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Envisioning A Coordinated Response:

Child Advocacy Centers

Charles WilsonDonna PenceJohn Stirling

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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

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Who would hurt a little child?

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Nationally

US Reports of child abuse – 3 million children nationwide– 872,000 victims of maltreatment– 18% physically abused– 10% sexually abused– 2500 homicides

AustraliaThe 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.

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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

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.

Hx tells us 1 in 4 Girls1 in 7 Boys will besexually abused

Only 28% to 50% of recognized abuse/neglect is reported by community professionals

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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

Effects of abuse on Kids(The Short Version)

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

Categories of Adverse Childhood Experiences

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%

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

ACE Studies - results

0

10

20

30

40

50

60

70

80

ACE 3ACE 5ACE 7ACE

patients with ___

Adverse Childhood Experiences

Consequences:

• obesity

• depression

• drug / alcohol abuse

• teen pregnancy

• incarceration

Adverse Childhood Experiences

But also:

• diabetes

• hypertension

• fractures

• job performance / satisfaction

• cigarette smoking...

Adverse Childhood Experiences determine the likelihood of the ten most common causes of

death in the United States

SmokingSmokingSevere obesitySevere obesity

Physical inactivityPhysical inactivityDepression, suicide attemptDepression, suicide attemptAlcoholism, illicit drug useAlcoholism, illicit drug use50+ sexual partners, STIs50+ sexual partners, STIs

My twenty minutes…

• What is abuse?

• What does it give children?

• What does it take away?

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?

Presentations

• Depression

• Anger control problems

• ODD

• ADHD

• Cognitive delays, school failure

• Drug/alcohol abuse

• Risk-taking behaviors, etc., etc., etc…

Physical Abuse

Sexual Abuse

Neglect

~40%

Domestic

Violence

Child

Abuse20 – 40%

Family dysfunction?

The Spectrum of Maltreatment

Physical Child Abuse

Sexual Child Abuse

Emotional Abuse

Neglect

Normal Normal DevelopmentDevelopment

Costs of Intervention

AGE

$ COST

Prenatal care

Therapeutic preschool

Incarceration

Drug treatment

Remedial education

10birth 20

Costs of Intervention

AGE

$ COST

< Brain malleability

It takes a whole brain to learn:

• Cognitive (left brain)– Vocabulary– Logical reasoning

• Experiential (right brain)– Emotional awareness– Self-regulation

Fight or Flight?

Neuroendocrinology

Stress

Hypothalamic / pituitary stimulation

Adrenal cortisol release

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

The Brain: Targets of Stress

• Cerebral cortex– EEG changes– smaller callosum

• Limbic system– neuronal changes– decreased size

• Brainstem/ Cerebellum– altered transmitters

Maltreated kids may have...

Symptoms of “stress response”:• Irritability

• Hyperarousal

• Dysregulation of affect

AKA: “Behavior problems”

Attachment

• “Intimate attachments to other human beings are the hub around which a person’s life

revolves.”- John Bowlby

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.”

Overview of attachment theory

Evolutionary advantage:

• A secure child can explore!

Goals of Development(after Von Horn)

• Attachment

• Regulation

• Cognition

Maltreated kids may have...

Attachment problems:• Persistent fear/alert state • Poor differentiation of affect• Dysregulation of affect

…and thus may avoid intimacy

Presentations

• Depression

• Anger control problems

• ODD

• ADHD

• Cognitive delays, school failure

• Drug/alcohol abuse

• Risk-taking behaviors, etc., etc., etc…

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

Conclusions

• Impact of trauma depends on:

• Trauma factors

• Family and environmental factors

• Child factors

Emotional Chain of Custody

Event(s)

Child Protection

Law Enforcement

Medical

Juvenile/FamilyCourt

Criminal Court

Substitute Care

New Schools

Mental Health

RECOVERY

Family

System InfluenceOffender Contact

Fire Fighers/ EMT

CPSAtty

GAL

DA Victim

Witness

Payor

School

Cultural Context

Community Context

Life Context

Family

Child Resilence Building

Parole / Prison

Experience shapes response to future trauma

Faith Community

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

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Child Abuse is BigChild Abuse is Bad

So what do we do about it?

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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?

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Bringing Systems Together

Summer of 1977

“Why don’t you big people talk to one another?”

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Systems in SilosParallel Investigations

Joint Investigation

TEAMWORK

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Spring of 1984

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

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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

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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

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Written Agreement Investigative 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

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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.

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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.

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Child Victim Witness Protocol Goals (Continued)

• Increase the effectiveness of the investigative and protective process.

• Prevent abuse to other children.• Facilitate the child’s access to

needed services such as medical treatment and trauma counseling.

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San DiegoCommunity Partners

• Health and Human Services Agency:– Child Welfare Services (CWS)

• Law Enforcement • District Attorney • County Counsel• Medical • Hospital based Children’s Advocacy

Centers• Trauma Mental Health Treatment • Kids in Court • Schools

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What Are The Questions You Need Answered?

• Was This Child Abused?

• Can We Determine By Whom?

• What Must We Do To Protect This Child or Others?

• Can/Should We Hold The Abuser Accountable in the Court System?

• Do We Have the Evidence To Support our Conclusions?

• How Can We Help The Child And Family Heal?

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INVESTIGATIVE PROTOCOL

What cases will be referred to the team?• Sexual abuse/physical abuse/neglect/violence?

• Who is going to be involved?

• What roles will they play?

• How will they coordinate their actions?

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INVESTIGATIVE PROTOCOL

• Receiving the report

• Notification of team members

• Investigative planning

• Order of investigative steps

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PRE-INVESTIGATIVE DECISIONS

• Where and by whom will children be interviewed?

• How will the interviews be documented?

• Where will the person suspected of the maltreatment be interviewed?

• What tools will the team used?

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INVESTIGATIVE STEPS

• Interviewing the child/children

• Interviewing other witnesses

• Medical examinations

• Crime scene

• Forensic evaluation

• Interviewing suspects

• On-going decision-making

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Issues With Protocols

• ARE THEY A FICTION?

• ARE THEY A PART TIME THING?

• ARE WE TRAINED TO FOLLOW THE PROTOCOL?

• HOW ARE NEW TEAM MEMBERS INTRODUCED TO THE PROTOCAL?

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What’s a CAC?

• CAC’s are not just a team – It’s a place– Child Friendly– Complete Separation of Offenders and

Victims– Capacity for Team to Observe the Interview

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Other Essential Components

• Organization Capacity - Governance– Embedded within Government Agency– Part of Existing Nongovernmental Agency– Hospital Based– New Nongovernmental Agency

• Cultural Competency and Diversity– Cultural Competence– Language

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Other Essential Components

• Forensic Interviews– Protocol Driven (Training)

– Neutral, Legally Sound, and Developmentally Appropriate

– Observable

– Include all team members who need the information

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Other Essential Components

• Medical

• Therapeutic– Available on site or through Referral– Regardless of ability to pay– Included protocol– Evidence Based Practice?

• Victim Advocacy– Included in the protocol– Crisis intervention available– Education

• KTIC

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Obtaining Trauma Informed Therapy

• Evidence Based Practices:

– Built upon a strong therapeutic relationship – Affect expression and regulation skills– Anxiety management– Relaxation skills– Cognitive processing/reframing– Construction of a coherent trauma narrative– Strategies that allow exposure to traumatic memories

and feelings in tolerable doses so that they can be mastered and integrated into the child’s experience

– Personal safety/empowerment activities– Resiliency and closure

Make sure that any individual/agency who provides therapy conducts a comprehensive trauma assessment

Seek out clinicians who know and use evidenced-based treatment models

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Case Review

• Regularly Scheduled

• Coordination

• Facilitation

• What Cases?

• Timing?

• Location?

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Team Meetings/Case Staffings

What are the goals of the meeting?• Coordinate investigation vs “meddle” in

another agency’s business;• Report what has been done vs satisfy

curiosity;• Problem solve vs. complain;• Share accountability vs. blame;• Evaluate system/s response and

effectiveness in each specific case

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Optional components:

• Intimate partner violence (domestic violence)

– Family Justice Centers

• Prevention

• Advocacy

• Public Education/Awareness

• Professional Education

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What Can We apply from the CAC model in WA?

• Team Vs Joint Investigation?

• Common Mission

• Teamwork

• Sharing Information and Coordinating Tasks

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Teamwork

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WHAT DO GOOD TEAMS HAVE IN COMMON?

• Think about a successful sports team, a work place team, or the deck crew of the Starship ENTERPRISE.

• What distinguishes them from a mere group of people?

• What makes one team more successful than another?

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DEFINITION OF A TEAM

A group of people who are necessary to accomplish a task that requires the continuous integration of the expertise (along with resources and authority) distributed among them.

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SUCESSFUL TEAMS HAVE

• TEAM INDENTITY

• INTERDEPENDENCE

• TRUST

• TASK SKILLS

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TO SUCCEED TEAMS MUST HAVE:

• Task Expertise

• Team members must possess the ability to integrate their different skills, expertise, and roles

• Team members must be willing to work together in a more complex system

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Create a Team Culture

Cultured is Often Defined By:• Shared experience (often historical)• Traditions• Values and belief system• The meaning of behavior• Language• Dress• Food

“Culture consists of those things you know, and that everybody else like you knows.”

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Teaming “On The Fly” in the Real World

Lessons from the Cockpit

Who’s Your “Team”?

• Gather key contact information from:– Law enforcement investigator– Child protective service worker– Prosecutor (when assigned)– Child abuse doctor– Hospital social worker

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Key Questions as the Investigation Unfolds

• Anticipate the friction points – What law or policy requirements that may impact other disciplines in WA?

• Agree on initial Investigative Plan:– Who will lead each interview? Who will be present?– Who will interview medical staff?– Who will interview family members present at the

hospital?– What are the acceptable time lines for investigative

tasks being completed?

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Initial Teaming “On The Fly”

• Brief one another on investigative actions taken or planned – peer to peer;

• Need to be in 2 places at once– Dispatch someone to the home or crime scene to

protect other children or secure the scene?

• Who else needs to be interviewed?• Set a time for further briefing/updating before

separating

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Investigative Questions To Include in Initial Briefing

• Nature of injuries• Potential Suspects (plural)

1. Name(s)2. Relationship to victim3. Current location4. Has been interviewed? (yes/no)5. Should restrictions be placed on their contact with child?

• Other Children at Risk?1. Names2. Location(s)3. Relationship to victim

• Location of Possible Crime Scenes: Is the scene secure? (yes/no)

• Known CPS & Criminal History of Principals

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Interview of Medical Providers

Questions: What are the injuries? What is the preliminary

diagnosis? What history was given? By whom? Has the hx changed? Is the child verbal? What did the child say? Was treatment sought timely/ appropriately? To what degree is the diagnosis based upon the

stated history? Did anyone make any relevant statements at the

hospital?

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Medical Provider (Con’t)

Does the hx explain the injuries? If not, what are the likely causes?

Are there other reasonable accidental or medical explanations for the condition?

Time frame for when the injuries occurred? What type symptoms would a child with these

injuries display following event? What additional information is needed to complete

the diagnosis? What is the child’s prognosis?

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Case Scenario 11

MAMA DON’T KNOW

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Referral

• Hotline call at 3:15 pm from Amy Lynn, BCMC Social Worker. Ms. Lynn reported that Mary White, 6 months old, is being treated in the ED for a major head injury. The injuries are life endangering; there is a history of a fall, but some physicians feel they may have been inflicted. The child’s prognosis is grave.

• The mother, Tammy White, cannot explain the injury, stating she was at work when “it happened.” The child was in the care of Ms. White’s boyfriend, Thomas Gordon. The mother told Ms. Lynn she has another child, Charles, age 5, who is home in the care of her mother (Mary’s grandmother) and Mr. Gordon.

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Referral

• Hotline call at 3:15 pm from Amy Lynn, BCMC Social Worker. Ms. Lynn reported that Mary White, 6 months old, is being treated in the ED for a major head injury. The injuries are life endangering; there is a history of a fall, but some physicians feel they may have been inflicted. The child’s prognosis is grave.

• The mother, Tammy White, cannot explain the injury, stating she was at work when “it happened.” The child was in the care of Ms. White’s boyfriend, Thomas Gordon. The mother told Ms. Lynn she has another child, Charles, age 5, who is home in the care of her mother (Mary’s grandmother) and Mr. Gordon.

Medical Record

• 3mo WF adm BIBA to ED w/GCS 5. OSH MRI > SDH s fx. Hx fall, R/O NAT… (remainder illegible)

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Medical Record

• Mary White, a 6mo old female baby is brought by ambulance to the Emergency Department at Big City Medical Center at1425, pale and unresponsive, actively seizing. Initial workup shows no bruising, some swelling of left leg.

• Mother accompanies child, says he was found unresponsive and “gasping for air” after a nap. Her boyfriend, who had been caring for the baby, told her he had fallen out of their bed earlier in the morning, had cried and gone back to sleep.

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Medical Record

• CT scan showed subdural “blood of different densities, suggestive of prior trauma” over the cortex; leg Xray revealed metaphyseal corner fracture of proximal tibia.

• Seizures were medicated, fracture splinted, and child appeared stable medically.

• Admitting diagnosis: Head trauma post fall; R/O NAT (rule out non-accidental trauma).

• Is this reasonable? Why?• Further workup? • Retinal hemorrhages and two healing rib fractures were

seen, as were elevated liver enzymes.

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Presentation

• Mary White, a 6mo old female baby is brought by ambulance to the Emergency Department at Big City Medical Center at 1425, pale and unresponsive, actively seizing. Initial workup shows no bruising, some swelling of left leg.

• Mother accompanies child, says he was found unresponsive and “gasping for air” after a nap. Her boyfriend, who had been caring for the baby, told her he had fallen out of their bed earlier in the morning, had cried and gone back to sleep.

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Presentation

• CT scan showed subdural “blood of different densities, suggestive of prior trauma” over the cortex; leg Xray revealed metaphyseal corner fracture of proximal tibia.

• Seizures were medicated, fracture splinted, and child appeared stable medically.

• Admitting diagnosis: Head trauma post fall; R/O NAT (rule out non-accidental trauma).

• Is this reasonable? Why?• Further workup? • Retinal hemorrhages and two healing rib fractures were

seen, as were elevated liver enzymes.

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Background Check:CWS/CMS

• No record is found for child Mary White.• Charles White was reported as being born with a

positive toxicology (cocaine). Services were provided to Ms. White and after 8 months case was closed.

• No other referrals on Ms. White.• No referrals on Mr. Gordon.

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Background Check: Law Enforcement

• No report on Ms. White.• Three calls to the home address in the past 8

months for loud noise, possible domestic violence (Ms. White not at home while officer was present), public drunk. No arrest made although Mr. Gordon was cited for noise violation. Mr. Gordon is a musician and his band was practicing at 10:00 pm and disturbing the neighbors.

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Hospital Interview: Ms. Lynn, SW

• The child, Mary, was brought to the BCMC ED by ambulance at 2:25 pm, accompanied by her biological mother, Tammy, who is described as highly agitated and defensive.

• The mother told Ms. Lynn the baby was fine when she went to her 6 am shift and was asleep when she came home at about 12:30 pm. She did not realize anything was wrong until her mother came by and went into to check the baby’s diaper.

• Ms. White has another child, 5 year old Charles, who is at home with Tammy’s mother and her boyfriend, Thomas Gordon.

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Hospital Interview: Tammy White

• Ms. White is interviewed in the chapel of the hospital. She explains that Mary was fine when she left for work at 5:30 am this morning. She walks to work. When asked how she knew Mary was “fine” she said Mary was awake and she fed her her without incident and “put her back down.”

• She came back home at 12:30 and found her boyfriend, Tommy, asleep in their bed. She checked on the baby in her crib. The room was dark and Mary appeared to be asleep. She did not want to wake her.

• She looked for Charles and did not find him and assumed he was playing at his friend Jimmy’s down the hall. She does not know Jimmy’s last name but he lives with his aunt in #11B.

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Hospital Interview: Tammy White

• She took a shower and was drying off when her mother, Alice, showed up. She let her in and when she went back to the bedroom Tommy was awake. After a few minutes she heard her mother calling loudly and ran to the kids’ room where her mother was now screaming that the baby was not breathing and to call an ambulance.

• Tammy grabbed her cell phone and called 911. Tommy tried CPR, “Like you see on TV.”

• When the paramedics arrived, Tommy told them that the baby had fallen earlier.

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Scene Interview: Thomas Gordon

• Gordon appeared haggard, and expressed concern for Mary’s health. He tearfully described how the baby had been sleeping next to him in the bed when he was awakened around 1130 by a sound and found her crying on the floor. He then put Mary in her crib and went back to sleep himself until Tammy’s return.

• When told of the other injuries, he did suggest he “might have been rough” with her when he was trying to get the baby to wake up before the ambulance came and also suggested the EMT’s were pretty rough.

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Interview: Thomas Gordon

• When told the injuries were far greater than could be explained by “roughness” in waking the baby up, he suggested maybe someone snuck in the house or Tammy might have “lost it” before she went to work. He offered that Tammy had been in a foul mood the night before and was swearing under her breath when she got up this morning around 5.

• He insisted the baby was quiet all morning and he thought she was asleep.

• Other useful scene information?• Bed height 17inches, carpeted floor, house filthy.

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Interview: Paramedic

• Kumar Jafee, the Emergency Medical Technician who responded to the 911 call, described finding the child on the living room couch, receiving ineffectual chest massage from Mr. Gordon, who attempted to leave immediately thereafter.

• The fall history was only obtained in response to the EMT’s questioning. The home appeared to be in general disarray; a soiled diaper was observed on the parents’ bed.

Hospital Interview:attending physician

• Dr. Harold Waggoner, intensive care specialist, states that in his opinion and experience, mother’s story of a fall “two or three feet” from the bed to a hard surface could account for the head injury and the acute leg fracture.

• He feels the older subdural implies a previous injury that may have rendered Mary more susceptible to injury and bleeding.

• He ascribes the rib fractures to birth trauma.

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Hospital Interview:child abuse consultant

• Dr. Susan Belknap, a child abuse consultant at BCMC, explains that the constellation of SDH, RH, and associated fractures could not have been produced by a short fall. She diagnoses abusive head trauma (Shaken Baby Syndrome).

• Though the rib fractures speak to earlier trauma, the SDH could be “hyperacute.”

• Symptoms would be expected to appear immediately, she says.

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Scene Interview: Charles White

• Charles was interviewed in the living room of the apartment. He appeared frightened and was unresponsive. He kept looking in the direction of the kitchen where Gordon was being questioned. His grandmother Alice is present and is encouraging him to talk.

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Scene Interview: Charles White (2)

• When taken outside the apartment to the playground area, in response to questions, Charles says Tommy is mean and hits his mom and him and he (Charles) doesn’t like him.

• He says he was watching TV when Tito came over and Tommy told him to go outside and play.

• Tito is Tommy’s friend.

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Forensic Interview: Charles White

Summary:• Charles tells the interviewer that Tommy is mean and

hits his mom and he (Charles) doesn’t like him. When asked about being “hit”, Charles said Tommy hits his head and on the face and sometimes on the back or arms. He offered Tommy made his lip bleed “real bad.”

• When asked if his mom hits him he said sometimes when she is “mad or drunk.” When asked how often his mom hits, he says not as much as Tommy. When asked where on his body she hits, he says mostly on his butt or arms.

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Forensic Interview: Charles White

Summary:• As for the injury to Mary, he tells he was watching TV

when Tito came over. Tito is Tommy’s friend. He was watching Power Rangers on TV (airs at 9 am). He said Mary was crying a lot and Tommy was “acting mean.” and Charles was scared.

• Tito brought some “white stuff” they put up their noses and then Tommy told Charles to go outside and play. Charles went to his friend’s. When asked if he has seen the white stuff before, Charles said, “all the time” and “Mommy and Tommy smell it a lot.”

• When asked if Tito has a last name, Charles says he doesn’t know, but Tito plays the drums.

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Interview with Grandmother, Delores Jackson

Summary: • She immediately blamed Gordon. He is a “no

account damn drug dealer” who has been violent before. She said she arrived around 1:30 to 1:45 and her daughter let her in the apartment. She said while Tammy went to get dressed she went to check Mary. The room was dark and the baby covered with a blanket. She felt the baby’s diaper and it was wet “but like it had been left on for a long time” she went to change the baby and found her limp and breathing very funny. She started to yell for Tammy to call an ambulance. She said that Tammy came in to see what the problem was and started to scream when she couldn’t get Mary to respond.

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Interview with Grandmother, Delores Jackson

• Tommy came in and said he knew what to do. He slapped the baby to get her to wake up and then pushed on her chest like in the movies.

• She said after the ambulance left she glared at Tommy who told her to “go to hell” and went in the bedroom and grabbed a backpack and then he left and came back 30 minutes later.

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Medical Screening of Charles

Summary:• The doctors note a healing cut inside his lower lip

and a chipped tooth. Also noted was bruise on his left ear. When asked how he got the bruise on his ear he said he didn’t know but Tommy hit his ear sometimes. When asked but his tooth he said he fell over a swing and then offered his mom “smacks him in the month sometimes for talking back. There are also numerous bruises on his arms and legs but Charles could not explain the origins of the bruises and the location and nature of the bruises could be explained by rough peer play.

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Interview with Neighbor Mrs. Ida Joplin

• Mrs. Ida Joplin, age 69 lives next door. She said that she has complained about the “goings on over there” for over a year. She thinks they sell drugs, as “nasty looking people are coming and going all day and night.” When asked about the day Mary was injured, she said the walls are thin and she can hear them “over there when they argue”, which she said is frequent. She remembered the baby crying before dawn and she had to get up and turn on her TV to drown out the noise.

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Interview with Neighbor Mrs. Ida Joplin

• She did not hear any thing else until mid morning when she heard a man yelling at someone and she turned down to TV to hear and see if she needed to “call the cops again.” All she heard was the baby crying and then it got quiet. She figured the baby had cried herself to sleep. When asked with time she said she was watching Dr Phil so it was between 10 and 11 AM.

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Building on the CAC concept

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Institute for Healthcare Improvement Model

Environmental Context

Organizational Context

Microsystem

Direct Contact

Social Workers, Investigators,

Therapists, Medical Professionals. Etc

And Families

Departments Within

Organizations

Organizations

Community/

Funders

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Complexity of Change in a CAC Environment

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www.chadwickcenter.org