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Kauffman Final Report

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CLOSING THE QUALITY CHASM IN CHILD ABUSE TREATMENT:IDENTIFYING AND DISSEMINATING BEST PRACTICES The Findings of the Kauffman Best Practices Project to Help Children Heal From Child Abuse.Over the past 27 years, inspired by the leadership of Dr. David Chadwick, theCenter for Child Protection at Children’s Hospital - San Diego has made amajor commitment to the prevention, treatment, and education of child abuseand neglect. The Center for Child Protection (renamed The Chadwick Centerfor Children and Families in 2002) is now the most comprehensive multidisci-plinary program in the country connected to a children’s hospital. We havebeen pleased to be active participants in the National Call To Action, aunique social movement aiming to end child abuse in America. Over the last 10 years, Children’s Hospital - San Diego has made a majorcommitment to relentlessly improving all phases of the quality of care it provides through rigorous use of clinical pathways developed based on the best evidence available. Coordinated by our Center for Child HealthOutcomes, over 65 pathways have been developed covering 35% of the children we treat with a 90% compliance rate. We have greatly benefited from the leadership and work of Dr. Donald Berwick and the Institute forHealthcare Improvement (IHI) in Boston, and from being part of the ChildHealth Accountability Initiative (CHAI) – a collaborative with otherChildren’s Hospitals to improve care. One of the lessons learned from IHI and the pioneering study “Crossing the Quality Chasm” by the Institute of Medicine was the tremendous gapbetween best care and everyday care in hospitals and office practices, and the fundamental system changes that were needed to close this chasm. Itoccurred to us that the child abuse field could benefit by learning from manyof the methodologies designed by the IHI and building them on to identifiedbest practices in child abuse. We set out to engage some of the nation’s leaders in child abuse and askedtheir guidance in how the best thinking of both fields could be broughttogether. We are particularly grateful to Dr. Ben Saunders and to the otheradvisors, many of whom are active members of the National Child TraumaticStress Network, mentioned in this document for their contributions. We arealso grateful to the Ewing Marion Kauffman Foundation for their support ofthis work. We hope that this document will stimulate further collaborationbetween the healthcare and child abuse fields, and will accelerate the improve-ment of care provided so that, one day, every child in America who is the victimof abuse will receive the best treatment provided in the most effective way. Domonique Hensler Charles Wilson Blair L. SadlerExecutive Director Executive Director President & CEONational Call To Action Chadwick Center Children’s Hospital-The Sam & Rose Stein Chair San Diegoin Child Protection FOREWORD1BackgroundThe Problem of Child AbusePace of Spread of InnovationKauffman Best Practices ProjectNational Call To Action: A Movement to End Child Abuse and NeglectNational Child Traumatic Stress NetworkLead Consultant and AdvisorsIdentification of Best PracticesTrauma Focused-Cognitive Behavioral Therapy For Child Sexual AbuseAbuse Focused-Cognitive Behavioral Therapy For Physical AbuseParent Child Interaction TherapySpreading Best Practices: The Art and Science of DiffusionThe Change ProcessThe Transtheoretical Model of ChangeThe IHI ExperienceUnderstanding the BarriersStrategies for Accelerating the Pace of Spread of Best PracticesRecommendationsEnvironment/Community LevelOrganization LevelMicrosystems LevelPractitioner-Client LevelNext StepsReferencesAppendices2717222629384143 TABLE OF CONTENTSThe Findings of the Kauffman Best Practices Project to HelpChildren Heal From the Effects of Child Abuse.Background: Child abuse touches the lives of millions of American childreneach year. In 2001 alone, 2.6 million reports of child abuse were made to childprotection authorities, resulting in over 600,000 substantiated cases involvingover 900,000 children (ACYF, 2003). Victimization surveys of adults and adolescents indicate that 8.5% of American youth have suffered severe physicalabuse and, at least, 8.1% have experienced a completed rape (Kilpatrick, et al.,2003; Saunders, et al., 1999; Boney-McCoy & Finkelhor, 1995). The short andlong-term effects of maltreatment in childhood are well-documented. Over 1300children die each year at the hands of their caregivers (ACYF, 2003). Childabuse has been found repeatedly to be a major risk factor for many mentalhealth disorders, emotional problems, behavior difficulties, substance abuse,delinquency, and health problems (Beitchman, et al., 1991; Beitchman, et al.,1992; Browne & Finkelhor, 1986; Duncan, et al., 1996; Felitti, et al., 1998;Fergusson, et al., 1996; Flisher, et al., 1997; Gomes-Schwartz, et al., 1990;Hanson, et al., 2001; Kendall-Tackett, et al., 1993; Kessler, Davis, & Kendler,1997; Kilpatrick, et al., 2000; Kilpatrick, et al., 2003; Pelcovitz, et al., 1994;Polusny & Follette, 1995; Saunders, et al., 1992; Saunders, et al., 1999). In 2001 alone, 2.6 million reports of child abuse were made to child protectionauthorities, resultingin over 600,000 substantiated casesinvolving over900,000 children(ACYF, 2003). 2CLOSING THE QUALITY CHASMIN CHILD ABUSE TREATMENTMillions suffer long term emotional consequences of maltreatment in child-hood, including depression, anxiety disorders, posttraumatic stress disorder,alcohol or drug abuse, smoking, and relationship problems. These problemsoften lead to more subtle effects on behavioral choices in childhood and adolescence that shape later adult life styles and produce long term healthimpacts, sometimes including early death from heart disease and cancer(Felitti, et al., 1998). Despite tremendous efforts for prevention and interven-tion over the past thirty years, child abuse remains the most common type ofmajor childhood trauma today, and its impact is pervasive in society.Many of the nearly one million children identified as abused or neglected eachyear are offered some form of intervention designed to make them safe, and tohelp them recover from the after-effects of the maltreatment. These childrenand families are seen by a wide range of practitioners, working in a variety ofpractice settings. They offer a dramatic, often dizzying, array of interventions.Twenty years ago, as child abuse emerged as a major topic in the clinical


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