The coronavirus disease 2019 (COVID-19) pandemic has changed the medical landscape, and the field of child abuse pediatrics has not been exempt from the reach of this disease. Previous widespread disease outbreaks and natural disasters have been associated with increased violence toward women and children,1 and child abuse programs noted increased rates of abusive head trauma during the 2007–2009 recession.2 The COVID-19 pandemic has led to increases in similar risk factors for child maltreatment, including employment instability, financial strain, reduced child care, and fewer available support structures.3–6 Marginalized populations (eg, those in child protection systems, who already experience preexisting disparities) may be at particular risk because of widening inequalities with the pandemic.7
Child abuse programs across North America have reported variable impacts of the COVID-19 pandemic, including changes to incoming referrals and modifications to clinical and educational activities. These impacts have yet to be described in the medical literature and are crucial to understand as child abuse clinicians and pediatric hospitalists adapt to the current context. In this commentary, we describe the impacts of the pandemic experienced by 1 interdisciplinary child abuse program practicing in a 300-bed tertiary care academic pediatric urban hospital in North America. This will include a discussion of necessary adjustments made by the program related to clinical practice, team functioning, clinician wellness, and medical education.
Changes Experienced by the Child Abuse Program
This interdisciplinary child abuse program is composed of pediatricians, nurse practitioners, social workers, and psychologists. The program provides 24-hour per day service, including inpatient, outpatient, and emergency department consultations. After closures in March 2020, the program documented a substantial reduction in incoming consultations (see Figs 1 and 2). A trend was also seen of fewer acute sexual assaults and more disclosures of historic sexual abuse. As communities reopened in May 2020, patient numbers gradually increased, and, anecdotally, there was a pattern of consultations for infants with positive workup for occult injuries who had bruising during the lockdown period that was not addressed. The pandemic highlighted the importance of early case planning, which involved planning discussions between clinicians and child protection workers and/or law enforcement before patient assessments. Although early case planning was already being used before the pandemic, it was expanded to include considerations of visitor restrictions and virtual assessment in select cases. This allowed the child abuse program, patients and/or families, and investigative partners to work collaboratively to offer unique solutions to conduct investigations and deliver medical care within the constraints of physical distancing requirements. For example, although an in-person examination by a child abuse physician is generally preferred for assessment of concerning skin findings, in some older children, review of photographs combined with a virtual history from the patient or nonoffending caregiver provided a reasonable alternative to in-person assessments. From mid-March 2020 to the end of August 2020, ∼10 virtual assessments were provided for suspected physical abuse. In the future, this form of virtual assessment may be helpful for patients in remote locations where in-person assessment by a child abuse physician cannot be facilitated. In-person assessments continued for cases involving suspected injury to an infant because of increased legal implications and the perceived importance of a detailed physical examination by a child abuse pediatrician. In-person assessments also continued for acute sexual assaults to maintain the same standard of medical care and forensic evidence collection.
Studies have revealed the effectiveness of providing virtual mental health care in the context of trauma.8,9 Because of pandemic restrictions, the psychosocial team transitioned immediately to virtual care for preexisting therapy clients. The team reviewed the medical literature on virtual mental health care, sought expert consultation with psychiatry, and created departmental processes to support virtual care for new clients. The psychosocial team triaged all new referrals to offer virtual assessments after investigations. From mid-March 2020 to the end of August 2020, 282 virtual psychosocial assessments were provided.
Sex trafficking survivors continued to be provided virtual and in-person assessments. Ongoing engagement with youth during this highly stressful time was critical to ensure youth were connected with access to medical and mental health care.
Clinicians in the child abuse program are routinely involved in providing medical expert testimony, most commonly in criminal court. Because of the pandemic, criminal court proceedings requiring medical expert testimony were deferred, even up to a year from the initially scheduled trial date. Urgent family court proceedings continued in a virtual format. It is anticipated that the pandemic will have possible impacts related to reduced visitations, delays in court cases, and delays in provision of supports for caregivers and children involved with the child protection system.
Team Functioning and Clinician Wellness
The child abuse team is a highly integrated interdisciplinary group, and this approach has been reported to have a number of advantages in child abuse cases.10 To maintain cohesive team functioning, various activities were moved to a virtual format, including case discussions and debriefs, quality assurance activities, and team updates on pandemic-related hospital processes.
Clinician wellness has also been impacted by the pandemic. Child abuse providers are inherently at elevated risk for secondary traumatic stress (STS), which is an increasingly recognized phenomenon experienced by those working with patients and/or families who have experienced trauma firsthand.11 Reduced in-person encounters and minimal routine contact with colleagues have presented unique challenges. Providing consultation and care in child abuse cases while working from home decreased the usual boundaries necessary in a discipline of complex and often distressing cases. An increase in STS symptoms has been noted in team members, and the program is engaging an outside counselor with expertise to offer virtual support and intervention as needed.
Like other medical educators,10 child abuse clinicians have experienced challenges in creating authentic patient encounters during the pandemic because of changes in patient volumes, fewer in-person consultations, and distancing measures placed for trainee safety. With the onset of the pandemic, the university initially suspended clinical rotations for medical students and elective students from other institutions. Clinical rotations for core pediatric residents and child abuse pediatrics fellows were modified to encourage remote learning from home. Because of limited clinical encounters, weekly virtual case discussions were developed to ensure trainee exposure to an adequate range of child abuse cases. All formal educational activities in the child abuse program were also transitioned to a virtual format, including fellowship academic rounds and joint subspecialty educational rounds.
Because of the medicolegal context, medical trainees are highly supervised with direct observation of their verbal communication with patients, caregivers, and investigators. Before the pandemic, medical trainees participated in many learning opportunities via observation of referral calls and case discussions with the interdisciplinary team in the shared clinical space. These spontaneous learning opportunities are challenging to replicate without face-to-face group interactions and a shared workspace.
Trainee wellness has been acknowledged as an area of concern during the pandemic, with medical trainees experiencing increased isolation and decreased boundaries between work and home.12 In addition, they are vulnerable to experiencing STS because inexperience is a reported risk factor.13 Before the pandemic, learners had numerous opportunities to debrief directly with interdisciplinary team members to process difficult emotions associated with cases. Supervisors could directly observe trainee reactions to cases and were better situated to recognize a struggling learner. The virtual orientation, midrotation check-in, and final rotation debrief with a supervising pediatrician now include an enhanced focus on wellness.
Positive Outcomes and Future Impacts
Despite concerns about the potential for increased family violence during the pandemic, there have been some positive observations. In some circumstances, the closures have created opportunities for children to share concerns with caregivers. In previous studies, authors have found that an increased level of parental bonding is a facilitator of disclosure,14 whereas not having the opportunity may delay or inhibit disclosure.15 Our program has noted an anecdotal increase in disclosures of historic sexual abuse by community caregivers and family acquaintances, and increased contact with a trusted caregiver may have contributed to this. With social distancing measures, there was an overall decrease in cases of acute sexual abuse by peers, community caregivers, and family acquaintances.
In addition, the previously described changes to clinical practice have resulted in virtual adaptations and enhanced early case planning with investigators that have resulted in helpful changes in maintaining timely access to medical evaluations and mental health supports within the constraints of physical distancing requirements. These strategies are anticipated to be maintained throughout and after the COVID-19 pandemic.
Child abuse programs across North America have experienced variable impacts as a result of the COVID-19 pandemic, and our program has adapted to provide virtual options for clinical care, medical education, and clinician wellness. With ongoing uncertainties regarding the future of the pandemic, hospital-based pediatricians can support families with increased social stressors by connecting them to appropriate community services before child abuse occurs. Pediatric hospitalists should also continue to be vigilant for signs of child abuse and make appropriate referrals to child abuse programs as well as child protection agencies, as warranted under legislation. A multicenter time-series analysis is planned to compare trends in consultation before, during, and after pandemic closures.
Drs Cho and Smith conceptualized and drafted the initial manuscript and reviewed and revised the manuscript; Ms Smith and Dr Cory reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.