The COVID-19 crisis has altered the fabric of American society and upended how families live, work, educate their children and seek health care. Parents are reporting increased levels of stress, and concerns have been raised by pediatricians, the media and advocacy groups about a potential surge in child maltreatment.
Parents have dealt with an economic downturn as well as the concurrent disruption of their children’s normal caregiving arrangements and routines due to child care and school closures. Stay-at-home and shelter-in-place orders, while initiated to mitigate virus transmission, also have increased the risk of intimate partner violence and confining children with their abusers. There also is concern for the under-detection of abuse due to the decreased interaction of children with mandated reporters like school staff.
Understanding the effects and implications of the COVID-19 pandemic on child maltreatment continues to be a priority area for investigation and intervention.
Previous research has shown a rise in maltreatment during times of disaster and economic decline, such as an increase in abusive head trauma that followed the 2008 U.S. economic recession (Berger RP, et al. Pediatrics. 2011;128:637-643, http://bit.ly/3qcA5FC).
Two studies conducted during the pandemic are of particular interest to pediatricians. One study summarized initial findings of the pandemic’s impact on children’s exposure to violence (Fore HH. Child Abuse Negl. 2020;104776, http://bit.ly/3e5QQzw). The study reported an association between parental job loss and child abuse (especially psychological abuse); observed decreases in child protective services (CPS) reporting by school personnel coinciding with school closures; and increased vulnerability of children to violence as a result of increased internet usage (exposure to abusive content, cyberbullying, child sexual exploitation).
The second study, conducted by the Centers for Disease Control and Prevention, used emergency department (ED) surveillance data (of approximately 73% of all ED visits in the U.S.) from January 2019 to September 2020 (Swedo E, et al. MMWR Morb Mortal Wkly Rep. 2020;69:1841-1847, http://bit.ly/2ZYGg5o). It found that while there was an overall decrease in pediatric ED visits during the pandemic, a higher proportion of visits were for child abuse. Additionally, a higher percentage of visits for child abuse during the pandemic resulted in hospitalization, suggesting that even with an overall decrease in seeking care, parents may have continued to seek medical evaluation for persistent or worsening signs of abuse.
Guidance for pediatricians
Even before the COVID-19 pandemic, child maltreatment was a widespread problem. The 2019 Child Maltreatment report based on national CPS data found that 656,000 children were maltreated annually (http://bit.ly/3kxEnGj).
In the midst of this difficult time for families, it is essential for pediatricians to ask specifically about family functioning and stress. Going beyond the basics of the rote social history to explore how families are coping and/or struggling during this time of unprecedented national crisis can help screen for risk factors and acute stressors, as well as identify family strengths and resilience.
As detailed in the AAP clinical report The Pediatrician’s Role in Child Maltreatment Prevention from the Council on Child Abuse and Neglect (http://bit.ly/37Vp19d), pediatricians at baseline represent a source of trust and stability for caregivers. Screening for social determinants of health and asking questions about basic needs like housing and food is strongly recommended.
If stressors like food insecurity or parent job loss are identified, understanding community programs and local resources can help pediatricians support families. It is imperative that pediatricians continue to set expectations at early well-child visits around developmental milestones and known triggers for abuse like crying and toilet training, as well as review effective discipline and corporal punishment alternatives.
While effective prevention of abuse is far from straightforward and requires a comprehensive, coordinated, multidisciplinary approach based in both policy and clinical practice, pediatricians can play an effective role on the front lines. In addition to specific guidelines for the evaluation of physical and , the AAP offers resources that can aid the general pediatrician in working with families to identify and mitigate stressors that predispose to violence.
Dr. Kazmir is a member of the AAP Council on Child Abuse and Neglect.
