Child Welfare: Increased Guidance and Collaboration Needed to Improve DOD's Tracking and Response to Child Abuse

GAO-20-110 Published: Feb 12, 2020. Publicly Released: Feb 12, 2020.
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Fast Facts

With more than 1.2 million school-age military dependents worldwide, the Defense Department works to prevent and respond to child abuse, including child-on-child abuse.

It’s difficult for DOD to track abuse cases from first report to final outcome because the organizations involved track different parts of the process and their databases don’t work together.

We also found that victims’ families get inconsistent information about the case response process. Some families we spoke to weren’t aware of all the resources available to them.

Our 23 recommendations include expanding DOD’s centralized database and better informing victims’ families.

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Highlights

What GAO Found

The Department of Defense (DOD) has limited visibility over reported incidents of child abuse—physical, sexual, or emotional abuse, or neglect by a caregiver—and child-on-child abuse due to standalone databases, information sharing challenges, and installation discretion. From fiscal years 2014 through 2018, the military services recorded more than 69,000 reported incidents of child abuse (see figure). However, personnel at all seven installations in GAO's review stated that they use discretion to determine which incidents to present to the Incident Determination Committee (IDC)—the installation-based committee responsible for reviewing reports and determining whether they meet DOD's criteria for abuse (an act of abuse and an actual or potential impact, e.g., spanking that left a welt). Per DOD guidance, every reported incident must be presented to the IDC unless there is no possibility that it could meet any of the criteria for abuse. However, personnel described incidents they had screened out that, per DOD guidance, should have been presented to the IDC. Without the services developing a process to monitor how incidents are screened at installations, DOD does not know the total number of reported child abuse incidents across the department.

Reported Incidents of Child Abuse (Physical, Sexual, or Emotional Abuse, or Neglect), by Department of Defense (DOD) Criteria for Abuse, Fiscal Years 2014-2018

Highlights_7_v3_103222-01

While DOD has expanded its child abuse policies and procedures to include child-on-child sexual abuse, gaps exist. For example, DOD standardized the IDC process in 2016, but the new structure does not include medical personnel with expertise, contrary to best practices for substantiating child abuse allegations. Without expanding the IDC membership to include medical personnel, members may not have all of the relevant information needed to make fully informed decisions, potentially affecting confidence in the efficacy of the committee's decisions. GAO also found that the availability of certified pediatric sexual assault forensic examiners across DOD is limited—according to DOD officials, there are only 11 in comparison to 1,448 incidents of child sexual abuse that met DOD's criteria for abuse from fiscal years 2014 through 2018. Without processes that help ensure timely access to certified pediatric examiners, child victims of sexual abuse overseas may not receive exams in time for evidence to be collected for use in prosecution, increasing the stress and trauma of affected victims.

Why GAO Did This Study

With more than 1.2 million school-age military dependents worldwide, per DOD, the department's organizations work to prevent, respond to, and resolve incidents of child abuse. Incidents of child abuse, including child-on-child abuse, can cause a range of emotional and physical trauma for military families, ultimately affecting servicemember performance.

GAO was asked to review how DOD addresses incidents of child abuse and child-on-child abuse occurring on a military installation or involving military dependents. This report examines, among other things, the extent to which DOD has (1) visibility over such reported incidents, and (2) developed and implemented policies and procedures to respond to and resolve these incidents. GAO reviewed relevant policies and guidance; interviewed officials at a nongeneralizable sample of seven military installations; analyzed program data; interviewed parents of children affected by abuse; and interviewed DOD, service, and civilian officials, including at children's advocacy centers.

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Recommendations

GAO is making 23 recommendations, including that the military services develop a process to monitor how reported incidents are screened at installations, that DOD expand the membership of the IDC to include medical personnel, and that DOD establish processes that help ensure timely access to certified pediatric examiners overseas. DOD concurred with 16, partially concurred with six, and did not concur with one of GAO's recommendations, which GAO continues to believe are valid, as discussed in the report.

Recommendations for Executive Action

Agency Affected Recommendation Status
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should expand the scope of the department's centralized database on problematic sexual behavior in children and youth, which is under development, to also track information on all incidents involving the abuse of a child (physical, sexual, emotional, and neglect) reported to the Family Advocacy Program or investigated by a military law enforcement organization, regardless of whether the offender was another child, an adult, or someone in a noncaregiving role at the time of the incident. (Recommendation 1)
Open
DOD did not concur with this recommendation. As of February 2022, DOD has not provided any information on efforts taken to address this recommendation or documentation that it has expanded the scope of the database, which is needed to fully implement this recommendation. We will continue to monitor the DOD's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should, as part of the ongoing development of the centralized database, identify and define the elements to be tracked by each responsible organization, such as the Family Advocacy Program and military law enforcement. (Recommendation 2)
Closed – Implemented
DOD concurred with this recommendation. In May 2022, DOD provided documentation that it had developed materials for users of the centralized database, such as a user guide and quick references that identify and define what information is to be tracked in the database. For example, the database collects information on incident category, a description of the behavior, whether services were offered and accepted, and whether the incident was subject to a law enforcement investigation and any associated military criminal investigative organization case number. Each of these data elements is defined in the user materials. According to DOD documentation, the database was launched on December 1, 2021 for headquarters and region service-level users. These actions meet the intent of the recommendation.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should develop a plan for how it will use the data it will collect in the centralized database to help ensure data-driven decision-making is used to inform program efforts. (Recommendation 3)
Open
DOD concurred with this recommendation. As of January 2022, DOD stated that developing a data use plan was included in the contracted statement of work for development of the database. DOD stated that it worked closely with system stakeholders to develop key metrics and anticipate reporting needs to ensure the database will support prevention, response, and other program improvement efforts. DOD stated that the data collection and use plan for ensuring data-driven decision making was used to inform program efforts. However, as of February 2022, DOD has not provided documentation of the plan and the database has not yet been implemented. In order to fully implement this recommendation, DOD will need to provide documentation of a plan for how it will use the data it will collect in the centralized database. We will continue to monitor DOD's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should establish a reliable schedule for the development and implementation of the centralized database on problematic sexual behavior in children and youth that includes key activities, the timeframes and resources needed to execute them, and GAO-identified practices for developing and maintaining a reliable schedule. (Recommendation 4)
Open
DOD concurred with this recommendation. As of January 2022, DOD stated that developing a reliable schedule for development and implementation is included in the contracted statement of work for the development of the database. However, as of February 2022, DOD has not provided documentation of the schedule and the database has not yet been implemented. In order to fully implement this recommendation, DOD will need to provide documentation of the schedule for the development and implementation of the centralized database that includes key activities, the timeframes and resources needed to execute them, and GAO-identified practices for developing and maintaining a reliable schedule. We will continue to monitor DOD's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should direct the service Family Advocacy Programs and military law enforcement organizations to document in their respective databases the date that they notified the other entity of a reported incident of child abuse. (Recommendation 5)
Open
DOD partially concurred with this recommendation. In February 2021, DOD outlined a number of steps that it planned to take to implement this recommendation by the end of calendar year 2023 since the recommendation was enacted into law through the National Defense Authorization Act for Fiscal Year 2021. DOD stated that it would issue a policy clarification memo on Family Advocacy Program (FAP) and military law enforcement notification of reported incidents of child abuse, as described in existing policy, as an interim step by the end of July 2021. As of February 2022, DOD has not provided the policy clarification memo or other updates on these efforts. In order to fully implement this recommendation, DOD will need to provide documentation that it has directed the service FAPs and military law enforcement organizations to document in their respective databases the date that they notified the other entity of a reported incident of child abuse. We will continue to monitor DOD's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should issue guidance that describes the process through which the service Family Advocacy Programs are to receive and incorporate information into their central registries regarding child abuse allegations and determinations involving their servicemembers and dependents that were recorded by another service's installation Family Advocacy Program. Such guidance should include a mechanism to monitor that the process is occurring consistently. (Recommendation 6)
Open
DOD partially concurred with this recommendation. In February 2021, DOD stated that it would reissue policy to explicitly reference the requirement that the services incorporate into their respective central registries met criteria incidents of abuse involving servicemembers and dependents recorded by another service's installation Family Advocacy Program by the end of calendar year 2021. However, as of February 2022, DOD has not provided documentation of an updated policy. DOD will need to provide documentation of the updated policy that describes the process and includes a mechanism to monitor the process, once issued, to fully implement this recommendation. We will continue to monitor DOD's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of the Army The Secretary of the Army should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 7)
Open
The Army concurred with this recommendation. In July 2021, the Army issued Army Directive 2021-26, which outlines how reported incidents of child abuse are to be screened at installations as part of the Incident Determination Committee and Clinical Case Staff Meeting processes. However, the guidance does not detail a process to monitor how reported incidents of child abuse are screened at installations. As of February 2022, the Army has not provided any additional information on its efforts to develop a monitoring process. The Army will need to provide documentation that outlines a monitoring process, once established, to fully implement this recommendation. We will continue to monitor the Army's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of the Navy The Secretary of the Navy should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 8)
Closed – Implemented
The Navy concurred with this recommendation. In response to this recommendation, the Navy developed a tiered review process to help ensure consistency, standardization, and sustainability of installation screening decisions . According to Navy documentation, on a monthly basis, regional FAP offices will review all reported incidents of child abuse and domestic abuse that were screened out and were not presented to the IDC for documentation sufficiency and internal consistency in case decisions. The regional offices are responsible for providing feedback to installations, identifying notable trends to inform future training needs, and re-opening reported incidents if necessary. On a quarterly basis, Commander, Navy Installations Command will request feedback from the regional offices on their compliance reviews using a standard template. The template requests information about the number of cases reviewed for compliance, the number identified for corrective action, and the reasons cases needed corrective action. Commander, Navy Installations Command instituted the quarterly review process in April 2022. This monitoring process meets the intent of our recommendation.
Office of the Secretary of the Navy The Secretary of the Navy should ensure that the Commandant of the Marine Corps develops a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 9)
Open
The Navy concurred with this recommendation. In April 2021, the Marine Corps issued Marine Corps Order 1754.11A, which outlines how reported incidents of child abuse are screened at installations. However, it does not include a process for how those screening decisions will be monitored. As of February 2022, the Marine Corps has not provided additional updates. To fully implement this recommendation, the Marine Corps will need to provide documentation that it has established a process to monitor how reported incidents of child abuse are screened at installations. We will continue to monitor the Marine Corps' efforts to address this recommendation and will update its status as more information becomes available.,
Office of the Secretary of the Air Force The Secretary of the Air Force should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 10)
Open
The Air Force concurred with this recommendation. As of January 2022, the Air Force stated that it had issued guidance describing how all reported child abuse incidents are to be monitored and screened. In addition, the Air Force stated that it was in the process of developing a new position for assessing compliance with DOD and Air Force policy. The Air Force also estimated establishing a schedule for virtual reviews and site visits of installation Family Advocacy Program offices by the end of February 2022. However, as of February 2022, the Air Force has not provided any additional updates. The Air Force will need to provide documentation of these planned actions, once complete, to fully implement this recommendation. We will continue to monitor the Air Force's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of Defense The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of the Department of Defense Education Activity, clarifies Department of Defense Education Activity guidance to define what types of incidents must be reported as "serious incidents" to help ensure that all serious incidents of which Department of Defense Education Activity leadership needs to be informed are accurately and consistently reported by school administrators. (Recommendation 11)
Closed – Implemented
DOD concurred with this recommendation. In July 2021, the Department of Defense Education Activity (DODEA) issued additional guidance defining the types of incidents that must be reported as serious incidents. Specifically, it updated DODEA Administrative Instruction 1347-01 "Student Disciplinary Rules and Procedures" and DODEA Administrative Instruction 3030-01 "Director Critical Information Requirements and Serious Incident Reports." The guidance standardizes the reporting criteria of each reportable incident, streamlines notification of serious incidents directly to leadership, and requires reporting of serious incidents by school administrators. These actions meet the intent of our recommendation.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should expand the voting membership of the Incident Determination Committee to include medical personnel with the requisite knowledge and experience. (Recommendation 12)
Closed – Implemented
DOD partially concurred with this recommendation. In July 2021, DOD updated DOD Manual 6400.01, Vol. 3 "Family Advocacy Program: Clinical Case Staff Meeting and Incident Determination Committee" to include as a core voting member of the Incident Determination Committee (IDC), a designated health care provider. Specifically, the healthcare provider is to be from or via the forensic healthcare program of the installation military medical treatment facility or another military medical treatment facility supporting the installation, with the requisite medical training and expertise to offer a medical opinion on domestic abuse, child abuse, and neglect-related injuries. Per the policy, all health care providers designated as core members are to complete the requisite training on the IDC process and procedures before their participation. These actions meet the intent of our recommendation.
Office of the Secretary of the Army The Secretary of the Army should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 13)
Open
The Army concurred with this recommendation. The Army stated that it was developing an Army Family Web Portal to provide comprehensive information related to Family Advocacy, law enforcement, and resources for families in order to synchronize information across commands and installations to ensure accuracy. The Army estimated it would complete the portal by January 2022. However, as of February 2022, the Army has not provided information on the status of this effort. The Army will need to provide documentation of these planned actions, once complete, to fully implement this recommendation. We will continue to monitor the Army's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of the Navy The Secretary of the Navy should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 14)
Closed – Implemented
The Navy concurred with this recommendation. In March 2021, the Navy created a guide entitled "Prevention and Response to Child Abuse and Neglect in the Navy" that discusses what happens after the Navy Family Advocacy Program (FAP) receives a referral for child abuse or neglect, such as notifications to local Child Protective Services, law enforcement, and the command, as required, if the referral meets certain screening criteria. The guide also discusses FAP support and resources as well as available referrals, such as to Child Advocacy Centers, military and civilian legal offices, and the Transitional Compensation Program.
Office of the Secretary of the Navy The Secretary of the Navy should ensure that the Commandant of the Marine Corps establishes efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 15)
Open
The Navy partially concurred with this recommendation. As of February 2021, the Marine Corps stated that its existing guidance provides for a victim advocate to be assigned to the non-offending parent of a victim of child abuse who requests services. However, as discussed in the report, parents we spoke with indicated that they were not aware of all available services and resources offered by the military, and that a comprehensive guide outlining the process would have helped them understand what was going to happen. As of February 2022, the Marine Corps has not provided any additional updates. To fully implement this recommendation, the Marine Corps will need to provide documentation that it has established efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following a report. We will continue to monitor the Marine Corps' efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of the Air Force The Secretary of the Air Force should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 16)
Closed – Implemented
The Air Force concurred with this recommendation. In February 2021, the Air Force created a guide entitled "Understanding the Family Advocacy Program (FAP) Process for Child Maltreatment Allegations" that discusses what happens after a report of child maltreatment, what happens if military or civilian law enforcement is involved, and how the FAP can help once the child is safe. The guide also discusses available services and the Incident Determination Committee process. The Air Force stated that the guide has been disseminated to all Air Force installations.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Secretaries of the military departments, should clarify, in guidance, the circumstances under which commanders may exercise their authority to remove a child from a potentially unsafe home on an overseas installation. (Recommendation 17)
Open
DOD concurred with this recommendation. In February 2021, DOD stated that it planned to identify and address gaps in guidance at overseas locations by September 2021. However, as of February 2022, DOD has not provided documentation that gaps have been identified and addressed. To fully implement this recommendation, DOD will need to provide documentation of guidance, once issued, that clarifies the circumstances under which commanders may exercise their authority to remove a child from a potentially unsafe home on an overseas installation. We will continue to monitor DOD's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of Defense The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of the Defense Health Agency, establishes processes that help ensure children who are sexually abused overseas have timely access to a certified pediatric sexual assault forensic examiner to conduct the examination. Initiatives could include certifying pediatricians or adult sexual assault forensic examiners as pediatric examiners during mandatory training or establishing shared regional assets. (Recommendation 18)
Open
DOD concurred with this recommendation. In February 2021, DOD stated that the Defense Health Agency was planning to develop and implement a Forensic Healthcare Examiner-Pediatric addendum course to train eligible healthcare providers to perform acute child sexual abuse medical forensic exams by October 2022. DOD also stated that it planned for each 24/7 emergency room military medical treatment facility outside the continental United States to have a minimum of one trained and certified pediatric examiner or access to telemedicine with a certified Child Abuse Pediatrician by October 2022. As of February 2022, DOD has not provided any additional updates. DOD will need to provide documentation of these planned actions, once complete, to fully implement this recommendation. We will continue to monitor DOD's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of Defense The Secretary of Defense, in collaboration with the Deputy Attorney General, should seek avenues to improve communication between the military criminal investigative organizations and United States Attorneys for relevant cases involving child victims to help ensure that investigators are notified when prosecution is declined, including the reasons for the declination when appropriate, such as details about any investigative deficiencies. (Recommendation 19)
Open
DOD concurred with this recommendation. In February 2021, DOD stated that a Department of Justice/DOD working group had created a draft electronic form to be used cross-organizationally by United States Attorneys and the military criminal investigative organizations. According to DOD, the form will provide details on juvenile-on-juvenile sexual assault cases to indicate whether prosecution was accepted or declined and, if declined, the date and reason for the declination. DOD stated that the form would be shared with the appropriate military criminal investigative organization and that the information would be retained by both the Department of Justice and DOD. As of January 2022, DOD estimated that the form would be executed through policy or procedural guidance by the end of June 2022. DOD will need to provide documentation of the form and policy, once complete, and the process that both organizations will follow to fully implement this recommendation.
Office of the Secretary of the Army The Secretary of the Army should seek to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Army installations and thereby increase awareness of those services across the department. (Recommendation 20)
Open
The Army partially concurred with this recommendation. The Army stated that it had completed a draft memorandum of understanding with the National Children's Alliance and that it was undergoing a legal review. The Army estimated finalizing the memorandum of understanding by December 2021. As of February 2022, the Army has not provided any additional updates. The Army will need to provide documentation of a memorandum of understanding with the National Children's Alliance, once complete, to fully implement this recommendation. We will continue to monitor the Army's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of the Navy The Secretary of the Navy should continue to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Navy installations and thereby increase awareness of those services across the department. (Recommendation 21)
Open
The Navy partially concurred with this recommendation. The Navy stated that it had completed a draft memorandum of understanding with the National Children's Alliance and that it was undergoing review by the Navy's Office of General Counsel. The Navy estimated finalizing the memorandum of understanding by the end of October 2021. As of February 2022, the Navy has not provided documentation to show that the memorandum of understanding has been established, which is needed to fully implement this recommendation. We will continue to monitor the Navy's efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of the Navy The Secretary of the Navy should ensure that the Commandant of the Marine Corps continues to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Marine Corps installations and thereby increase awareness of those services across the service. (Recommendation 22)
Open
The Navy concurred with this recommendation. The Marine Corps stated that it was working with the National Children's Alliance to develop a memorandum of understanding and that it estimated finalizing it by the end of December 2021. As of February 2022, the Marine Corps has not provided documentation to show that the memorandum of understanding has been established, which is needed to fully implement this recommendation. We will continue to monitor the Marine Corps' efforts to address this recommendation and will update its status as more information becomes available.
Office of the Secretary of the Air Force The Secretary of the Air Force should seek to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Air Force installations and thereby increase awareness of those services across the department. (Recommendation 23)
Open
The Air Force concurred with this recommendation. As of April 2021, the Air Force stated that DoD Manual 6025.18 only permits the disclosure of child abuse physical health information to public health authorities, government authorities, and law enforcement. The Air Force stated that it was exploring ways with the National Children's Alliance to overcome this barrier and had set a completion date of September 2021. However, as of February 2022, the Air Force has not provided an update on the status of these efforts. To fully implement this recommendation, the Air Force will need to provide documentation of a memorandum of understanding with the National Children's Alliance. We will continue to monitor the Air Force's efforts to address this recommendation and will update its status as more information becomes available.

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