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Surgeon General Meeting
The Prevention of Child Maltreatment
Summary of Key Steps for Achieving the Public Health Approach
By Shay Bilchik, President and CEO, Child Welfare League of America
Thanks go to the Surgeon General and the other federal agencies, including the Children's Bureau, for calling us all together on this very important topic. I give special thanks to those who shared very personal stories as a way to help us see and understand more clearly the importance and urgency of our work over the past two days and the efforts we must make to prevent child maltreatment in the future.
I have no power point with which I will dazzle you - as did others who preceded me at this podium. Your visual entertainment will be looking at me, the gestures I may make with my hands, and perhaps my colorful tie. The other "entertainment" I have to offer are my words - and it is with them that I hope to effectively summarize the dialogue we have had over the past two days. And while many of you have served as Exposituers as you led the discussion in each topical area, I hope I may stir the pot and be somewhat of a Provocatuer!
The Surgeon General believes in action, and I believe it is safe to say that we all believe in action. So I ask that we join the Surgeon General in promoting action on this public health problem after we leave here today.
It has been said by our host today that it is a sign of a good meeting when the participants run out of time for their discussion before they run out of ideas. I would add that it is also a sign of a good meeting and discussion on a powerful topic such as child maltreatment, when the participants have cried, laughed and been stretched in their thinking. I think this meeting has been a success on all of these levels!
So all of that sounds and feels pretty good; but what does the Surgeon General identifying child maltreatment as a public health problem, do for this issue? Indeed, child maltreatment has been "studied" before - nationally and in virtually every state - with the appointment of commissions, task forces, and special legislative committees -- and even reports by Grand Juries that see the exploration of social issues confronting the community as part of their responsibilities. And to be honest, after all of this studying not much has changed in our societal efforts to prevent child maltreatment.
So what is potentially different with this effort? My answer is that what the Surgeon General and the public health model bring to this problem is rigor! His office and the model bring a template for how to better understand and then attack this problem in its entirety - an all out war on child maltreatment!
What it does not bring automatically, however, is ownership of the problem by the American public - and I will address that later in my summary.
The public health model, as laid out so well by Maxine Hayes earlier today, calls for assessment and epidemiological analysis, development of a plan for reducing the problem (along with policy development), assurance and evaluation. Our first challenge in applying this model is to define prevention for purposes of this undertaking - are we talking about primary, secondary or tertiary prevention as the scope of our efforts? Or are we, as some of you have suggested, needing to elevate our work to the sphere of health promotion and health optimization? Since we did not actually fully discuss and then define the scope of this undertaking, I am taking the liberty of assuming, based on the breadth of the dialogue we have had and the programs and policies discussed, that we are encouraging the Surgeon General to address the full panoply of primary, secondary and tertiary prevention efforts as the scope of this effort. In addition, that we are recommending keeping this effort more narrowly focused on child maltreatment, although considering the broader context of health optimization as the work proceeds.
So we have described the components of a public health approach and the scope of work for this undertaking - now the really hard work begins: rigorously adhering to the steps described above as we move forward.
First, we will need to conduct an assessment of the problem. We need to make sure we have all the data we need to assess the problem; and we need to identify each relevant data source as we quantify the full extent of the problem of child maltreatment, finding information in:
- HHS and other federal reports
- Reports from other systems of care of instances of maltreatment that are not reported to, or are diverted from, a formal system
In this regard we need to assess the full scope of the problem by the better identification of instances of maltreatment known to school officials, emergency rooms, private physicians treating patients across the socio-economic spectrum, the clergy and youth workers in after school programs - to name a few sources. We also need to better identify children suffering emotional neglect. And we need to use multi-system assessment centers to identify many of these children - so they are known to us no matter what system's door they enter as a result of maltreatment. The federal agencies focused on the well being of our children will be able to help us as we move forward in building capacity to make sure we identify and understand the full scope of the problem of child maltreatment in America today.
Next we need to determine the effective interventions to attack the problem - understanding the causes of maltreatment and using the methodologies known to us to be effective (high levels of rigor and effectiveness demonstrated in their evaluations) and those thought to be effective, although based on evaluations that are of a little less rigor - and then we need to commit to continue to build the base of knowledge of effective, culturally competent practice. With that information - and several examples of such programs and strategies were presented over the last two days - we can target our prevention efforts at:
- Caretaker abuse - parents and others serving in a caretaker role
- Abuse by teachers, coaches, camp counselors, the clergy, and child care workers
- Instances of shaken baby syndrome
- Neglect - the most pervasive form of maltreatment
- Maltreatment co-occurring with domestic violence
- Maltreatment taking place in urban, suburban, rural, and tribal communities
- Maltreatment taking place in poor, middle income and upper income settings
- And maltreatment taking place in white, black, Indian, Hispanic or Asian families
The Institutes within NIH and the other federal agencies focused on child maltreatment will be able to help the field build on its current base of knowledge on the root causes of maltreatment and effective preventive methodologies.
Our next challenge in moving forward with the public health model will be to take those effective methodologies and educate the public about the problem of child maltreatment and our ability to address it - and then work to have the public take ownership, commit to action, and demand action on a policy level. I need to distinguish here between the public health issues of youth violence and smoking, as compared to child maltreatment, when we think about this messaging challenge and the impact of the Surgeon General's involvement and his identification of this issue as a public health problem.
The problem of youth violence was already owned by the American public when it was first declared to be a public health problem. Smoking was not viewed as much of a public health issue before the Surgeon General identified it as such, but even more important in capturing the public's attention was when tens of millions of smokers were associated with the deadly effects of second hand smoke. After that, it didn't take long for us to take ownership of the problem - as all of our good health and lives were at stake.
Right now, child maltreatment is either someone else's problem or too uncomfortable to deal with. As a society, we don't own the maltreatment of children on Indian reservations or within tribes, or in poor families, or even in our own neighborhoods if it is in the affluent communities of Bloomfield Hills, Michigan, Potomac, Maryland, or Boca Raton, Florida. - or within our own family. That needs to change.
So how do we change that? What I heard us say over the past two days is that we need strong, visible leaders willing to commit to educate and lead on what societal and individual actions are needed. For example, we need the Surgeon General, President and First Lady Bush, Secretary Leavitt, Rep, Tom Delay, Senator Hillary Clinton, prominent Governors and Mayors, and celebrities who are invested in this issue - Bruce Willis, Alonzo Mourning, and Oprah Winfrey, all on board as part of a multi-year effort utilizing the public health model.
We also need the media to take on this challenge of education and knowledge building, helping the public to ultimately care about this problem - about these children - and to take ownership of it and them as if they were their own children.. We can use the Ad Council and public service ads, corporate cause marketing, and paid advertising. We can enlist the assistance of groups like the Sesame Workshop and Mr. Rogers Neighborhood, both of whom we heard from in a very powerful and eloquent manner. But even if we pull all of those leaders together and partner with the media, it will still be hard work and we will need to be resolute in our commitment to carry it through.
Someone made the point that we need to be as effective as the "Got Milk" campaign in carrying out this messaging campaign. That is an intriguing point, as the information I have is that while we all know the slogan "Got Milk," the bottom line is that this was not really an effective campaign. It fell short of its intended goals because while people remembered the slogan, it didn't change the consumption of milk. Can it be done? Absolutely! Nike did it and Verizon has been extraordinarily effective in re-branding itself - how many of you remember who Verizon was before they were Verizon? We have seen other effective campaigns that changed behavior, beyond the very effective campaign to reduce smoking: "Buckle up for Safety."; "Only You Can Prevent Forest Fires"; and Don't Be a Litterbug" are all examples.
We will need to use technology, including the internet and the web and mount cutting edge communication efforts through means such as viral communications.
And even with all the media we can muster, we will still need the Surgeon General to help us mobilize communities and create community partnerships to help promote the understanding and commitment to this issue that we need. It will take great leadership to deal with the "nay-sayers" who will claim our efforts are misguided and an intrusion on individual and family rights. Indeed, it will take strength to navigate over the bumps in the road we will experience in building this public will and encouraging societal responsibility for our abused and neglected children.
In this public health approach our next task will be to complete a rigorous matching of each dimension of the problem; risk factors matched with protective factors and policies and programs being implemented; and over time bringing our efforts to scale. We need to adopt a strategic plan, based on a public health model to prevent child maltreatment in America. This will need to include systems integration and basic systems change. And it will need to be accompanied by adequate resources to create this matching or alignment. This means that the Surgeon General and Secretary Leavitt will be sitting side by side, analyzing the Federal Child and Family Service Reviews and the implications for reform and system and outcome improvement - both for this generation of CFSR data and the next.
It is that analysis that will lead us to the solutions around how to better build and equip our workforce, reduce caseloads and insure more appropriate workloads, and provide the tools each worker needs to be successful in their work, including a full array of treatment options.
And Secretary Leavitt and Surgeon General Carmona will need to strategize how to bring primary prevention to a level of prominence that would result in the investments needed to address those risk factors facing our most vulnerable children and families.
I have a visual - the Surgeon General and Secretary Leavitt arm-wrestling the Director of the Office of Management and Budget over the resources needed to do this work - two against one; with President Bush overseeing the competition. When we look closely we can see the President gently pushing along with the Surgeon General and the Secretary. That is the picture we need to see in order to get the resources we need to do this work. And I am sure you can picture your own state officials in the same kind of competition over funding.
Which brings me back to one of the benefits of the public health model - it brings with it the rigor we need to best establish how to attack this problem; and a clear picture that it is hard to turn away from as we identify the scope of the problem; what is needed to attack it; and implement those things wherever they are needed in a family focused, strength based manner.
I have a couple of "takeaways" from this meeting that I want to share at this point.
The first is on system's integration and collaboration. These are good things to talk about, as long as they are not code words for "do more with less"...and are not justifications to cut budgets, pointing to anticipated efficiencies. As we heard at this meeting, Marc Cherna, Director of the Department of Human Services in Allegheny County, Pennsylvania, effectively integrated services and created economies of scale and operational efficiencies, but he had the authority to accomplish those things all within his own department -- and it still took additional investment and time to turn around that system. Others have to struggle with the issues of turf, power, control, setting aside of system biases, and preconceived notions about those "other" systems of care. As Peter Block, an expert in organizational change has described in his writings: they have to develop trust, be transparent in how they carry out their work and relate to one another, and engage in what he calls "acts of surrender" - which may include sharing resources.
Meeting this challenge will be a key part of how we move forward. It is important, therefore, that we identify the current knowledge that exists on how to do this collaborative work most effectively and then build on that knowledge. We need to examine the research on the Systems of Care initiatives supported by SAMHSA and the Safe Schools/Healthy Students program funded by a multi agency effort in dozens of communities across the country. And we need to use provisions in CAPTA and the JJDP Act - and others - that direct more multi-systems work on the federal level, that in turn will translate to the benefit of local practitioners and the children and families they serve.
What we know is that this takes time. So we will need to be patient as our respective workforces get to know one another, and we engage in the cross training that will need to take place, and ultimately see the breaking down of the institutional barriers that stand in our way.
And as I continue on this public health model "path," and we use this collaborative approach to plan and implement our strategy, we will also need to measure our progress over the life of our efforts - over the life of our action plan. And we will need to conduct these measurements across the continuum of the services we provide.
Which leads us, using this public health approach, to the point where we begin the process again - a cycle of knowledge building and implementation occurring on an ongoing basis…..with various elements of the public health approach constantly in play. As a result, we are continually learning and improving practice and policy - leading us closer to our goal of preventing child maltreatment.
In closing, it is critical that we not lose the momentum we have created these past two days. With the Surgeon General in a unique and powerful position to move us forward, we must leave here with a sense of urgency. Perhaps you felt that sense of urgency in the letters that Judge Cindy Lederman highlighted in her presentation; or perhaps Michele Pierce's powerful exchange of notes with her neighbor that displayed an extraordinary sense of humanity; or through Cici Porter's and George Lithco's life experiences with maltreatment.
I might add to those sources of inspiration another way of looking at where we are today that might help us see that we can not lose a day in taking on this issue as a public health problem. Every day that goes by, at least four children will die as a result of maltreatment and over 2400 children will suffer an abusive act or be neglected. Since last year when this undertaking was announced, 1400 children have died from maltreatment.
I think the picture and exigency is clear -- so let us not lose a day as we leave this gathering.
Thank you for allowing me the opportunity to provide these summary remarks.
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