Commentary: The Legal System Response to Child Maltreatment.

Legal actions are perhaps the most powerful responses to child maltreatment. Criminal and child protection investigation and forensic interviewing can provide the evidence needed to support a child victim's disclosure. Prosecution of child maltreatment can hold perpetrators accountable. Juvenile and family court actions can provide for children's safety and oversee their care in state custody and journey to a permanent home. This commentary introduces readers to a special issue of the journal Child Maltreatment that focuses on the legal system response to child abuse and neglect. We provide an overview of the issue's 11 research articles and additional commentary. These works provide crucial new knowledge on gaining information from child victims involved in the legal system, on the law enforcement and prosecution response to child maltreatment, and on the legal framework supporting child protection.

The Relationship of DNA Evidence to Prosecution Outcomes in Sexual Assault Cases.

This study examined the relationship between DNA evidence and outcomes of prosecution of sexual assault. Researchers coded data from prosecutor and crime laboratory files for sexual assault cases referred to prosecutors between 2005 and 2011 in a metropolitan jurisdiction in the northeastern United States. Cases with a DNA match were significantly more likely to move forward and result in conviction, even with other predictor variables statistically controlled. Analyses suggest DNA evidence contributes to case progression but also is a result of it. These findings strengthen the case for quality forensic medical examinations, investment in DNA analysis, and increased prosecutor training.

Patient and family experience with transthyretin amyloid cardiomyopathy (ATTR-CM) and polyneuropathy (ATTR-PN) amyloidosis: results of two focus groups.

BACKGROUND: Transthyretin amyloidosis, or ATTR, is a progressive and debilitating rare proteopathy generally manifested as either transthyretin amyloid polyneuropathy (ATTR-PN) or transthyretin amyloid cardiomyopathy (ATTR-CM). Irrespective of the clinical presentation, affected patients manage a chronic and life-threatening condition that severely impacts their quality of life. Although the primary symptoms and diagnostic criteria for ATTR are increasingly being discussed in the medical literature, due in large part by continual advances in uncovering disease pathophysiology, there exists a surprising paucity of published data on the patient journey and family experience. In order to address this disparity, two focus groups, one for ATTR-CM and one for ATTR-PN, were convened and asked to describe the diagnostic process, symptoms, and impact on their own quality of life that was experienced from these rare and typically misdiagnosed illnesses. RESULTS: Patients in both ATTR groups often underwent a long and difficult diagnostic odyssey characterized by seemingly nonspecific physical manifestations resulting in mismanagement and suboptimal care, inadequate interventions, and delays in establishing the correct diagnosis, which was integral to determining the specialized treatment they needed. Collectively, patients with ATTR-CM and patients with ATTR-PN reported a similar number of symptoms, but the type of symptoms varied. The ATTR-CM group identified intolerance to activity, inability to exercise, insomnia and fatigue as the most challenging symptoms. The ATTR-PN group identified fatigue, diarrhea/constipation and sensory deficits as the most difficult symptoms. In general, ATTR was reported to be highly stressful for both patients and their families. Spouses of patients with ATTR-CM were often in a caregiver role and reported experiencing considerable anxiety. Patients with ATTR-PN were stressed not only by the physical consequences of their illness, but also by its effects on their parents and other relatives, as well as concerns about children and grandchildren inheriting the disease-causing mutations associated with ATTR. Despite such challenges, family members are identified as an important resource of coping, motivation, inspiration and support. CONCLUSIONS: Several steps can be taken to reduce the challenges and burdens of living with ATTR, including increased education for primary care physicians and specialists who unknowingly encounter ATTR, increased access to and ready availability of mental health services and support, and increased engagement with support groups and advocacy organizations. Input from patients and their representatives should guide clinical trials, increase the availability of genetic testing, and generate natural history and qualitative studies detailing patients' experience. Although each recommendation is impactful in itself, taken together they would jointly facilitate a shortened and ameliorated patient journey through more timely diagnosis and greater access to personalized medical care.

Prosecutors' Perspectives on Biological Evidence and Injury Evidence in Sexual Assault Cases.

Little prior research has explored how prosecutors perceive and utilize biological and injury evidences in sexual assault cases. In this qualitative study, semistructured interviews were conducted with assistant district attorneys (ADAs) working in an urban district attorney's office in the northeastern United States. ADAs were asked to describe how biological and injury evidences could be probative and their strategies for using this evidence. The interviews suggest that prosecutors perceive the probative value of biological and injury evidences on a continuum, varying based on case characteristics. Prosecutors felt that undergoing a forensic medical examination in itself supported victims' credibility. Biological evidence bolstered victims' credibility if it matched the victim's account better than the defendant's. They perceived DNA evidence as helpful when it identified unknown suspects, confirmed identification of suspects by other means, or rebutted defendants' denial of sexual contact. DNA evidence was also helpful when victims were incapacitated, too traumatized to recall or talk about the assault, or too young to identify assailants, and when police used the information in interrogating suspects. The biggest limitation to biological evidence prosecutors cited was overcoming the consent defense. The ADAs reported they used DNA evidence even when it was not particularly probative, because it confirms the correct person is being prosecuted, it communicates the victim's and prosecution's seriousness, and it meets jury expectations in trials. Prosecutors found injury evidence useful because it corroborated victims' accounts and helped refute defendant claims of consensual sex. The findings may assist in educating others about biological and injury evidences in these cases, and could inspire professionals and advocates to work to develop and support a broad range of investigative methods.

Biological Evidence in Adult and Adolescent Sexual Assault Cases: Timing and Relationship to Arrest.

This study examined the timing of the crime laboratory report relative to arrests in sexual assault cases and explored the relationship between biological evidence and arrest in those cases in which the crime laboratory report came first and thus could have influenced the arrest decision. A random sample (N = 528) of cases that occurred between 2008 and 2010 and included a report to police was drawn from a Massachusetts statewide database of medical reports on sexual assault cases. Data from medical providers were merged with data abstracted from crime laboratory reports and with data requested from police departments. The vast majority (91.5%) of arrests took place before crime laboratory analysis could be conducted. The crime laboratory report was available before or near in time to the arrest in 11 cases. These cases were significantly more likely than other cases to have DNA profiles of the assailant, DNA matches to the suspect, and a match to another investigation in the FBI's CODIS DNA database. Given that the probable cause needed to make an arrest in these cases was presumably established only after crime laboratory analysis was available, DNA may have helped lead to the arrest in these cases. However, these results should be interpreted very cautiously, because statistically significant results in early, small studies can have inflated effect sizes and often do not replicate in future studies. Because most arrests occur well before biological evidence is available, improvements in recovering biological evidence may have modest effects on arrest rates, though they may impact arrest rates by identifying more serial offenders. Future research on the relationship of biological evidence to arrest should use methods to increase sample size of relevant cases, such as oversampling cases with later arrests and using case control study designs. Future studies should also use case abstraction and interview methods to explore how police use biological evidence to make arrests.

Forensic medical results and law enforcement actions following sexual assault: A comparison of child, adolescent and adult cases.

BACKGROUND: In sexual assault cases, little research has examined differences in forensic medical findings and law enforcement response by victim age across the entire age range. OBJECTIVE: This study addressed this gap by comparing four victim age groups: adults, adolescents over the age of consent, adolescents under the age of consent, and children under 12. PARTICIPANTS AND SETTING: Cases were randomly sampled from a statewide database of medical reports on sexual assault examinations conducted in hospital emergency departments, including only cases reported to law enforcement (N = 563). METHODS: Data were combined from a medical report database, from coding of medical documentation and crime laboratory reports, and from case data provided by law enforcement. RESULTS: Rates for both younger and older adolescent victims and adult victims were comparable, with no statistically significant differences on most variables: penetration, perpetrator use of force, non-genital and genital injuries, presence of biological evidence, generating assailant DNA profiles, DNA match to suspect, hits in the FBI's DNA database, and law enforcement unfounding (i.e., determining allegations to be false or baseless). Child victims were significantly less likely to have a non-genital injury, and their cases were significantly more likely to be founded by law enforcement. Arrests were significantly more likely when victims were under the age of consent. CONCLUSIONS: Despite significant differences by victim age, similarity between adolescent and adult cases was substantial. Both younger and older adolescents may be at higher risk of physical violence during sexual assault than previously recognized, and need greater attention in response systems.

Families' Experience of Pediatric Onset Multiple Sclerosis.

This study interviewed parents to understand families' experience with pediatric onset multiple sclerosis (POMS), which make up 2.7% to 10.5% of all MS cases. 21 sets of parents of children with a confirmed diagnosis of POMS were recruited from two pediatric MS centers. Families experienced stress from the uncertainty prior to diagnosis, anxiety over symptoms and possible progression of the disease, frustrations with the uncertain effects of disease-modifying treatments (DMTs), and difficulties with injections. Families had to cope with cognitive and physical effects of POMS at school, decisions about expectations and independence for the child, and extra demands POMS placed on the family. Most parents reported benefitting from support from physicians, the National Multiple Sclerosis Society, and the MS community. Families had benefitted from DMTs, and, despite the stresses, most had adapted successfully to the illness. Advice from interviewees to other parents and recommendations for improving family support are presented.

FOOD NEGLECT AND INFANT DEVELOPMENT.

The impact of food insecurity on child development in the general U.S. population is well-established, yet little is known about the harm of food neglect relative to other types of maltreatment. Due to the harmful physiological impact of inadequate nutrients and the social impact of food-related stress, it was hypothesized that food neglect would be more likely to impair infant cognitive and language development than physical abuse, sexual abuse, and other forms of neglect. Families of infants (N = 1,951) investigated by Child Protective Services were studied using the second cohort of the National Survey of Child and Adolescent Well-Being (NSCAW II; NSCAW Research Group, 2002). Results from multivariable logistic regression models that controlled for likely confounding variables showed that the odds of impairment in cognition and language were significantly greater when food neglect was the most serious form of maltreatment. Considering that both food insecurity and child neglect are associated with poverty and parental mental health problems, it will be important for child welfare and mental health professionals to work collaboratively to better the health of these vulnerable children.

Qualitative Analysis of Prosecutors' Perspectives on Sexual Assault Nurse Examiners and the Criminal Justice Response to Sexual Assault.

OBJECTIVE: The aim of this study was to understand prosecutors' perspectives on the contribution of Sexual Assault Nurse Examiners (SANEs) to evidence collection and trials in sexual assault cases. BACKGROUND: Several studies have suggested that a sexual assault case is more likely to progress in the criminal justice system when a SANE conducts the forensic medical examination. However, little is known about how prosecutors perceive SANEs and what they value about SANEs versus other medical professionals. METHOD: Semistructured interviews, conducted in one jurisdiction with eight assistant district attorneys who prosecute sexual assault cases, included questions about the value of SANEs in evidence collection and trials. Interview transcripts were analyzed to identify common themes and variability among prosecutors. RESULTS: Most prosecutors identified advantages for SANEs in evidence collection, trial preparation, and testimony. Specific advantages cited by one or more prosecutors included superior documentation, thoroughness of the physical examination, better identification of injuries, quality of relationships with patients, professionalism, skill in trial preparation and testifying, and credibility with jurors. DISCUSSION: These findings help validate SANEs' contribution to the criminal justice response to sexual assault, despite the study's limitations in sample size and inclusion of only one jurisdiction. The study also suggests the value of further education about SANEs for prosecutors who may not have the opportunity to learn about the range of skills SANEs possess.

The practice of prosecuting child maltreatment: Results of an online survey of prosecutors.

Despite efforts by advocates, practitioners, and legislators to alleviate the burden on child maltreatment victims in the criminal justice system, many challenges remain for prosecutors as they seek to hold offenders accountable while minimizing the emotional impact on children. More than 200 state and local prosecutors in 37 states responded to an online survey to share their perspectives on current challenges, procedures to support children in the adjudication process, and the impact of the U.S. Supreme Court opinion in Crawford v. Washington (2004), sex offender registries, and "Safe Harbor" legislation to protect child sexual exploitation victims. Respondents' most pressing challenges were obtaining evidence to corroborate children's statements and the difficulties of working with child victims. Child testimony was ranked as more frequent than any other type of evidence, and least frequent were DNA, photos or videos of criminal acts, and other physical evidence. Prosecutors rely primarily on victim/witness assistants and courtroom tours to prepare children for testimony; technological alternatives are seldom used. Results suggest a real but limited impact of the Crawford opinion on the need for child testimony and on the decision to prosecute. Survey findings indicate a need for greater attention to thorough investigations with particular attention to corroboration. Doing so may strengthen the child's credibility, which is especially critical in cases lacking physical or medical evidence of maltreatment.

Criminal investigations in child protective services cases: an empirical analysis.

This study analyzed the frequency and correlates of criminal investigation of child maltreatment in cases investigated by child protective service (CPS), using national probability data from the National Survey of Child and Adolescent Well-Being. Criminal investigations were conducted in slightly more than 25% of cases. Communities varied substantially in percentage criminally investigated. Sexual abuse was the most frequent type of maltreatment criminally investigated followed by physical abuse. Logistic regression results indicated that criminal investigations were more likely when caseworkers perceived greater harm and more evidence; when CPS conducted an investigation rather than an assessment; when a parent or a legal guardian reported the maltreatment; and when cases were located in communities in which CPS and police had a memorandum of understanding (MOU) governing coordination. Most variation between communities in criminal investigation remained unexplained. The findings suggest the potential of MOUs for communities wanting to increase criminal investigation.

The seven pillars of quality care in a statewide pediatric sexual assault nurse examiner program.

This article describes a systematic approach used by a statewide pediatric sexual assault nurse examiner program to ensure the quality of forensic medical examinations it provides in child sexual abuse investigations. Seven strategies for enhancing quality are described: (a) hiring experienced professionals, (b) effective training, (c) comprehensive protocols, (d) ample support for pediatric sexual assault nurses, (e) management oversight, (f) a clinical coordinator to provide ongoing training and technical assistance, and (g) a quality assurance process in which expert child abuse pediatricians review each statewide pediatric sexual assault nurse examination. To show the evolution of quality care over time, the program's experience from 2004 to 2010 is reviewed, and quality assurance data are analyzed.

Identifying the substance abuse treatment needs of caregivers involved with child welfare.

Parental substance use significantly increases risk of child maltreatment, but is often under-identified by child protective services. This study examined how agency use of standardized substance use assessments and child welfare investigative caseworker education, experience, and caseload affected caseworkers' identification of parental substance abuse treatment needs. Data are from a national probability sample of permanent, primary caregivers involved with child protective services whose children initially remained at home and whose confidential responses on two validated instruments indicated harmful substance use or dependence. Investigative caseworkers reported use of a formal assessment in over two thirds of cases in which substance use was accurately identified. However, weighted logistic regression indicated that agency provision of standardized assessment instruments was not associated with caseworker identification of caregiver needs. Caseworkers were also less likely to identify substance abuse when their caseloads were high and when caregivers were fathers. Implications for agency practice are discussed.

Child welfare policy and practice on children's exposure to domestic violence.

OBJECTIVES: This article reviews research, policy and programming in Australia, Canada and the US on the child welfare response to EDV. METHOD: The review draws on searches of standard research databases, interviews with researchers and practitioners, and the authors' own research. RESULTS: Although EDV is underreported, across studies 7% to 23% of youths in general population surveys experienced EDV, 36-39% of youth in DV cases have witnessed the violence, and 45-46% of primary caregivers in child maltreatment investigations have experienced DV. Mandatory reporting can increase the number of cases that come to the attention of child welfare, but without resources for training and programming can lead to inappropriate reports, lack of referral for further assessment, and strains on the child welfare system. Improving the child welfare response to EDV can include collaboration between child welfare workers and DV advocates; increased training on screening for DV; new protocols on DV; and dedicated DV staffing within child welfare agencies. In recent years, policy and program attention to EDV has also been embedded within broader national efforts to protect children from violence and maltreatment. Differential response models that eschew investigation in favor of assessment and service delivery hold promise for families with DV. CONCLUSIONS: Empirical data are limited, but current research and practice experience suggest that child welfare agencies seeking to improve the response to EDV should collaborate with other disciplines involved with preventing and responding to DV, seek resources to support training and programming, consider methods that avoid stigmatizing parents, and build in a program evaluation component to increase knowledge about effective practice.

Mental health professionals in children's advocacy centers: is there role conflict?

Two recent chapters in professional books have criticized children's advocacy centers for creating role conflict for mental health professionals because of their work with criminal justice and child protection professionals in children's advocacy centers as part of a coordinated response to child abuse. This article argues that these critiques misunderstand children's advocacy center practice and overestimate the risk of role conflict. Children's advocacy center standards set a boundary between forensic interviewing and therapy, which in most children's advocacy centers are done by separate professionals and never by the same professional for a given child. Many mental health professionals serve children's advocacy centers as consultants with no treatment role. Children's advocacy center therapists are rarely involved in investigation, and their participation in multidisciplinary teams focuses on children's interests and well-being.

Do parents blame or doubt their child more when sexually abused by adolescents versus adults?

Although the importance of parental support for child sexual abuse victims is well documented, the nature of parental support for victims sexually abused by adolescents is less understood. In this exploratory study, we examine whether parents differ in their levels of blame or doubt for their child when sexually abused by adolescents versus adults. Data included 161 reports of child sexual abuse. Parental blame toward their child was higher when sexually abused by an adolescent versus an adult suspect. In the bivariate and multivariate analysis, parental blame was significantly higher as victim age increased, for Black, non-Hispanic children, and when there was an adolescent suspect. Practitioners need to recognize that high levels of blame and doubt could exist for adolescent victims of sexual abuse and when children are sexually abused by adolescents.

The relationship of child functioning to parental physical assault: linear and curvilinear models.

Previous research suggests a curvilinear relationship between child disability and physical abuse, with children with mild impairments at greater risk than both children with severe impairments and superior functioning. Using a national probability sample of families investigated for maltreatment (N = 1675), this study tested for both linear and curvilinear relationships of child functioning to parental physical assault. Linear relationships were found between problem behaviors and minor and severe assault, and between social skills and minor assault: the more impaired the level of child functioning, the greater the risk. Curvilinear relationships were found in which children with mildly impaired or average language skills were at greater risk for minor assault than both children with severe impairment or above average and superior skills. Children with superior daily-living skills were at lower risk for severe assault than all other children. Implications for understanding processes underlying parental physical assault of children with impairments are discussed.