Child abuse and neglect: it’s about prevention

Ecological framework of child abuse prevention
The ecological framing of the prevention of child abuse and neglect relies on an understanding of the factors that influence childhood health outcomes.1 Children are surrounded by the immediate environment of family, home, day care, school, and community. Their lives are also influenced by other components such as the educational system, the health care system, and the multitude of health and human services that compose their neighborhoods. These are, in turn, influenced by rules, regulations, laws, and policies that provide the framework and resources in support of the systems needed to enable children not only to survive, but also to reach their full potential, have hope, and be happy.2,3 The absence of discrimination, racism, and bias is critical for children to thrive.4 Economic security is fundamental, as are connections to other individuals. How well the various systems that touch a child’s life speak to each other and are centered on the child and family determine the health of that child.2 This has never been so evident as during the COVID-19 pandemic.

As clinicians, we focus on the system of care for children and the longitudinal relationships that support healthy minds and bodies.2 This includes the family and the relationship many families have with their pediatrician/child health professional. The REACH Institute “First Principles” are a set of guiding values and practices as discussed in a previous Contemporary Pediatrics article.5 Included are the importance of the developmental and contextual assessment of every child; the need for team formation, communication, and decision-making; the principle of “do no harm” (which most of us have extended to “do good”); and the use of evidence-based practices.

Guiding principles for the prevention and treatment of the consequences of child abuse and neglect complement those of the mental health principles from REACH. They center around the concepts of prevention and halting further trauma and mental health consequences. Prevention can be described as primary prevention when applied universally to avoid harm in the first place by enhancing protective factors and reducing risk factors in a child’s life. Targeted or secondary prevention methods interrupt the onset of harm after exposure to harm or potential harm. Tertiary prevention mitigates harm that has already occurred. Data support the primacy of primary prevention and the importance of averting the negative effects of adverse childhood experiences in the first place.6-10

Tiers of prevention of child abuse and neglect
The US health care system has been designed mostly to focus on secondary and tertiary prevention. An example of secondary prevention is the use of blood lead screening to identify children who have already been exposed to the lead toxin and then to abate their environment in response to this exposure. Primary prevention would have eliminated the toxin altogether. Tertiary prevention is the use of chelation to prevent further harm to organ systems such as brain, kidney, heart, etc.11

In child abuse and neglect, our system of care has been focused mainly on tertiary prevention. The 1970s brought a significant accomplishment in the societal acknowledgment that children do have the right to be protected from harm by the adults responsible for their well-being and that some professionals have the mandate to report if there is a suspicion (not certainty) of abuse. As of 2019, all US states either designate physicians as mandatory reporters of child abuse/neglect or require all individuals to report suspected abuse/neglect, regardless of profession.10 Most pediatricians comply with their mandate to report most of the time, but studies have revealed some gaps. In one study, pediatricians were less likely to report suspected abuse if they believed that child protective services were not likely to help.12 In others, the nature of the injury, the pediatrician’s assessment of family and child risk factors, the length of time the pediatrician had known the family, and the child’s race affected pediatricians’ decision to report.13,14 Research has documented racial and socioeconomic disparities and biases in evaluation and reporting of child abuse.15–18

Over the past 2 decades we have learned a lot about how not to retraumatize children when they are being evaluated for abuse and neglect and about the need for the evaluation to be multidisciplinary and to focus on the child’s mental health.19 Teams have integrated child abuse pediatricians, social workers, psychologists, case workers, home visitation programs, and liaisons with inpatient services (both medical and psychiatric) to meet the clinical needs of more severely affected children. A comprehensive history, beginning with a non-accusatory, nonleading and nonjudgmental questions, is a core of the evaluation. If a child presents with a physical injury, for example, a pediatrician might ask the caregiver, “Please tell me what happened.” Active listening is critical in not introducing information that has not been provided by the caregiver giving the history.Fact finding may include the questions of when, what, and where to establish the history of the trauma or event in a nonleading way. An onscene investigation by child protective services and an assigned detective, especially when evaluating serious injury, is important to understand how the injury might have occurred and to compare the history of the trauma to the actual physical environment in which the injury is reported to have occurred.

If an infant isn’t gaining weight and there is a concern of failure to thrive and neglect,the pediatrician might say, “Let’s review your baby’s feeding history. Let’s start from when they woke up and take me through the next 24 hours.” Clarifying questions to gain specifics are appropriate. If the child is old enough to be interviewed or if there is a credible witness, separate interviews can help the clinician assess any discrepancies.

A comprehensive physical exam that is both thorough and respectful can help the pediatrician decipher whether the history the caregiver gives is consistent with the clinical evidence and a plausible mechanism of injury. The physician may choose to order laboratory tests and radiologic studies. A detailed psychosocial history, often aided by a social worker, is important to help with evaluation and diagnosis. With all the available clinical data, the pediatrician then must establish a differential diagnosis, decide on the likelihood of abuse/neglect, and develop a treatment plan. This treatment plan may include the involvement of other specialists to attend to the physical and mental health needs of the child. Careful discharge planning in coordination with child protective services is part of the treatment plan.If the child is in immediate danger, hospitalization and/or separation from the caregivers may be necessary, supported by court action. If the evidence suggests that it is safe to send the child home, a detailed follow-up plan is needed.

While the effects of child abuse and neglect are wide-ranging and, in many cases, long-lasting, opportunities exist to support families with evidence-based medical and mental health treatments. Many programs have set up long term follow-up of children and adolescents within a medical home. A medical home consists of “family-centered, community-based, coordinated care … offering comprehensive, continuous, culturally effective, and compassionate care.”2 In cases of abuse that require separating the child from the family, the longitudinal relationship of the family with the pediatrician can facilitate reunification or other appropriate disposition plans for the child.The primary care physician is encouraged to not lose contact with the family and to ask the court to follow with specific visits to the pediatrician for that child and siblings, even if the children are placed in foster care.In addition, unless it is felt to not be safe for the child (e.g. in cases of sexual abuse), the caregivers could be given permission to attend supervised specialty follow-up to the child abuse pediatrician and other specialists.Addressing the caregivers’ mental health problems is important in the treatment plan regardless of whether unification with the family is envisioned.This serves as a preventive approach to build caregiver capacity to parent effectively.

A focus on primary prevention
According to the National Child Abuse and Neglect Data System (NCANDS), at least 8.4 in 1,000 children in 2020 were victims of child maltreatment, defined as neglect, physical abuse, sexual abuse, and/or sex trafficking.20 The NCANDS data show a decrease in child protective services investigation responses or alternative responses from 3,476,000 for federal fiscal year (FFY) 2019 to 3,145,000 for FFY 2020. Clinical researchers have begun to publish on the lessons learned during the COVID-19 pandemic and the policy implications for the primary prevention of child abuse and neglect.21,22 Infants and young children are at greater risk than older children and teens,20 but an increase in abusive head trauma, usually seen in children under 2 years, was not reported in Maassel’s study.22 The period of lockdown did result in a breakdown of many of the social networks for many schoolchildren. Given that a large proportion of reports of abuse and neglect for this age group comes from school professionals (21%),20 it could be postulated that the decreased presence of children in schools could have led to a decrease in the monitoring of these children. However, at least one researcher contends that this reduction may reflect “diminished disproportionate reporting of families of color, one example of bias that has led to widely acknowledged racial disparities in child welfare reporting.”21

In addition, while positive experiences are likely not evenly distributed, Maassel postulates that, although the pandemic did result in a marked increase in unemployment, several factors may have mitigated the negative impact to families. For example, the improved work-life balance afforded by remote work may have had beneficial effects by promoting more extended quality contact with multiple caretakers. This beneficial influence may have been especially important for children under the age of 2 years who, as a group, are more likely to suffer the most severe abuses. The subsidies provided to families to compensate for the loss of wages afforded the opportunity for family support systems to mitigate risks and buffer families from the harms of economic deprivation (eg, homelessness, mental health distress, food insecurity, etc.) These speculations and their related policy implications certainly will need corroboration in research.

Broader efforts to prevent child abuse and neglect involve transforming our system of care with a strong focus on proactive support of families. Instead of the current reactive system, the new system needs to envelop families in several layers of care. These include protection from unemployment; family leave policies that allow families to care for children and other family members as needed; and child-care provisions to support safe, developmentally appropriate, and accessible child care, especially in households where all adults are working outside the home. Additionally, financial support for a medical home model including home visitation has shown benefits.23

Provisions of the $1.9 trillion pandemic-related American Rescue Plan Act of 2021 include emergency funding for the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program and the Child Abuse Prevention and Treatment Act (CAPTA). MIECHV is a federal-state partnership that provides evidence-based home visiting services in all 50 states, the District of Columbia, and five US territories. Reauthorization of the law, which expires in September 2022, is strongly supported by the Home Visiting Coalition, a national coalition of multiple child-focused organizations.24 Unfortunately, only 2 to 3% of families are currently served at the level of funding provided by MIECHV, so scaling of the evidence-based intervention of home visitation is needed.25 Child health professionals are encouraged to understand the complexities of these funds and the opportunity to utilize these dollars at state and local levels to support families and advance health equity.

Primary prevention is always better than treatment. Universal home visits to the families of every newborn (with services customized by risk stratification) could support parents to respond appropriately to their infant’s needs, support positive experiences, ameliorate risk factors in the home or neighborhood, reduce parental stress, and improve mental health. Our current supply of child psychiatrists, psychologists, psychiatric nurse practitioners and social workers is not adequate to meet the mental health needs of all children. Hence, the training of primary care clinicians in evidence-based mental health care is essential to promote health and early recognition of distress (eg, depression, anxiety, trauma-related symptoms, etc.) and to link children and teens to evidence-based treatments as necessary.

Guiding principles
The general guiding principles for the prevention of child abuse and neglect should include:

• Focusing on primary prevention
• Exploring and assessing supportive models rather than punitive approaches to families, which may involve alternative reporting of child abuse and neglect alongside the provision of mental health services and linkages to community-based services
• Funding and implementing systems of care that contribute to continuous rather than fragmented services, including a medical home model with liaison to evidence-based universal home visitation programs and other relevant evidence-based services
• Training health professionals in health equity to enhance their ability both to provide unbiased, culturally responsive assessments when a concern of child abuse and neglect occurs and to respond effectively to the mental health needs of children, teens, and immediate caregivers by providing appropriate treatment
• Emphasizing hopeful, long-term, future-oriented approaches rather than pessimistic approaches mired in the past; committing to long-term solutions to promote child health; and recognizing the role that positive experiences play in supporting children and in buffering adverse events

These principles can guide the decisions and actions of pediatricians. Pediatricians and other child health professionals, aware of the ecological determinants of care, can develop a partnership with each parent or caregiver, implementing concrete efforts at prevention, quality assessment, and treatment of the child or teen and developing a therapeutic alliance aimed at promoting the present and future well-being of that child and family.

BIO
Danielle Laraque-Arena, MD, FAAP, is president and professor emerita of SUNY Upstate Medical University. A pediatrician and child abuse specialist, she is currently a senior scholar in residence at the New York Academy of Medicine and adjunct professor of epidemiology at the Mailman School of Public Health, Columbia University. She is a founding member of the faculty of The REACH Institute and board member of Prevent Child Abuse America.

References
1. Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977,32(7):513-531. doi:10.1037/0003-066X.32.7.513
2. Laraque D, Sia CCJ. Health care reform and the opportunity to implement a family-centered medical home for children. JAMA. 2010;303(23):2407–8. doi:10.1001/jama.2010.809
3. Sege R. Reasons for HOPE. Pediatrics. 2021;147(5):e2020013987. doi:10.1542/peds.2020-013987
4. Laraque-Arena D., Young VP. Children affected by racism. In: Foy JM, ed. Promoting Mental Health of Children and Adolescents: Primary Care Practice and Advocacy. American Academy of Pediatrics; 2019:483-504
5. Jensen P. Guiding principles in managing pediatric mental health issues. Contemp Pediatr. 2022;39(2). https://www.contemporarypediatrics.com/view/guiding-principles-in-managing-pediatric-mental-health-issues
6. Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med. 2009;37(5). doi:10.1016/j.amepre.2009.06.021
7. Danese A, Moffitt TE, Harrington H, et al. Adverse childhood experiences and adult risk factors for age-related disease: Depression, inflammation, and clustering of metabolic risk markers. Arch Pediatr Adolesc Med. 2009;163(12):1135-1143. doi: 10.1001/archpediatrics.2009.214
8. Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA. 2009;301(21):2252-2259. doi:10.1001/jama.2009.754
9. Merrick MT, Ford DC, Ports KA, et al. Vital signs: estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention — 25 states,
2015–2017. Morb Mortal Wkly Rep. 2019;68:999-1005. doi:10.15585/mmwr.mm6844e1
10. Jones CM, Merrick MT, Houry DE. Identifying and preventing adverse childhood experiences: Implications for clinical practice. JAMA. 2020;323(1):25–26.
11. Laraque D, Trasande L. Lead poisoning: successes and 21st century challenges. Pediatr Rev. 2005;26(12):429-436.
12. Child Welfare Information Gateway. Mandatory reporters of child abuse and neglect. Children’s Bureau, Administration on Children, Youth, and Families, US Department of Health and Human Services. 2019.https://www.childwelfare.gov/pubPDFs/manda.pdf
13. Flaherty EG, Sege R, Binns HJ, Mattson CL, Christoffel KK, for the Pediatric Research Group. Health care providers’ experience reporting child abuse in the primary care setting. Arch Pediatr Adolesc Med. 2000 May;154,489-493. doi:10.1001/archpedi.154.5.489
14. Flaherty EG, Sege RD, Griffith J, et al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics. 2008 Sep;122(3), 611-619. doi:10.1542/peds.2007-2311
15. Hymel KP, Laskey AL, Crowell KR et al. Racial and ethnic disparities and bias in the evaluation and reporting of abusive head trauma. J Pediatr. 2018 July;198:137-143. doi:10.1016/j.jpeds.2018.01.048
16. Lane WG, Dubowitz H. What factors affect the identification and reporting of child abuse-related fractures? Clin Orthop Relat Res. 2007;461:219-225. doi:10.1097/BLO.0b013e31805c0849
17. Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002;288:1603–9. doi:10.1001/jama.288.13.1603
18. Wood JN, Hall M, Schilling S, Keren R, Mitra N, Rubin DM. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics. 2010;126:408-414. doi:10.1542/peds.2010-0031
19. Laraque D, DeMattia A, Low C. Forensic child abuse evaluation: a review. Mt Sinai J Med. 2006; 73(8):1138-1147.
20. Children’s Bureau. Child maltreatment 2020. Administration on Children, Youth and Families, Administration for Children and Families, U.S. Department of Health & Human Services. 2022. https://www.acf.hhs.gov/cb/data-research/child-maltreatment
21. Sege R, Stephens A. Child physical abuse did not increase during the pandemic. JAMA Pediatrics. Published online December 20, 2021. doi:10.1001/jamapediatrics.2021.5476
22. Maassel NL, Asnes AG, Leventhal JM, Solomon DG. Hospital admissions for abuse head trauma at children’s hospitals during COVID-19. Pediatrics. 2021;148(1):e2021050361.
23. Valado T, Tracey J, Goldfinger J, Briggs R. Healthy Steps: Transforming the promise of pediatric care. Future of Children. 2019;29(3):99–122. https://files.eric.ed.gov/fulltext/EJ1220075.pdf
24. Home Visiting Coalition. What can Congress do? https://nationalhomevisitingcoalition.org/what-can-congress-do/.
25. National Home Visiting Resource Center. 2020 Home Visiting Yearbook. James Bell Associates and the Urban Institute; 2020.