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Child Abuse and Neglect: A Framework for Supporting Patients and Families :

February 27, 2020

The very connected series of articles this month in Pediatrics in Review may be hard to digest in one reading. The topic of child abuse and neglect is challenging to deliver for many reasons but given its far reaching health implications, I hope readers can gain new insights that will inform their practice. Index of Suspicion editor Dr. Fischer succinctly tells us that “sometimes health problems result from imperfect relationships” which I would offer as an astutely helpful framework for the reader this month. A few further thoughts to reflect on as you read.

Remember that all relationships usually start with a positive intent. Getting to know someone, being hired to work, choosing a doctor, or becoming a parent. Central to any of these are people connecting with some shared purpose and expectations. When violence, maltreatment, or neglect somehow enters that space, those hopes and expectations suffer. These are the cases that challenge and even shock providers. I am always reminded of what Dr. C. Henry Kempe said decades ago, “Abusive parents love their children very much but not very well.” That positive intent is there – it’s just been disrupted, hidden, or nearly lost. So what do we do?

Trust yourself and others you call upon to restore what may be missing. Our patients trust us: our knowledge, our history with them, and our ability to offer help, healing, and support. They may not be immediately able to share their concerns or what is happening.  Being present, ready, and open to when they can is all you can do. Screening for social determinants of health, family violence, and even occult injuries when appropriate in infants and young patients with unusual trauma presentations is a way to invite that dialogue. Working towards collegial partnerships with agencies that serve children (child welfare, home visitors, public health nursing) builds trust with you as provider in your shared goals of safety, health and resiliency. So what happens when that sense of trust is violated when a family falsifies a history, refuses needed help, or makes decisions that risk health and safety of a child?

Acknowledge what emotions you have, seek support, and refocus on the child and family. The feelings of anger, betrayed trust, deception, sadness and failure are expected when these cases erupt in our practices. We have to be aware of biases against families that may develop when exposed to child maltreatment, child welfare involved patients, or victims of violence who have delayed seeking help. It can be hard to see the restorative nature of our work on behalf of them when we have these feelings.  Colleagues can support medical decision-making and reporting to child welfare, as well as talking through the emotions that come with these decisions. Self-resiliency can be maintained even in the aftermath of difficult cases. Our patients still need that of us as we leave one room and enter another where that next child is waiting for us. 

Remember that hope is not lost and evidence-based help can work. For over a decade now, we have had a growing body of scientific knowledge on how early experiences and environmental influences can leave a lasting neurodevelopmental impact on brain architecture, learning, behavior, and both physical and mental well-being. With such extensive evidence now on the impacts of toxic stress on the life trajectory of children, an evidenced-based approach has taken hold in our screening, identification, and treatment for our patients. Learn more by visiting some of the AAP resources here.

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