Introductions

1. Envisioning A Coordinated Response:Child Advocacy CentersCharles WilsonDonna PenceJohn Stirling 1

2. Introductions • Goals for the Day • Size, Scope, and Impact of Child Abuse • Concepts and core details of CAC’s • Functions of multidisciplinary child abuse investigation teams • Applying concepts of CAC MDT’s to WA child protection environment • Addressing questions and concerns

3. Who would hurt a little child?

4. Nationally US Reports of child abuse • 3 million children nationwide • 872,000 victims of maltreatment • 18% physically abused • 10% sexually abused • 2500 homicides Australia The incidence of child abuse in Australia is worsening, : • child abuse notifications; • substantiated abuse cases; • children on care and protection orders; and • the number of children in out-of-home care. • Indigenous children continue to be significantly over represented in every one of these areas.

5. Child Maltreatment Pyramid • CAN Fatalities (1,000-2,600) • Serious Disabilities (18,000) • Serious Injuries (570,000) • CAN Incidences (900,000) • Reported CAN (2.8 m) • Unreported Cases Only 28% to 50% of recognized abuse/neglect is reported by community professionals Hx tells us 1 in 4 Girls 1 in 7 Boys will be sexually abused Adapted from NIS-III Executive Summary, 1996; Herman-Giddens et al. JAMA, v282(5) 1999; Wang & Harding, Current Trends..Fifty State Survey, Nov. 1999; U.S. DHHS Child Maltreatment 1998, Wash., DC, 2000.

6. Rady Children’s Hospital’s Trauma Center • 2.2% admitted for child abuse • 32% who die in the hospital are victims of fatal child abuse • Trauma is not just physical

7. Effects of abuse on Kids(The Short Version)

8. The Relationship Between Adverse Childhood Experiences and Adult Health: Turning Gold Into Lead Vincent J. Felitti, MD “Health Alert”, Vol. 8, No. 1 Family Violence Prevention Fund

9. Category Prevalence(%) Abuse, by Category Psychological (by parents) 11% Physical (by parents) 11% Sexual (anyone) 22% Household Dysfunction, by Category Substance Abuse 26% Mental Illness 19% Mother Treated Violently 13% Imprisoned Household Member 3% Categories of Adverse Childhood Experiences

10. Adverse Childhood Experiences Score ACE score Prevalence 0 48% 1 25% 2 13% 3 7% 4 or more 7% • More than half have at least one ACE • If one ACE is present, the ACE Score is likely to range from 2.4 to 4

11. ACE Studies - results

12. Adverse Childhood Experiences Consequences: • obesity • depression • drug / alcohol abuse • teen pregnancy • incarceration

13. Adverse Childhood Experiences But also: • diabetes • hypertension • fractures • job performance / satisfaction • cigarette smoking...

14. Adverse Childhood Experiences determine the likelihood of the ten most common causes of death in the United States Smoking Severe obesity Physical inactivity Depression, suicide attempt Alcoholism, illicit drug use 50+ sexual partners, STIs

15. My twenty minutes… What is abuse? What does it give children? What does it take away?

16. Incidence: vs disease Cystic Fibrosis: 1: 2500 births Diabetes Mellitus: 1: 1000 children Childhood Leukemia: 1: 30 000 Child Abuse: 1: 7 What Would Willie Do?

17. Presentations • Depression • Anger control problems • ODD • ADHD • Cognitive delays, school failure • Drug/alcohol abuse • Risk-taking behaviors, etc., etc., etc…

18. Physical Abuse Sexual Abuse Neglect ~40%

19. Domestic Violence Child Abuse 20 – 40% Family dysfunction?

20. The Spectrum of Maltreatment Normal Development Physical Child Abuse Sexual Child Abuse Parenting Emotional Abuse Neglect

21. Costs of Intervention Incarceration $ COST Therapeutic preschool Drug treatment Remedial education Prenatal care birth 10 20 AGE

22. Costs of Intervention < Brain malleability $ COST AGE

24. It takes a whole brain to learn: • Cognitive (left brain) • Vocabulary • Logical reasoning • Experiential (right brain) • Emotional awareness • Self-regulation

25. Fight or Flight?

26. Neuroendocrinology Stress Hypothalamic / pituitary stimulation Adrenal cortisol release

27. Neuroendocrinology Studies show abuse victims have: Enhanced pituitary sensitivity - Duval, 2004 Cortisol spikes w/ trauma reminders - Elzinga, 2003 Higher cortisol levels, abnl variation - Ciccetti, 2001 Cortisol spikes, higher baseline - Bugenthal, 2003 Heightened inflammatory response - Altemus, 2003

28. The Brain: Targets of Stress Cerebral cortex EEG changes smaller callosum Limbic system neuronal changes decreased size Brainstem/ Cerebellum altered transmitters

29. Maltreated kids may have... Symptoms of “stress response”: • Irritability • Hyperarousal • Dysregulation of affect AKA: “Behavior problems”

30. Attachment • “Intimate attachments to other human beings are the hub around which a person’s life revolves.”- John Bowlby

31. Overview of attachment theory Bowlby’s definition of attachment: • “Any form of behavior that results in a person seeking proximity • to some other differentiated and preferred individual, • usually conceived as stronger and/or wiser.”

32. Overview of attachment theory Evolutionary advantage: • A secure child can explore!

33. Goals of Development(after Von Horn) • Attachment • Regulation • Cognition

35. Maltreated kids may have... Attachment problems: • Persistent fear/alert state • Poor differentiation of affect • Dysregulation of affect …and thus may avoid intimacy

36. Presentations • Depression • Anger control problems • ODD • ADHD • Cognitive delays, school failure • Drug/alcohol abuse • Risk-taking behaviors, etc., etc., etc…

37. Conclusions • Abused and neglected kids • Suffer a wide variety of effects arising from • Chronic activation of the threat response, and • Lack of parental support to provide • Coping tools (self-regulation) that enable • Cognitive and interpersonal learning

38. Conclusions • Impact of trauma depends on: • Trauma factors • Family and environmental factors • Child factors

39. NCTSN Mission NCTSN Mission To raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States. To raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States. NCTSN Vision • The NCTSN will raise public awareness of the scope and serious impact of child traumatic stress on the safety and healthy development of our nation's children and families. • We will improve the standard of care by integrating developmental and cultural knowledge to advance a broad range of effective services and interventions that will preserve and restore the future of our nation's traumatized children. • We will work with established systems of care, including the health, mental health, education, law enforcement, child welfare and juvenile justice systems, to ensure that there is a comprehensive continuum of care available and accessible to all traumatized children and their families. • We will be a community dedicated to collaboration within and beyond the Network to ensure that widely shared knowledge and skills create a national resource to address the problem of child traumatic stress. Emotional Chain of Custody

40. Lisa’s 911 Call • Think about the stress • What is going on biologically inside this child? • How many traumatic moments occur in the space of 5 minutes

41. Child Abuse is BigChild Abuse is Bad So what do we do about it?

42. Strengths and Challenges • What is working well in Western Australia? • What are you most proud of about the system in Western Australia? • What doesn’t work so well? • What would you like to see done differently?

43. Bringing Systems Together Summer of 1977 “Why don’t you big people talk to one another?”

44. Joint Investigation Systems in SilosParallel Investigations TEAMWORK

45. Spring of 1984 “You’re supposed to be helping............ but you’re making it worse!”

46. So What’s a CAC Essential Components of a CAC • Team • A Place • Organization • Protocol • Cultural Competency and Diversity • Forensic Interviews • Medical • Therapeutic • Victim Advocacy • Case Review • Case Tracking

47. What’s a CAC? • First – It’s a Team • Law Enforcement • Child Protection • Prosecutor • Medical • Mental health • Victim Advocacy • All Involved in the Investigation • Routinely Share Information • Written Agreement-Protocol

48. Written AgreementInvestigative Protocol • Establishes the basic mode of operation of the team • Gives all a common frame of reference • Can be easily modified on a case by case basis

49. San Diego Child Victim -Witness Protocol Our Mission The County of San Diego and all of its incorporated cities will assist and protect all children, both victims and witnesses, who are exposed to any kind of abuse through a multi-disciplinary collaborative effort by those in law enforcement, child protection, mental and medical health, and the justice system.

50. San Diego Child Victim-Witness Protocol Goal • Minimize further trauma to child through a cooperative multidisciplinary effort which will limit the number of times children are interviewed and treat children with dignity and respect.