coordination, predicted both the quality of services and the outcomes for children. This finding is important because most studies of children's service systems have focused largely on improving coordination, under the belief that increased coordination would lead to improved clinical outcomes. Instead, this study suggests that attention to the climate in which service providers work is critical to understanding children's outcomes, including children who have been abused and are in state custody.

Areas of Future Research Opportunity

Despite significant progress, NIMH staff has identified areas of significant gaps in child abuse and neglect research, and where significant research opportunities and needs exist. Among the most significant of these are:

* What are the actual impacts of specific types of maltreatment experiences - physically, psychologically or sexually abusive acts and psychological and physical neglect - on children? Through what developmental, psychological, social, or biological processes do these effects occur? What developmental, psychological, biological and social factors interact with maltreatment to determine the effects of maltreatment experiences? What outcomes of maltreatment are likely to lead to long-term mental health problems?
* How can results from basic research studies on normative and pathological parent-child interaction, family interpersonal functioning, and children's neurobehavioral development be used to create more effective preventive approaches for child maltreatment?
* What is the efficacy of currently existing intervention programs for maltreating families and their child victims, such as family-based interventions, various types of foster care, and victims treatment programs? How can outcomes and therapeutic processes of such programs be adequately studied? How do clinicians and child welfare professionals make judgments about children's mental health needs and need for services? How can effective interventions be appropriately implemented in community settings and be evaluated?
* How can the methodological and conceptual sophistication of the field of child abuse research be enhanced, including improvements in sampling procedures, definitions, measurement and assessment, research designs in longitudinal and treatment research studies, and data analytic methods? How can newer investigators be attracted into the field and how can research training be enhanced?

National Institute of Nursing Research

The NINR has a sustained interest in improving the health of children and adolescents. Health promotion for individuals in these age groups involves helping them acquire skills, knowledge, appropriate attitudes, and opportunities to make choices that increase the likelihood of good health over the course of their lives. NINR's emphasis on promotion of healthy lifestyles and the exploration of effective approaches to good health is the critical determinant of NINR's interest in and support of research on child abuse and neglect, primarily through studies of related antecedents, at-risk profiles, appropriate outcome measures, and consequences of neglect and abuse. The current NINR child-abuse portfolio includes nine studies; an example of this research is described below.

Understanding Infant Colic and Persistent Crying

The persistent, often nerve-wracking crying that accompanies infant colic is cited as a major predisposing factor in child abuse and neglect, particularly in families with limited resources and social support systems. Colic occurs in about one-in-four infants and in families representing all levels of income and education. Although the cause of the disorder is unknown, one theoretical model views infant colic as a developmental sleep disorder in which normal sleep-wake cycling is upset. Testing this theory, NINR investigators compared the behaviors of a group of irritable infants with those of a group of non-irritable infants over a period of four months. Findings supported the hypothesis of immaturity in infant self-regulation of sleep-wake states. By viewing infant colic as a developmental disorder, effective interventions can be designed and tested.

Areas of Future Research Opportunity

NINR is considering a major research initiative in FY 1999 to examine behaviors related to child health and risk reduction. Examples of promising areas of exploration related to child abuse and neglect that will be included in this initiative are:

* The development of highly sensitive instruments to identify "at-risk" children and the adverse health effects resulting from abuse and neglect
* The identification of barriers to the use of health-enhancing practices and survival/protective strategies among those at-risk for abuse and neglect
* The development of interventions aimed at under-served but overrepresented population groups at risk for poor parenting outcomes (lower socioeconomic status, inner-city, adolescent parents, and rural residents)
* The determination of cross links among at-risk children, abuse survivors, and the roles of parenting
* The development of methodological approaches to improving the available battery of tests for detecting and monitoring children at risk for abuse and maximizing the accuracy of data obtained through self-report techniques. The National Institute of Nursing Research (NINR) supports basic and clinical research to establish a scientific basis for the care of individuals across the life span -- from management of patients during illness and recovery to the reduction of risks for disease and disability and the promotion of healthy lifestyles. According to its broad mandate, the Institute seeks to understand and ease the symptoms of acute and chronic illness, to prevent or delay the onset of disease or slow its progression, to find effective approaches to good health, and to improve the clinical environments in which care is provided. The NINR's research extends to problems encountered by patients' families and care givers. It also emphasizes the special needs of at-risk and under-served populations.

Other NIH Institutes

Other NIH Institutes conduct research relevant to child abuse and neglect. These Institutes include (but are not limited to) the National Institute of Neurologic Disorders and Stroke, the National Institute of Deafness and Communication Disorders, and the National Institute of Dental Research. Such studies focus on, for example, the effects of head trauma (due to abuse or other causes) on children, anxiety in abused children undergoing dental procedures, and social communication deficits in children who have suffered head trauma. Given the range of health problems that maltreated children may experience, an important strategy for NIH and the CANWG will be to coordinate child maltreatment research activities with all relevant Institutes, identify additional research opportunities that affect all NIH Institutes, and ensure that guidelines for the assignment of research applications are fully spelled out, in order to reduce any potential for confusion or unnecessary redundancy in the assignment, review, and funding of child maltreatment-related research applications.

IV. TRANS-NIH AND INTERDEPARTMENTAL ACTIVITIES

One of the major recommendations developed by the writers of the NRC report involved the need to develop methods, procedures, and resources that can resolve ethical problems associated with child abuse and neglect research including informed consent, privacy, and confidentiality. While this area deserves a great deal of sustained effort, it has already been the focus of important NIH efforts since the publication of the NRC report. Three activities in particular are of note:

* In May 1993, the NIMH supported the first conference on ethical issues in mental health research with children, which assembled the views of scientists, families, bioethicists, and regulators. A major product of that conference was a recently published book entitled Ethical Issues in Mental Health Research with Children and Adolescents (Kimberly Hoagwood, Peter S. Jensen, and Celia B. Fisher, Eds, 1996). One of the chapters (Putnam, Liss, and Landsverk) outlines some of the major ethical issues particularly involved in studies of children who have been maltreated. This chapter addresses some of the complex ethical and legal dilemmas raised in research with maltreated and victimized children.
* An effort has also been made to consider the ethical issues involved in conducting violence research as a whole, resulting in the recent publication of an NIH report. This report, Ethical Considerations in Violence-Related Research, included recommendations for violence studies of both children and adults, and included child abuse as one of the major topics of interest. The report is focussed on eight areas: participation, informed consent, participant distress, reporting requirements, confidentiality, clinical issues, debriefing, and community involvement. The report outlines some points for researchers to consider in the design of studies, and for grant reviewers to consider in evaluating research applications.
* A third effort underway to address ethical issues, not only in the child abuse area but also in other types of NIH-funded research, is the recently released special Request for Applications (RFA) on Informed Consent in Research Involving Human Participants. The goal of this program is to identify methods for improving the informed consent process in scientific research. Up to $6.7 million has been set aside for 7 to 10 three-year research grants to conduct research on issues such as innovative methods for clearly conveying consent information; the determinants for participation, retention, and satisfaction in research; and assessing the effect of including relatives, friends, or an ombudsman in the consent process. With respect to children in particular, the RFA encourages research on identifying and determining the impact of special issues related to informed consent in research involving children and adolescents (e.g., parental responsibilities and consent, autonomy issues in adolescents, emancipated or institutionalized minors).
* Another important collaborative effort already underway is the Federal Interagency Task Force on Child Abuse and Neglect which meets quarterly and consists of more than 30 Federal agencies that conduct or support research, provide or fund services, or are otherwise concerned with child abuse and neglect issues. The Task Force has an Interagency Research Committee on Child Abuse and Neglect composed of more than 20 Federal agencies, including the NIH Institutes of NIMH, NICHD, and NIDA, which support or conduct research on child abuse. Currently, the Interagency Research Committee provides a forum in which member agencies can exchange information on ongoing research and research funding activities in the area of child abuse and neglect. The Interagency Research Committee also annually compiles a list of research projects and grants that were funded in the prior fiscal year and sponsors an annual meeting in which research portfolios in child abuse and neglect of the participating agencies are presented and research issues in childhood maltreatment are discussed. The Research Committee has also supported an ongoing series of conferences on definitional issues in child maltreatment research. These conferences bring together leading child maltreatment researchers into workgroups to arrive at consensus positions on explicit criteria to use in characterizing maltreatment and maltreatment samples in research studies.

V. CHALLENGES AND OPPORTUNITIES

Research on child abuse poses particular challenges to investigators and funding agencies alike. With respect to ethical issues, there is an inherent conflict between the usual guarantees of confidentiality explicit in research, and the legal and ethical requirements to report suspected maltreatment. Also of concern is the legal limbo with respect to the informed consent/assent of children placed in foster care because of suspected or confirmed maltreatment. Further, the recent trend toward funding services through state-administered block grants may increase the difficulty in getting access to victim populations for the purpose of collecting data.

Another challenge concerns the need to ensure that current review guidelines for assignment of child abuse research across the NIH Institutes is sufficiently detailed. For example, there are some areas of child abuse and neglect research where it has not been fully spelled out which NIH institute might be the most appropriate home for the funding of such research.

Despite these and other challenges, important research has already been funded by NIH in the area of child abuse, yet much remains to be learned. Using the research priorities outlined in the 1993 National Research Council (NRC) report, Understanding Child Abuse and Neglect as an initial point of reference, the CANWG coded all current NIH research according to the NRC-identified priorities, in order to identify areas where significant advances had been made since the NRC report and where major research gaps still existed.

With respect to gaps in content, the CANWG identified three significant areas where substantially more research effort is needed. First, little research has been funded that examines the definition, identification, and assessment of child abuse. Second, little is known about the causes, prevention, or amelioration of child neglect (vs. physical abuse), although we know that the magnitude of neglect is great and its consequences severe. And third, while NIH has funded some research on the prevention and treatment of physical and sexual abuse, considerably more intervention research is needed to determine the most appropriate and effective interventions for child maltreatment. For example, one area of research opportunity is revealed by recent studies demonstrating that maltreatment is associated with biological central nervous system changes including dysregulation of the hypothalamic-pituitary-adrenal axis, increased activity of some brain neurotransmitters, and decreased volume of the hippocampus. Research is needed to determine to what extent these changes are preventable by early intervention or reversible by later interventions.

Two areas related to the research infrastructure and research dissemination deserve special note: The first, also highlighted by the NRC report is the need "to identify organizational innovations that can improve the process by which child maltreatment findings are disseminated to practitioners and policy makers." The role of state agencies in supporting, disseminating, and utilizing empirical research deserves particular attention. NIH must work closely with these other agencies to translate and disseminate its child abuse research findings for application of this knowledge in "real world" settings.

Also, the CANWG identified critical needs in the area of training and infrastructure. There is a serious shortage of investigators trained to study child abuse, and few mentors qualified to train them in the type of interdisciplinary research skills needed to advance the field.

VI. FUTURE PLANS

Working with its NIH representatives, the CANWG identified a range of potential program-building activities that might be undertaken to increase efforts in child maltreatment research across the NIH Institutes and with other federal partners.

To build the research capacity of this fledgling field, the CANWG will explore the development of a series of conferences and/or workshops to train and attract new investigators. These meetings might include training potential investigators in issues of child abuse assessment, identifying areas of research opportunity, and enabling young investigators to engage in the necessary interdisciplinary research strategies needed to find answers to important child abuse questions.

Other proposed meetings will focus on the continued enhancement of the methodological and conceptual sophistication of the field of child abuse, and will be aimed at fostering improvements in sampling procedures, definitions, measurement and assessment, research designs in longitudinal and treatment research studies, and data analytic methods. Several meetings addressing these definitional and assessment issues have already been initiated, sponsored in partnership with other federal agencies through the Federal Interagency Research Committee on Child Abuse and Neglect.

Another kind of program building activity to be considered by the CANWG will be the potential use of various funding mechanisms and announcements to encourage more research proposals on critical topics, particularly in the gap areas identified through the CANWG's review of the NIH grant portfolio. The CANWG also plans to work closely with other federal agencies to explore ways to increase knowledge transfer and research application to practice. Pending availability of funds, options for the CANWG to consider in the coming years include:

* requesting that future NIH child abuse researchers submit a brief summary highlighting the findings and their implications for research and policy distilling the grantee's brief summary of the final report into a regularly published document at project completion
* establishing a contract with a science writer to identify and translate existing findings from its portfolio of child abuse research into lay terms for use by practitioners and policymakers
* distributing child abuse information materials to mailing lists, existing clearinghouses, and/or publishing research findings on a web site
* asking NIH grantees to deposit their data in one of two archives already established in NIJ and NCCAN
* exploring improved ways of working with the NIH Offices of Scientific Information to ensure that new child abuse findings are brought to their attention for dissemination to the media
* encouraging the use of the recent NIH report on Ethical Considerations in Violence-Related Research to enhance the capacity of Institutional Review Boards and NIH Initial Review
* convening consultants or outside contractors to assess ethical issues involved in child maltreatment research studies
* distributing currently available information and summary documents on the ethical and legal issues involved in conducting research with maltreated children (such as the recently published NIMH volume Ethical Issues in Mental Health Research with Children and Adolescents, 1996) to researchers, human subjects committees, and NIH grant reviewers

VII. CONCLUSIONS

While there has been substantial research progress since the publication of the National Research Council's Report Understanding Child Abuse and Neglect given the apparent magnitude and devastating effects of child abuse and neglect, acceleration of research efforts in this area are needed, particularly in the areas of (a) assessment and definition of child abuse and neglect, (b) child neglect in general, and (c) intervention. To ensure that these research efforts are useful and used in "real world" settings, increased efforts will be needed to enhance knowledge transfer, especially through strengthened partnerships with those agencies with mandates for provisions of services to states, as well as with the professional associations that develop and train practitioners and potential clinical investigators. Given the array of obstacles that have hampered research efforts in the child maltreatment area to date, isolated efforts addressing any single problem area are not likely to be successful. Instead, a coordinated, concerted effort to address the range of infrastructural, content-related, and translational problems will be needed to generate and maintain the necessary research progress to address this important health problem in children and families. The Appropriation Committee's interest in this area is both timely and appropriate.