A father brings his 10-year-old to your office because the boy is having a hard time paying attention at school, gets in fights with classmates and is oppositional with his teacher.
As you take the psychosocial history, it’s important to ask whether the child has been exposed to any abuse, neglect, abandonment or other traumas, according to the updated AAP clinical report Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment.
“Children who have suffered early abuse or neglect may later present with significant health and behavior problems that may persist long after the abusive or neglectful environment has been remediated,” according to the report from the AAP Committee on Child Abuse and Neglect; Council on Foster Care, Adoption, and Kinship Care; American Academy of Child and Adolescent Psychiatry; and the National Center for Child Traumatic Stress. The report is available at https://doi.org/10.1542/peds.2017-0100 and will be published in the April issue of Pediatrics.
Since the original report was published in 2008, much has been learned about the relationship between adverse childhood experiences and later psychosocial problems. The updated report aims to help pediatricians recognize and manage behavioral problems in maltreated children.
“This is a tough problem for pediatricians, but we offer the opportunity to do a world of good for kids,” said Robert D. Sege, M.D., Ph.D., FAAP, a lead author of the clinical report and a former member of the AAP Committee on Child Abuse and Neglect. “One of the things that we now know is that children’s brains are so malleable, they’re so capable of growth and healing.”
Effects of maltreatment
More than 25% of U.S. children have experienced abuse or neglect, according to studies cited in the report. These children can have symptoms of extreme distress, including sleep problems, attention issues, anger, irritability, withdrawal and repeated and intrusive thoughts.
These symptoms can continue long after the maltreatment has ended. For example, research shows that adolescents who were maltreated early in life are more likely to attempt suicide, use drugs and engage in risky sexual behavior.
Studies also show that children who are maltreated are labeled as “problem children” more frequently than their peers.
Pediatrician’s role
“Pediatricians who are seeing children for these behavior problems should consider whether they might be the result of past abuse and neglect,” Dr. Sege said.
If trauma has occurred, the pediatrician can help caregivers understand that the child is not simply being defiant and may react differently than other children in a similar situation, according to the report. The provider can explain that the child may not feel psychologically safe even if he is physically safe and could have extreme reactions to a minor stimulus such as a sound, sight or smell that reminds him of the trauma. In those situations, parents can be taught to prepare their child for triggers.
The report notes that parents and teachers can inadvertently exacerbate behavior problems if they respond harshly or punitively. Instead, caregivers can be encouraged to use positive parenting strategies, such as distracting young children who are misbehaving and setting clear rules that children can understand and enforcing them consistently, Dr. Sege said.
If children do not respond to common behavioral management techniques or severe problems persist, pediatricians should refer them for a trauma assessment or treatment by a mental health professional.
“Once they’ve assessed that a child has behavior problems that are a result of past abuse or neglect, we’re very fortunate there are now evidence-based therapies that help children heal from these problems,” Dr. Sege said. “We describe in the report what some of those therapies are and give suggestions on how a pediatrician might find therapists qualified to deliver those therapies.”
Clinical considerations
The report outlines the following clinical considerations for pediatricians:
- Inquiries regarding past traumatic experiences, including child abuse and neglect, may be included in the social and family histories of patients.
- Treatment for severe or persistent behavioral consequences of child maltreatment is indicated and effective.
- Pediatricians may be able to help parents and teachers better understand the behavioral consequences of past maltreatment.
- Pediatricians also can help advise social service agencies on common behavioral problems exhibited by children in foster care who have been maltreated and advocate for prompt referral to effective therapies.
