Researchers and clinicians have documented the alarming incidence of child maltreatment and the lifetime morbidity that can result from early trauma. The challenge remains: Can such a complex, widespread and serious condition be prevented? And if so, what role might pediatricians play?
A robust and growing body of evidence links a wide variety of interventions to significant reductions in maltreatment. The updated and expanded AAP clinical report The Pediatrician’s Role in Preventing Child Maltreatment reviews these findings and highlights the ways a pediatric practice can help in prevention.
The report, from the Council on Child Abuse and Neglect, is available at https://doi.org/10.1542/peds.2024-067608 and will be published in the August issue of Pediatrics.
Causes of maltreatment, protective factors
Child abuse and neglect increasingly are seen as resulting from a complex interplay of factors related to the child, the family and their community.
A child’s chronic illness, disability or even an irritable temperament can increase a caregiver’s stress. The caregiver, in turn, may lack understanding of child development and behavior. The caregiver also may struggle with social or financial support, mental health or substance use issues. The community may be violent and lack opportunities or the resources to provide an adequate safety net. A vulnerable child may lose the battle between stressors and resilience.
Resilient families have positive social relationships and are knowledgeable about parenting and child development. They have access to housing, food and vital services, which helps them manage stresses.
Children who have safe, stable, nurturing relationships with adults are able to communicate, regulate their emotions, maintain relationships and deal with adversity.
The pediatrician’s role in prevention
For the pediatric provider, prevention of maltreatment begins with awareness.
Maintaining a social history for all families can provide clues that a family might be more or less resilient, and can be used to track sources of ongoing stress. Special attention should be paid to assessing what has been termed relational health, the child’s social support and positive relationships. The report discusses a variety of efficient, readily available screening tools to assist in evaluating a family’s risks and resilience.
At periodic health maintenance visits, anticipatory guidance can explore parental expectations and address predictable stressors like discipline and toileting.
Other interventions are targeted, focusing on families with identified risk factors such as a child’s challenging behaviors or a parent’s deteriorating mental health. The pediatrician’s role often is to facilitate referral to other professionals. Home visiting programs, parenting education and early childhood education are examples of effective targeted interventions to improve parenting skills.
When the identified need is more concrete, families may be directed to food banks, legal aid or community social workers. Caregivers’ perception of economic helplessness and fear correlate to child maltreatment; mitigation of these conditions has been shown to improve child safety.
Special topics
Even after abused children have been identified and removed from immediate danger, they remain at heightened risk for revictimization. For the pediatrician, prevention of further morbidity begins with an understanding of trauma’s long-term effects and heightened surveillance during regular care. A watchful approach can result in timely referral for mental health intervention when needed.
The report also addresses perceived impediments to dealing with complicated maltreatment cases in the office, including documenting and coding for services. It also expands on the special challenges of preventing sexual abuse and teen maltreatment.
- Obtain a thorough social history initially and periodically.
- Acknowledge and address parents’ concerns while reinforcing effective parenting.
- Guide parents in providing effective, nonphysical discipline.
- When caring for children with disabilities or chronic illness, be cognizant of their increased vulnerability.
- Be alert to indicators of parental intimate partner violence, unhealthy substance use and depression, and know how to respond if a caregiver reports such problems.
- Learn about community resources to facilitate referral when appropriate.
- Prepare the physician-led team to accommodate the complex presentations of families undergoing stress.
- Offer practical guidance to caregivers on supporting the child or adolescent who has been victimized to prevent further maltreatment or morbidity.
- Monitor frequently for signs and symptoms of toxic stress and continued maltreatment, and recommend therapeutic interventions and mental health services.
Dr. Stirling is a lead author of the clinical report.
