The Pediatrician and Child Maltreatment

Child abuse and neglect are inherently challenging problems for pediatricians. It is hoped that this article makes this work easier, albeit not easy, and highlights the many ways that pediatricians can make a valuable difference in the lives of these vulnerable children and their families.

Key points

  • An ecologic model of parenting includes risk and protective factors at the level of the child, parent, family, and community/social setting.

  • Primary care clinicians have the potential to engage families and focus on prevention of abuse and neglect.

  • To provide effective help to children and families, pediatricians need to partner with community agencies.

  • Pediatricians need to follow the mandated reporting laws and report suspected abuse, neglect, or sexual abuse to Child Protective Services.

It is more than 50 years since Kempe and colleagues’s seminal report on the “battered child,” and since then, much has been learned about child abuse and neglect. Despite considerable advances, however, addressing child maltreatment, including physical, sexual, and emotional abuse and neglect, remains a daunting challenge for many pediatricians. In this issue of Pediatric Clinics of North America , we have invited authors to help address conceptual and clinical issues facing many practitioners all too frequently.

In this introductory article, we set the stage with broad principles that guide clinical work regarding child maltreatment and offer useful pointers for practice. First, it is helpful to consider the broader context for viewing child maltreatment and significant developments in the understanding of children’s health and development and pediatric practice.

Importance of the first few years

For decades, pediatricians have been well aware of how critical the first few years of life are for child and brain development. Exciting advances in neuroimaging have further refined this understanding. Indeed, brain architecture is found to be influenced by young children’s environment and interpersonal interactions. This, in turn, influences their cognitive, social, and emotional development, perhaps for many years. Although the first few years are especially important, the story hardly ends at age 3. Rather, influences during childhood, adolescence, and even into a person’s 20s are also significant in shaping health and development.

Toxic stress

Unfortunately, many children live with multiple adversities, the effect of which can be toxic stress. Shonkoff and colleagues defined toxic stress as resulting “from strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship.” Turner and colleagues found the remarkable prevalence of adversities with which many children and youth contend and that many of them face not 1 or 2 but multiple adversities.

Different forms of child abuse and neglect can lead to toxic stress. These and other risk factors, such as parental substance abuse and depression, were found in the Adverse Childhood Experiences Study to potentially induce a toxic stress response and were linked to poor mental and physical health outcomes many years later. It is thought that this stress response disrupts brain circuitry and other organ and metabolic systems during sensitive developmental periods. Such disruption may result in anatomic changes or physiologic dysregulations that are the precursors of later impairments in learning and behavior and are the roots of chronic, stress-related physical and mental illness. In an effort to cope with these chronic stresses and the emotional pain linked to the childhood adversities, many teens and adults turn to cigarettes, drugs, alcohol, or overeating; these maladaptive coping strategies can lead to their own serious health effects.

The potential role of toxic stress and early life adversity in the pathogenesis of health problems underscores the importance of effective surveillance for significant risk factors in the primary health care setting. There are clear implications for pediatricians: how can clinicians prevent or mitigate the toxic stress in many children’s lives and help ensure their health and wellbeing well into adulthood?

A broad view of maltreatment

The battered child report by Kempe and colleagues focused on severe physical abuse. Subsequently, concerns of neglect, sexual abuse, and emotional abuse were all added as different forms of child maltreatment. As more has been learned about conditions or circumstances that harm children, other parental behaviors are increasingly viewed as maltreatment. For example, corporal punishment has long been accepted as appropriate for socializing children; some regard it as necessary. Mounting evidence, however, points to the potentially harmful physical and psychological impact of harsh punishment. Arguably, this can be considered maltreatment, although most such instances are not addressed through Child Protective Services (CPS). Children’s exposure to domestic (or intimate partner) violence is another example. Many studies show that exposure to domestic violence jeopardizes children’s health, development, and safety—directly or indirectly. Some CPS agencies now expect mandated reporters also to report children’s exposure to domestic violence as maltreatment. Still more broadly, Gil drew attention to societal neglect. Although the current focus is narrowly and conveniently on parental behavior, there are reasonable concerns regarding societal contributions to children’s poor health and development. For example, poverty remains the strongest predictor of many bad child outcomes, and approximately 1 in 5 US children live in poverty. Another example is the lack of health insurance, affecting 6.6 million US children in 2012 ; the associations between health problems and limited access to health care have been well established.

Development of the field of pediatrics

Twentieth century advances in public health, immunizations, antibiotics, and nutrition dramatically improved the health of many US children. These advances enabled increased attention to children’s quality of life and their environment. Thus, new problems came into focus: divorce, teenage pregnancy, child abuse, and attention deficit disorder, to name a few; these were labeled the “New Morbidity.” Today, these and other problems such as obesity, the impact on children of the media, school violence, firearms in the home, and drug and alcohol abuse have become important concerns for pediatric practice.

Despite recognition of the new morbidity, however, medical training has been slow to adapt, and practitioners often do not feel comfortable addressing problems such as child abuse and neglect. There is a clear need to better educate pediatricians in such areas and to develop models by which they can readily consult with subspecialists. The American Academy of Pediatrics’ Bright Futures Project supports pediatricians in addressing the new morbidity.

Beyond the biomedical model

Engel was a psychiatrist concerned with the traditional narrow biomedical model of health and illness. Although the role of psychological and environmental influences had been recognized by the ancient Greeks, Engel was concerned with modern medicine being increasingly focused on the molecular level. In a seminal report on a biopsychosocial model, Engel postulated that biological, psychological (including thoughts, emotions, and behaviors), and social factors all significantly influence human functioning, health, and illness. For example, a low-income family living in substandard housing with mold and cockroaches may trigger asthma attacks in its young child. In addition, the burdens of poverty may contribute to the mother’s depression and alcohol abuse. In turn, she neglects to fill her child’s prescription, aggravating the asthma. The implications for child abuse and neglect are clear.

Child maltreatment cannot simply be explained by sick or deviant parents. Rather, multiple and interacting factors are usually contributing to the problem. This understanding has been labeled the “ecological model,” acknowledging the potential role of the individual child and parent, family level, and community/societal factors. This model does not excuse parents from their primary responsibility to raise and protect their child. It does, however, draw attention to other factors that also deserve attention, including, for example, social policies to improve children’s access to health care. Clinically, the need for collaborative interdisciplinary assessment and interventions is evident.

Protective factors

Child abuse and neglect cannot be fully understood by identifying risk factors. The role of protective factors that may buffer the impact of problems also needs consideration. These may be internal, such as a child’s intelligence or a father’s caring for his child. They may be external, such as a supportive grandparent, a substance abuse treatment program, or a helpful pediatrician. Indeed, risk and protective factors can be found in most individuals and families. It is especially useful to identify protective factors, as they offer a constructive way to work with families. For example, rather than admonishing a parent for not filling a prescription, one can point to the father’s love of his child, and say: “I can see how much you love Amy. You really don’t want her back in the hospital. How can we make sure we keep her healthy?” This is not about being nice; rather, it is about being constructive and strategic in how best to engage parents and optimize children’s care.

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Oct 2, 2017 | Posted by in PEDIATRICS | Comments Off on The Pediatrician and Child Maltreatment

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