Children's Advocacy Centers

The first Children's Advocacy Center (CAC) was established in the mid-1980s in Huntsville, Alabama, by then-District Attorney Robert E. (Bud) Cramer Jr. (Elmquist et al., 2015; Faller and Palusci, 2007; Cramer, 2005; OJP, 2020). Its primary goal was to increase the number of successful criminal prosecutions in child sexual abuse cases, and a second goal was to conduct investigations in a more child-friendly manner (Elmquist et al., 2015). At the time, it was customary for child abuse victims to undergo multiple intrusive interviews and repeated questioning in medical settings, social services offices, and police stations (Wolfteich and Loggins, 2007; Elmquist et al., 2015; Faller and Palusci, 2007). Many child victims experienced the process and the surroundings as intimidating, impersonal, redundant, and frightening (Faller and Palusci, 2007; Cross et al., 2007). The first CAC provided a warm, friendly environment where children could be interviewed just once; various professionals (such as the police officer, prosecutor, and child protection worker) observed through a one-way mirror and then met to decide on next steps (Faller, 2015; Faller and Palusci, 2007). A third goal was to help reduce the time families spent in the child protection system and increase the timeliness of service referrals (Wolfteich and Loggins, 2007).

After serving as district attorney for 9 years, Cramer was elected to the 102nd Congress (1991–1992) and to the eight succeeding Congresses (congress.gov, n.d.a). During his tenure, he developed and strengthened congressional support for the first CAC (now called the National Children's Advocacy Center) and for the National Children’s Alliance, a nationwide coalition of CACs (Cramer, 2005; OJP, 2020). On April 1, 1992, he introduced H.R. 4729—The National Children’s Advocacy Program Act of 1992 (congress.gov, n.d.b). The majority of the language in this bill was later incorporated into Sec. 6 ("Children’s Advocacy Program") of P.L. 102–586, An Act To Amend the Juvenile Justice and Delinquency Prevention Act of 1974 To Authorize Appropriations for Fiscal Years 1993, 1994, 1995, and 1996, and for Other Purposes (34 U.S.C. §20303, et seq.). Sec. 6 amends the Victims of Child Abuse Act of 1990 (42 U.S.C. §13001, et seq.), thereby providing federal funding for regional and local CACs (Faller and Palusci, 2007; NCA, n.d.a; RCAC, 2024). Eventually, the scope of CACs was expanded to include not only sexual and physical abuse, but also neglect and other maltreatment (Jackson, 2004; Krushas et al., 2023; Walsh et al., 2003).

Today, the CAC is the predominant multidisciplinary model for responding to child sexual abuse in the United States (Westphaln et al., 2021). In 2023, CACs in the United States provided medical treatment/exams for more than 91,000 children, counseling therapy for more than 116,000 children, referrals to counseling therapy for nearly 115,000 children, onsite forensic interviewing for nearly 260,000 children, and offsite interviewing for more than 7,000 children (NCA, 2024a). Additionally, in 2023 more than 1,448,000 children and 447,000 adults received prevention services from CACs.

As of 2024, a total of 961 CACs were assisting communities in all 50 states and the District of Columbia, guided by the National Children's Alliance (NCA), which accredits qualified CACs (NCA, 2024b). The NCA helps communities respond comprehensively to child abuse victims by offering a variety of specialized services to CACs, multidisciplinary teams, and practitioners (Hornor, 2008). As of June 2024, 72 percent of U.S. counties had formal access to an NCA-member CAC (NCA, n.d.b). Also, the CAC model is used in more than 34 countries (OJP, 2020), and there has been research conducted internationally (e.g., Cook et al., 2022; Ernberg, Magnusson, and Landström, 2020; Göransson et al., 2022; Tener, Tarshish, and Turgeman, 2020). This literature review focuses on research studies conducted with U.S. samples.

Children's Advocacy Centers (CACs) coordinate the investigation, treatment, and prosecution of child abuse cases carried out by multidisciplinary teams of professionals in law enforcement and prosecution, child protective services (CPS), victim advocacy services, and medical and mental health services (NCA, n.d.a; OJJDP, 2022). CACs seek to effectively respond to, investigate, and prosecute child maltreatment cases; reduce the stress experienced by child victims and nonoffending family members during the investigation process; and guarantee that services are provided to all child victims in a timely manner (Elmquist et al., 2015; Wolfteich and Loggins, 2007).

CACs are required to have the following features (OJJDP, n.d.):

• Child-appropriate facility.
• Multidisciplinary team.
• Designated legal entity responsible for program and fiscal operations.
• Forensic interviews conducted in an objective, nonduplicative manner.
• Medical evaluation and treatment.
• Therapeutic intervention.
• Victim support/advocacy.
• Case review and tracking.

The National Children's Alliance (NCA) has formulated CAC standards that address 10 elements: 1) multidisciplinary team; 2) access to services; 3) forensic interview; 4) victim support and advocacy; 5) medical evaluation; 6) mental health; 7) case review and coordination; 8) case tracking; 9) organizational capacity; and 10) child safety and protection (NCA, 2023a; NCA, 2023c). This section summarizes some of the research literature on CACs related to multidisciplinary teams, forensic interviews, medical evaluations, and mental health services provision.

Multidisciplinary Teams

One of the CAC model's defining features is the multidisciplinary team (MDT) [Herbert and Bromfield, 2019; Westphaln et al., 2022]. An MDT is a group of professionals from specific and distinct disciplines who collaborate with each other throughout a child's involvement with the CAC. The MDT's purpose is to coordinate investigations and service delivery, and much of this work is accomplished through case review meetings. MDTs seek to maintain open lines of communication and transparency; foster trust; mitigate potential trauma to children and families; and ensure an overall response of the highest quality, while preserving and respecting both the clients' rights and each agency's mandates and obligations (Cross, Whitcomb, and Maran, 2022; NCA, 2023a).

According to NCA standards, an MDT should include representation from law enforcement, CPS, prosecution, medical services, mental health services, victim advocacy, and the CAC (NCA, 2023a). Several evaluations have measured participation in MDTs by practitioner type. A survey of CACs in the United States found that case review meetings are routinely attended by CPS workers (98 percent in responding communities), law enforcement (96 percent), forensic interviewers (95 percent), victim/witness advocates (95 percent), prosecutors (94 percent), mental health professionals (90 percent), and medical professionals (79 percent) [Herbert, Walsh, and Bromfield, 2018]. In some communities, regular attendees also include juvenile court representatives, domestic violence counselors/advocates, and rape crisis counselors/advocates (Herbert, Walsh, and Bromfield, 2018; Westphaln et al., 2022).

Studies have found that law enforcement is more likely to be involved in CAC cases than non-CAC cases (e.g., Cross et al., 2007; Cross et al., 2008; Smith, Witte, and Fricker-Elhai, 2006). For example, a study of 76 cases of child abuse in a mid-south rural county found that in the CACs, local law enforcement investigated 71 percent of the cases (either exclusively or jointly with CPS), compared with 33 percent of the cases in communities without CACs (Smith, Witte, and Fricker-Elhai, 2006).

A large, multisite study funded by the Office of Juvenile Justice and Delinquency Prevention (OJJDP) found that CACs were more likely to have joint police-CPS investigations than communities without CACs (81 percent of CACs versus 52 percent of comparison cases) [Cross et al., 2007]. This study, called the Multisite Evaluation of Children's Advocacy Centers, examined four CACs in Dallas, Texas; Charleston, South Carolina; Huntsville, Alabama; and Pittsburgh, Pennsylvania. When data collection began, each CAC had operated for at least 15 years, and all had specialized forensic child interviewers and MDTs. The researchers collected data from more than 1,400 cases across the four research sites, including both CAC cases and comparison cases (Cross et al., 2007; Cross et al., 2008; Walsh et al., 2007).

There has been some research on the effective functioning of MDTs (e.g., Buchan, 2019; Newman, Dannenfelser, and Pendleton, 2005; Westphaln et al., 2022). A qualitative evaluation used semi-structured interviews with members of an MDT at a midwestern CAC to examine factors that fostered and hindered teamwork (Westphaln et al., 2022). The researchers found that teamwork was promoted by commitment, openness, clear communication, responsiveness, and appropriate resources. Challenges to effective teamwork included the following: role confusion and ambiguity, conflicting perspectives, poor communication, inadequate staffing, complex politics (which referred to challenges involving inter- or intra-agency relationships), and structural barriers. The authors noted that their findings emphasized to a much greater extent the agency-level challenges of complex politics and structural barriers, compared with literature on the effective functioning of other types of child protection teams.

Another area of research addresses the well-being of MDT members (e.g., Beer et al., 2023; Bonach and Heckert, 2012; Letson et al., 2020; Scanlon, 2024). A study of 885 professionals working in MDTs determined that respondents had higher-than-average levels of burnout and very high levels of secondary traumatic stress (Letson et al., 2020). Additionally, the study found that child welfare professionals had higher burnout scores than professionals in many of the other roles. When asked to identify positive aspects of their jobs, respondents cited the following: making a difference in the community, having satisfaction and pride in their work, opportunities to collaborate and network, and increasing their expertise and knowledge. Respondents included medical professionals, forensic interviewers, victim advocates, administrators, child welfare workers, law enforcement, prosecutors, and mental health therapists from CAC settings across the United States. Overall, participants indicated that their roles were both rewarding and challenging.

A study examining secondary traumatic stress among 257 CAC forensic interviewers found that the respondents had "mild" levels of secondary traumatic stress. The authors found that internal job support, external social support, and external job support each helped to mitigate secondary traumatic stress (Bonach and Heckert, 2012). Internal job support included perceptions of support from professionals, colleagues, supervisors, and administrators; compliments about work; and having others to confide in at work. External job support included perceptions of support from clients and the public. External social support included perceptions of support from family and friends and having others to confide in outside of work.

Forensic Interviews

The purpose of forensic interviews is to gather information from children, following allegations of child abuse, to determine whether abuse occurred and, if it did, the nature of the allegations. The NCA standards for forensic interviews require that a CAC coordinate the work of multiple professionals working on the same case, provide child-friendly interviewing locations, limit redundant interviewing, and use an evidence-supported protocol (Cross et al., 2007; Cruz et al., 2020; NCA, 2023a; Vieth, 2020). The child tells their story once to a trained interviewer who knows the right questions to ask. Then, based on the interview, an MDT makes decisions together about how to help the child and prosecute the abuse case (NCA, 2023a). An evaluation of a CAC operating for 2 years in a rural community found that forensic interviews occurred, on average, 8 days after the referral (Bonach, Mabry, and Potts-Henry, 2010). It is considered a best practice to have the forensic interview as soon after the initial disclosure of abuse as the child's mental state will permit, and as soon as an MDT response can be coordinated (Newlin et al., 2015).

The NCA standards specify that forensic interviews must be conducted in a manner that is unbiased, developmentally and philosophically responsive, dedicated to fact-finding, and legally sound. When a child is unable to provide information regarding any abuse-related concern during the forensic interview process, other interventions to assess the child's safety and well-being are required (NCA, 2023a).

A study using the sample from the Multisite Evaluation of Children's Advocacy Centers mentioned above (Cross et al., 2007; Cross et al., 2008) found that 83 percent of CAC interviews occurred in child-friendly CAC facilities. In communities without CACs, interviews took place at CPS offices (22 percent), police facilities (18 percent), home (16 percent), or school (19 percent). Also, 52 percent of the CAC interviews were recorded, compared with 17 percent of interviews completed without CACs.

Additionally, the multisite study found that team forensic interviews (interviews with two or more observers) were conducted in 28 percent of CAC cases and 6 percent of cases in comparison communities. The authors explained that the prototype of a team forensic interview was a case in which an interview specialist conducted the interview while representatives from at least two agencies watched. If only CPS and police investigators were present at the forensic interview, the authors considered it to be a joint investigation (not a team interview). Police and CPS were involved in joint investigations in 41 percent of CAC cases, compared with 15 percent of the comparison cases (Cross et al., 2007; Cross et al., 2008).

The NCA standards also require that forensic interviews use evidence-supported procedures (NCA, 2023a) such as the National Institute of Child Health and Human Development's Investigative Interview Protocol. An evaluation found that cases following this protocol had a statistically significant greater likelihood of resulting in charges being filed, compared with cases handled before the protocol was implemented (Pipe et al., 2008).

The CAC interview usually consists of one-on-one interaction between the interviewer and the child. Other interested professionals may offer input into the questioning, watch the interview from another room through a one-way mirror, and provide feedback and ideas for possible elaboration during the interview (APSAC Taskforce, 2023; Faller, 2015; Faller and Palusci, 2007).

Some researchers have examined the number of forensic interviews conducted with child victims. In the multisite evaluation cited above (Cross et al., 2007), 65 percent of children had just one interview, and 95 percent of children had no more than two interviews. Although just one interview may be preferable to avoid retraumatizing the child and prevent the influence of suggestive questioning (Faller, 2020; Newlin et al., 2015), multiple sessions of forensic interviewing may be beneficial, given the variety of needs children may have and the complexity of their disclosures (APSAC Taskforce, 2023; Duron and Remco, 2020; Newlin et al., 2015).

Forensic Medical Examinations

The NCA standards require that specialized medical evaluation and treatment services be available to all CAC clients (NCA, 2023a). Forensic medical exams are conducted to: 1) diagnose and treat medical conditions that may be associated with abuse or neglect, 2) reassure the child that everything is all right with their body, 3) document possible physical and forensic findings, and 4) allow the collection of evidence that may be present on the child’s body or clothing (NRCAC, 2023). In the absence of medical evidence, an exam can involve a doctor or nurse in the case who is able to provide expert testimony that medical evidence can be absent even when abuse may have occurred (Cross et al., 2007; Cross et al., 2008; Smith et al., 2006).

Within CACs, several factors influence whether a medical evaluation occurs. In the Multisite Evaluation of Children's Advocacy Centers, researchers found that victims who were physically injured while being abused, girls, children with reported penetration, white victims, and younger children were more likely to have medical exams than victims without these characteristics (Walsh et al., 2007).

Mental Health Services

NCA standards require that CACs provide therapeutic interventions for child victims (NCA, 2023a; OJJDP, n.d.). These services must be offered by professionals trained in delivering mental health treatment that is evidence supported and trauma focused. As nonoffending caregivers also need mental health support (e.g., Fong et al., 2020), the NCA standards mandate that the CAC also provide such services to caregivers (NCA, 2023a). The services must address the emotional impact of abuse allegations, the child's safety and well-being, the caregiver's involvement in the child's treatment, the risk of future abuse, and issues or distress that the allegations may trigger in the caregiver (NCA, 2023a).

A study examined more than 2,000 children served by CACs in one state between 2018 and 2020, who were screened for posttraumatic stress disorder (PTSD) [McGuier et al., 2023]. The study found that 45.5 percent of the children exhibited traumatic stress symptoms. Brief interventions were delivered to 66 percent of the children. Also, about 53 percent of the children were referred to evidence-based trauma treatment and 39 percent to community mental health services. Children assessed as being at moderate or high risk of PTSD were more likely to receive the brief intervention and a referral to trauma treatment than children with lower risk.

Another study looked at some of the reasons children do not receive mental health services (Fong, et al., 2016). Data were gathered by interviewing  22 nonoffending caregivers with children younger than 13 years who were victims of sexual abuse. All children were seen at a CAC in Philadelphia, Pennsylvania. Most of the caregivers reported that mental health services were generally necessary for their children after the abuse. Respondents whose children did not receive mental health services believed that they were unnecessary, mostly because their child was not exhibiting behavioral symptoms or because of concerns about the services re-traumatizing and stigmatizing their child. The study authors recommended that there be a focus on improving communication with caregivers about the benefits of mental health services for children.

Differences Among CACs

To measure the extent to which CACs are similar to (or different from) the flagship CACs that are most commonly included in research studies, a study examined variations in CAC characteristics, as reported by 361 CAC directors across the United States (Herbert, Walsh, and Bromfield, 2018). The directors responded to questions related to case review, the characteristics of the cross-agency team, governance, and systems for case tracking/review of practices. Although some characteristics were "ubiquitous across CACs" (such as interviewing, victim advocacy, and cross-agency work), there were several differences, which led the authors to identify three types of CACs that currently exist:

1. Basic CACs provide basic services, such as interviewing and cross-agency case review, and a site for representatives of core agencies (such as law enforcement officers, CPS workers, and prosecutors), to meet and collaborate on cases.
2. Aggregator CACs integrate many of the expected services into their response, but they have fewer partner agencies and services on-site, and fewer services are provided by CAC staff compared with the centralized, full-service model; aggregator CACs are more likely to rely on referrals to other service providers than are centralized, full-service CACs.
3. Centralized, full-service CACs serve as "one-stop shops" for children and families affected by abuse; they have many partner agencies and offer on-site services, mostly provided by their own staff members.

In 2022, child protective services (CPS) agencies in 52 states (including Washington, DC, and Puerto Rico) responded to allegations of maltreatment for more than 3 million children, according to a report by the U.S. Department of Health and Human Services' Children's Bureau (2024). CPS agencies determined that 558,899 of these children had experienced abuse and neglect, which represents a national rate of 7.7 victims per 1,000 children (Children's Bureau, 2024).

The report characterized the victims as follows:

• Age. Children younger than 1 year had the highest rate of victimization, at 22.2 per 1,000 children of the same age in the national population. Victimization rates decreased as children aged. The victimization rate of children who were 1 year old was 9.9 per 1,000; 2 years, 9.3 per 1,000; 16 years, 5.0 per 1,000; and 17 years, 3.4 per 1,000.
• Sex. The victimization rate for girls was 8.2 per 1,000 girls in the population, which was higher than the boys' victimization rate (7.1 per 1,000 boys in the population). Among the 558,899 abused and neglected children in 2022, 52.5 percent were girls and 47.2 were boys.
• Race/ethnicity. American Indian or Alaska Native children had the highest rate of victimization at 14.3 per 1,000 children in the population of the same race or ethnicity; and Black or African American children had the second highest rate at 12.1 per 1,000 children of the same race or ethnicity. Among the reported 558,899 abused and neglected children in 2022, 41.6 percent were white, 23.7 percent were Hispanic, 21.7 percent were Black or African American, 1.5 percent were American Indian or Alaska Native, 1 percent were Asian, and less than one percent were Native Hawaiian or Other Pacific Islander. Also, 5.8 percent were of two or more races, and 4.5 percent were of unknown race.
• Forms of abuse. Of the reported victims, 74.3 percent experienced neglect, 17.0 percent were physically abused, 10.6 percent were sexually abused, and 6.8 percent were psychologically maltreated.
• Person most often alleged to have perpetrated the abuse. Parents were identified as the individuals who perpetrated the abuse for 89 percent of the victims.

In 2023, a total of 381,364 children were served by 961 Children's Advocacy Centers (CACs) and presented with the following characteristics (NCA, 2024a):

• Age. About 29 percent of the children served in CACs in 2023 were ages 0–6 years, 37 percent were ages 7–12, 33 percent were ages 13–18, and 1 percent were undisclosed.
• Sex. Most children served in CACs were female (64 percent, representing 244,492 girls). There were also 133,247 boys (35 percent of all children served) and 3,625 children whose sex was undisclosed.
• Race/ethnicity. About half the children served in CACs were white; 18 percent, Black; 18 percent, Hispanic; 2 percent, American Indian/Alaska Native; 1 percent, Asian/Pacific Islander; and 11 percent, "other" or undisclosed.
• Forms of abuse. Although a single case may involve several forms of abuse, child sexual abuse was the most common form of reported abuse at CACs (62 percent of children), followed by physical abuse (22 percent), neglect (8 percent), witness to violence (7 percent), drug endangerment (4 percent), and "other" (9 percent).
• Person most often alleged to have perpetrated the abuse. In cases handled by CACs, the parent was identified most commonly as the person who had perpetrated the abuse (for 36 percent of children). Others identified as the individual who perpetrated the abuse were stepparents (6 percent), parents' boyfriends/girlfriends (6 percent), other relatives (19 percent), other known persons (22 percent), or unknown persons (12 percent).

In addition to the national estimates, researchers have examined data related to the children served in CACs in specific cities, states, regions, and other geographic locations. This information often provides a more in-depth look at the children being served across the United States, highlighting the variations in their demographics and needs.

In 2010, for example, more than 2,000 children were seen in 12 CACs in Arkansas because of abuse allegations, and 1,685 of these children provided data that were entered into the CACs' mental health screening system (Conners-Burrow et al., 2012). The data showed that 70 percent of the registered children were female, 79 percent were white, the largest age grouping was 5–9 years (35.5 percent), the most common type of abuse experienced was sexual abuse (85 percent) followed by physical abuse (10 percent), and a nonrelative individual known to the victim was most commonly alleged to have perpetrated the offense (26 percent) [Conners-Burrow et al., 2012].

A 2015 study described the abuse experiences of 62 sexually exploited runaway adolescent girls and boys presenting to an urban hospital-based CAC within the midwestern United States in 2006–2013 (Edinburgh et al., 2015). Most of the children were female, came from diverse ethnic backgrounds, and ranged from 12 to 17 years of age. Most lived at home with at least one parent, but nearly one third reported homelessness, one in four reported living with a trafficker, and three were incarcerated. Youth were most often sexually exploited after running away or being kicked out of their home, but exploitation was not always linked to having a trafficker. More than half (57 percent) of the girls reported problem substance use, 71 percent reported cutting behaviors, 75 percent had suicidal ideation, and 50 percent had attempted suicide.

Edinburgh and colleagues (2014) analyzed the demographics and other characteristics of the adolescent girls who presented to the hospital-based CAC mentioned above (Edinburgh et al., 2015) from January 2007 to March 2013, after being raped by multiple people during a single event (n = 32). The authors compared these girls with girls who were sexually assaulted by one person (n = 534). Girls who were raped by multiple people were more likely than girls who were sexually assaulted by one person to have run away, to have drunk alcohol in the past month, and to have engaged in binge drinking in the past 2 weeks. More than one third of the girls who were raped by multiple people during a single event had sexually transmitted infections.

Bonach, Mabry, and Potts-Henry (2010) evaluated a CAC program in operation for 2 years and serving a rural community in the eastern region of the United States. The sample population consisted of 108 nonoffending caregivers who voluntarily brought 120 child victims to the CAC for allegations of sexual abuse. The average age of the child victims in the sample population was 9 years old, and most were girls (69 percent). In 20 percent of the cases, the individual suspected of perpetrating the abuse was the father. Other individuals suspected of perpetrating the abuse included the following: the stepfather or mother's boyfriend (14 percent of cases), brother (8 percent), mother (3 percent), stepmother or father's girlfriend (1 percent), other male relative (11 percent), other known person (42 percent), or unknown (1 percent). Roughly 70 percent of the cases were referred to the CAC by child welfare services, and nearly 22 percent of cases were referred by law enforcement. Disclosure of sexual abuse by the child victim occurred in 55 percent of the cases.

Carlson and colleagues (2015) conducted a descriptive study summarizing data from 841 case reports at a CAC in the northwest region of the United States. The children most often seen at this CAC were female (73 percent); white (67 percent); and living with their mothers, with both parents, or with a parent and stepparent (80 percent). Girls experienced sexual abuse at a higher rate than boys. Incidences of sexual abuse increased for girls across each age group (18 percent of the girls were ages 2–5 years, 38 percent were ages 6–10, and 45 percent were ages 11–17). For the boys, the frequency of abuse by age was different: in the sample of boys, 56 percent were ages 6–10 years, 21 percent were ages 2–5, and 23 percent were ages 11–17. The authors concluded that these findings related to age and sex were consistent with the existing research literature. For all age groups, relatives were identified as perpetrating the abuse more than half the time. Most children (85 percent) in the sample had been subjected to the high-impact sexual abuse behaviors of fondling, penetration, or a combination thereof. About half of the children in the sample disclosed their sexual abuse, and when they did, they most often disclosed it to their mothers.

Children's Advocacy Centers (CACs) were established to improve the response to, and prosecution of, child maltreatment (Elmquist et al., 2015; NCA, 2023b). Various studies have examined the ways CACs have improved investigation processes, increased access to medical examinations, enhanced service provision for victims, and increased criminal prosecutions of the individuals alleged to have perpetrated the abuse.

Forensic Medical Examinations

Studies have found that children served in CACs are more likely to have forensic medical examinations than children served in communities without CACs (e.g., Edinburgh, Saewyc, and Levitt, 2008; Smith, Witte, and Fricker-Elhai, 2006; Walsh et al., 2007). For example, researchers sought to determine whether there were differences in health care assessments and treatment received by adolescent victims referred to a hospital-based CAC in an urban county in Minnesota, compared with adolescent victims treated by other community providers (Edinburgh, Saewyc, and Levitt, 2008). Slightly more than three quarters of the sample were female, and the average age was about 12 years. More than 60 percent of the victims were abused by penile vaginal/anal penetration. The researchers found that 85 percent of adolescents served in the CAC received a physical exam, compared with 36 percent of the comparison group (Edinburgh, Saewyc, and Levitt, 2008).

Researchers analyzed 1,220 cases of reported sexual abuse, comparing CAC cases with cases processed in similar communities without CACs; they discovered that suspected sexual abuse victims at CACs were two times more likely to have a forensic medical examination (Walsh et al., 2007). Also, children in nonpenetration cases at CACs were four times more likely to receive exams compared with those in comparison communities. This study was part of the previously mentioned Multisite Evaluation of Children's Advocacy Centers funded by the Office of Juvenile Justice and Delinquency Prevention (Cross et al., 2008). Similarly, a study of 76 child abuse cases, in a rural southern county, found higher rates of medical examinations in the CAC-based cases compared with the typical child protective services (CPS) cases (Smith, Witte, and Fricker-Elhai, 2006). Fifty-seven percent of the children in cases served by the CAC received medical exams, compared with 13 percent of children in cases served by CPS standard procedures.

Services for Victims

There has been some research on the effect of CACs in increasing access to services for victims. For example, the aforementioned study of a hospital-based CAC in Minnesota (Edinburgh, Saewyc, and Levitt, 2008) found that the victims served by the hospital-based CAC were more likely to be referred to counseling: 75 percent of the youth in the CAC group were referred for counseling, compared with only 11 percent of the comparison group (Edinburgh, Saewyc, and Levitt, 2008). For the adolescents in the non-CAC group, investigations were conducted by police elsewhere in the community using non-CAC care providers, including Sexual Assault Nurse Examiners (SANE) nurses, nurse practitioners, family physicians, pediatricians, emergency physicians, and internists, who performed visual examinations.

A systematic review of studies examining responses to child abuse allegations found that one of the most consistent differences between the MDT approach used by CACs and non-MDT approaches was that the MDT approach increased the uptake of needed mental health and other support services (Herbert and Bromfield, 2019). The authors analyzed 17 studies with outcomes related to the referral, uptake, and completion of mental health, counseling, and other support services for children and families.

Substantiated Maltreatment Dispositions

A disposition is a determination by a CPS agency that evidence is or is not sufficient under state law to conclude that maltreatment occurred. Types of dispositions include substantiated, unsubstantiated, indicated, no finding, no alleged maltreatment, and alternative response (Children's Bureau, 2024).

A small body of literature has examined the influence of CACs on dispositions such as substantiation. Substantiated cases are ones in which the allegation of maltreatment or risk of maltreatment was supported or founded (Children's Bureau, 2024). This determination is generally based on the answers to two questions: 1) "Is the harm to the child severe enough to constitute child maltreatment?" and 2) "Is there sufficient evidence to support the designation of the case as one of child maltreatment?" (OPRE, 2007).

A study of 184 child abuse and neglect cases from a large metropolitan area in Florida found that the CAC model had better investigator efficiency and better substantiation rates than traditional child protective services (CPS) investigations (Wolfteich and Loggins, 2007). Investigator efficiency was defined as the number of days from the initial report of alleged abuse until the Florida Department of Children and Families reached a formal decision of substantiation. The researchers also found that the MDT model had outcomes similar to the multidisciplinary Child Protection Team model first developed in Florida in 1978. Further, a study analyzing data in the National Child Abuse and Neglect Data System (NCANDS) from Nebraska, New Mexico, Nevada, Utah, and Kansas determined that the number of CACs in a state or county had a statistically significant impact on case disposition (Ruggieri, 2011). In areas with more CACs, the likelihood of substantiation increased. Additionally, a systematic review of studies comparing MDT approaches used by CACs with non-MDT approaches showed that substantiations were significantly more likely when an MDT approach was adopted (Herbert and Bromfield, 2019).

Some studies have examined how the outcomes of the MDT decisionmaking process align with the CPS decisionmaking process. For example, a study evaluated the MDT's determination of the likelihood of child sexual abuse, and its relationship to the outcome of the CPS disposition (Brink et al., 2015). This MDT, which was in a CAC at a large midwestern children's hospital, determined that abuse was highly likely in 70 percent of the 1,422 cases. CPS substantiated (or indicated the allegation of child sexual abuse) in 79 percent of the cases. The study authors concluded that MDT consensus regarding the likelihood of child sexual abuse was in "moderate agreement" with the CPS disposition, and that this agreement appeared to be driven by the type of disclosures.

Criminal Prosecutions

Research on the prosecution of child abuse and neglect is limited and focuses mainly on sexual abuse cases. This research has found that most cases of sexual abuse do not proceed to prosecution and conviction (e.g., Stroud, Martens, and Barker, 2000; Font and Maguire-Jack, 2021). For example, a study examining 500 child sexual abuse reports found that fewer than one in five cases proceeded to prosecution (Block et al., 2023; Block and Williams, 2019).

As noted earlier, one of the goals of CACs is to facilitate successful prosecutions (Elmquist et al., 2015; Ruggieri, 2011). A systematic review was conducted of studies examining MDT approaches used by CACs and non-MDT approaches. The review found "reasonable evidence" to support the idea that MDTs are effective in improving criminal justice responses compared with standard agency practices (Herbert and Bromfield, 2019).

Some research on sexual abuse case processing suggests that CACs are more effective in bringing cases to prosecution than non-CAC approaches. For example, a study of a CAC program in the eastern United States, which had served a rural community for 2 years, found that criminal charges were filed in 25 percent of the sexual abuse cases (Bonach, Mabry, and Potts-Henry, 2010). Also, a study examining 76 child abuse cases, in a rural county in the mid-South, found that, of all the substantiated cases, those seen at the CAC were almost twice as likely to be referred for prosecution as those investigated using standard procedures (Smith, Witte, and Fricker-Elhai, 2006). All cases were for sexual abuse or serious physical abuse. The authors explained that this increased referral rate was likely due to the greater involvement of law enforcement in CAC-based investigations (see Characteristics of Children's Advocacy Centers).

Another study examined a sample of 160 cases in three communities served by the Dallas County District Attorney to analyze the length of time between key events in the criminal prosecution of child sexual abuse cases (Walsh et al., 2008). The study found that the charging decision was made in fewer days for cases investigated at CACs, compared with the two comparison communities. The authors considered this finding to be important because previous research suggested that the length of time between key events, such as the charging decision and case resolution process, is related to victims' recovery.

A different study examined changes in the rate of felony sexual abuse prosecutions in two districts of a large urban city over a 10-year period (Miller and Rubin, 2009). In one district, the number of children seen by CACs for sexual abuse almost tripled (from 400 children to 1,187 children), compared with a neighboring district whose use of CACs for sexual abuse did not change substantially (from 800 children to 1,000 children).

The study authors found that substantiated reports of child sexual abuse declined in both jurisdictions during the 10 years. Felony prosecutions of child sexual abuse significantly increased in the district where the use of CACs tripled (from 56.6 to 93.0 prosecutions per 100,000 children), but not in the other district. By the end of the study, the rate of felony prosecutions in the district experiencing the nearly threefold increase in the use of CACs was 69 percent greater than the rate in the other district.

Within CACs, a variety of factors affect criminal case processing. Researchers examined one of the four sites (Dallas, Texas) in the Multisite Evaluation of Children's Advocacy Centers to identify case features related to whether charges were filed and whether there was a conviction (i.e., whether a charged case ended with a guilty plea or conviction at trial) in child sexual abuse cases processed by a CAC (Walsh et al., 2010). The authors found that cases with a corroborating witness, a child disclosure, an offender confession, or an additional report against the offender were more likely to have charges filed than cases that did not have these characteristics. Even when cases lacked strong evidence (e.g., a confession, physical evidence, an eyewitness), cases with a corroborating witness were nearly twice as likely to be charged.

Parent/Caregiver and Child Satisfaction

As previously indicated, one of the goals of CACs is to improve the investigative experience of child victims and nonoffending family members and reduce the stress and trauma they experience (Cross et al., 2008; Elmquist et al., 2015). To measure the extent to which this goal is achieved, researchers have studied caregiver and child satisfaction with the CAC process.

A qualitative study surveyed 26 nonoffending caregivers, who were served by a CAC in a rural community, about their satisfaction with specific entities within the MDT and their overall experience with the CAC (Bonach, Mabry and Potts-Henry, 2010). The CAC had seen about 120 children from the date the center opened to the date data were collected 2 years later. Results indicated that the caregivers were satisfied with their experiences. The authors determined that these findings were consistent with earlier literature on consumer satisfaction with CACs (e.g., Cross et al., 2008; Jensen et al., 1996; et al., 2010; Kolbo and Strong, 1997; Snell, 2003). The respondents rated the MDT collaborating agencies "fairly highly," and the authors suggested that satisfaction with services, including logistical coordination and staff courteousness and helpfulness, was especially important to overall satisfaction with the CAC.

Another study gathered and analyzed information obtained from interviews with 203 caregivers and 65 children and youth, using data from the Multisite Evaluation of Children's Advocacy Centers mentioned above (Jones et al., 2010). Respondents described mostly high levels of satisfaction, especially with the investigators' emotional support and interviewing skills. Caregivers also reported some dissatisfaction, specifically with the investigators’ commitment to prosecuting the person alleged to have committed the offense and the absence of clear and regular communication about case status. Children and youth shared both praise and criticism about the investigators' interviewing skills. Relatively few complaints were made by caregivers and youth about the investigation's duration, medical exams, lack of services, or failures of interagency communication, which have been areas of considerable reform in the past several decades (Jones et al., 2010).

Additional analysis of the same dataset found that most caregivers (78 percent) were very satisfied with how the medical professional worked with their child, 18 percent were somewhat satisfied, and 3 percent were somewhat or very unsatisfied. Similarly, most caregivers (79 percent) were very satisfied with the medical professional’s overall job performance, 16 percent were somewhat satisfied, and 5 percent were somewhat or very unsatisfied. The authors discovered no significant differences in satisfaction between the CAC and the comparison community samples (Walsh et al., 2007).

Compared with cases in the same dataset that were investigated without a CAC, researchers found that nonoffending caregivers in CAC cases were more satisfied with the investigation than those from comparison sites, even after controlling for relevant variables such as demographics, offender characteristics, and case outcomes (Jones et al., 2007; Walsh et al., 2007). The increased levels of satisfaction among caregivers in the CAC group were based on more intangible aspects of investigations, such as support from investigators and a greater sense of comfort and safety during interviews (Jones et al., 2007). There were few differences between CAC and comparison samples in children's satisfaction.

Children's Advocacy Centers (CACs) are community-based, multidisciplinary organizations designed to reduce the stress experienced by child victims and nonoffending family members during the investigation process, improve case outcomes, and ensure that services are provided to all child victims (Elmquist et al., 2015; NCA, 2023b; Wolfteich and Loggins, 2007). CACs were established to improve the state’s response to, and prosecution of, child maltreatment, which had historically been frightening, confusing, and traumatizing for children (Elmquist et al., 2015; Ettinger, 2022; Faller, 2015).

In 2023, CACs served more than 380,000 children (NCA, 2024a). These children, who were mostly girls (64 percent), had experienced sexual abuse (62 percent of the children), physical abuse (22 percent), neglect (8 percent), witnessing violence (7 percent), drug endangerment (4 percent), and other forms of abuse (9 percent).

Researchers have examined how CACs function and how their practices and outcomes compare with traditional child protective services responses. Generally, they have found that CACs are more likely to involve law enforcement in investigations (e.g., Cross et al., 2007; Cross et al., 2008; Smith, Witte, and Fricker-Elhai, 2006), to have child-friendly environments for forensic interviews (Cross et al., 2007 and Cross et al., 2008), to record interviews (Cross et al., 2007 and Cross et al., 2008), to conduct forensic medical evaluations (e.g., Edinburgh, Saewyc, and Levitt, 2008; Smith, Witte, and Fricker-Elhai, 2006; Walsh et al., 2007), and to increase referrals to mental health services (Herbert and Bromfield, 2019).

CACs have had positive effects on child abuse substantiation rates, investigation efficiency, and criminal prosecution rates (Miller and Rubin, 2009; Ruggieri, 2011; Smith, Witte, and Fricker-Elhai, 2006; Wolfteich and Loggins, 2007). Researchers have also found that caregivers in CAC cases are more satisfied with the investigation, compared with caregivers in cases investigated without a CAC (Bonach, Mabry and Potts-Henry, 2010; Jones et al., 2007; Jones et al., 2010; Walsh et al., 2007).

Suggested Reference: Development Services Group, Inc. March 2025. Alternatives to Detention and Confinement. Model Programs Guide. Literature review. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/childrens-advocacy-centers

Prepared by Development Services Group, Inc., under Contract no. 47QRAA20D002V.