Child Abuse and Neglect Over 75 Years of Pediatrics

Commentary From the AAP Council on Child Abuse and Neglect

After years of short-lived attempts to address child abuse and neglect, the American Academy of Pediatrics established the Task Force on Child Abuse and Neglect in 1985 in response to a resolution to respond to an increased recognition of child abuse and neglect by pediatricians. This task force became a provisional committee in 1988 and then a full committee (the Committee on Child Abuse and Neglect) in 1990. Similarly, the Section on Child Abuse and Neglect was approved by the Board of Directors in 1989 and became a full section in 1990.

After years of working in parallel, the committee and section merged to become a council (Council on Child Abuse & Neglect or COCAN) in 2017. The council’s mission is to improve care and outcomes of infants, children, and adolescents through the prevention, identification, management, and treatment of child abuse and neglect. To do this the Council develops policy, builds partnerships, educates the pediatric community, and advocates on behalf of children, families and healthcare providers.

Child Abuse and Neglect Over 75 Years of Pediatrics

Angela Bachim, MD, FAAP¹, Suzanne B. Haney, MD, MS, FAAP², Christopher Greeley, MD, MS, FAAP³

Affiliations: ¹Assistant Professor of Pediatrics, Baylor College of Medicine, Houston, TX; ²Associate Professor of Pediatrics, University of Nebraska Medical Center, Omaha, NE; ³Professor of Pediatrics, Baylor College of Medicine, Houston, TX

Highlighted Articles From Pediatrics

• Committee on Infant and Pre-School Child. Maltreatment of children: the physically abused child. Pediatrics. 1966;37(2):377-382
• Brem J. Child abuse control centers: a project for the Academy [letter]? Pediatrics. 1970;45(5):894-895
• Dubowitz H. Child abuse programs and pediatric residency training. Pediatrics. 1988;82(3):477-480

In celebration of the 75^th anniversary of Pediatrics, we aimed to capture the evolution of 2 important themes relevant to the Council on Child Abuse and Neglect (COCAN). the 3 quarter-century epochs of Pediatrics, we have noted (1) important evolution in the role of pediatricians in responding to child maltreatment and (2) increasing focus on the prevention of child maltreatment. When Pediatrics published its first issue, child abuse was not universally seen as a medical concern: COCAN did not exist, the Child Abuse Prevention and Treatment Act had not been passed, and Kempe’s landmark paper that coined the term “battered child syndrome” was newly published.¹

The Committee on Infant and Pre-School Child published the first American Academy of Pediatrics (AAP) report on the national discourse on child maltreatment and new state mandatory reporting laws, “Maltreatment of Children,”² citing the recently published Kempe et al paper and highlighting the growing public interest in child maltreatment. This policy statement reported an estimate of 10,000 child victims nationally (of note, the earliest reliable national estimates around 1995 put the number at more than 1 million³). It was quite notable that even in the initial discussion over the physician response to child maltreatment, the focus was not on identification and punishment of suspected abusers but on how physician reporting is only one part of the community response to child maltreatment. Highlighting the rise of mandated reporting laws, this statement said: “As of September 1965, 47 states had passed legislation dealing with the abused child. In most cases these laws require physicians or other health personnel, who have reasonable cause to suspect that a child has had serious physical injury or injuries inflicted upon him other than by accidental means, to report the case to the proper authority…” The report emphasized that the purpose of mandated physician reporting laws was “to cause the protective services of the community to be brought to bear in an effort to protect the health and welfare of these children and to prevent further abuses.” The report also offered principles to guide legislation that focused on building up the community agencies to respond to the reports of suspected abuse. It framed maltreatment largely as a social problem, recognizing that the response “involved local departments of welfare, voluntary child protective associations, other social agencies, and the courts-family, juvenile, or district court with juvenile jurisdiction”.

In 1970, Dr. Jacob Brem suggested that the AAP create a standing Committee on Child Abuse, reinforcing the importance of the team approach in recognizing and responding to the reports of suspected child abuse.⁴ The AAP created a distinct Committee on Child Abuse and Neglect in 1990, the precursor for the current Council on Child Abuse and Neglect (COCAN).

In 1988, the second quarter-century of Pediatrics, Dr. Howard Dubowitz examined the need to develop more formal training in pediatric graduate medical education on child maltreatment.⁵ Dubowitz argued that without specific training, pediatricians were also susceptible to biased reporting, potentially leading to both increased reporting of poor and minority families and also not reporting all cases in which they suspected abuse.⁵

As the child maltreatment literature grew, hospitals developed child protection teams to address concerns over child maltreatment and family violence, and individual institutions developed non-accredited programs for further training in child maltreatment to meet the need. In 2009 the American Board of Pediatrics created the board certification process for Child Abuse Pediatrics as a field.

At the 50^th anniversary of Pediatrics, Dr. Richard Krugman, who was also the inaugural chair of COCAN, chose 3 landmark articles on child abuse and neglect to highlight.⁶ He began his commentary by noting the lack of literature on child abuse published as compared to pediatric infectious diseases or neonatology. He attributed the paucity of publications to the lack of funding from the National Institutes of Health and lack of interest from academic pediatric departments, as child maltreatment was labeled as a social or legal rather than a medical problem. He ended his commentary by hoping “the relative desert of child maltreatment research will recede and flourish far more in the next 50 years than it has to date.”⁶

In the third quarter-century of Pediatrics, Dr. Angelo Giardino et al published a seminal commentary on child abuse pediatrics as a new, board-certified specialty and its mission.⁷

A second notable theme in child maltreatment literature in Pediatrics is the increasing focus on child abuse prevention. Dr. Ray Helfer was a pioneer in child abuse prevention who authored several books and many journal articles that recognized that child abuse was intergenerational. In the early years of Pediatrics, Helfer’s work is emblematic: “The Etiology of Child Abuse.”⁸ Here he proposed factors outside of the parent-child duo that increase risk for a child to be abused, which included the parent’s own childhood history, factors that build the capacity for resilience in their own lives, and stressors on the family. He adeptly concluded that the risk for child abuse cannot be extinguished solely by addressing the immediate crisis situation, because the underlying risks that make the family vulnerable to abuse remain and may precipitate a future crisis. Helfer’s framing was well before his time. Today, we refer to these vulnerabilities as social determinants of health and adverse childhood experiences (ACEs).

Helfer’s appreciation of the nuance of the etiology of child maltreatment promoted innovative preventive work that appeared in the pages of Pediatrics. We echo Dr. Krugman’s recognition of Dr. David Olds’ randomized trial of home visiting programs as having “documented not only the long-lasting reduction of reported child abuse, but significant improvement in family functioning as well.”⁹ Going beyond educational intervention, Olds’ home visiting program strengthened the informal supports from the families’ own social networks in the postpartum period and served as a connecting link to additional social support programs including vocational training, Planned Parenthood, mental health resources, legal aid, and nutritional support.

The evolution of the understanding of prevention throughout the publication of Pediatrics is demonstrated by significantly more articles to consider in choosing landmark articles for child maltreatment research, including prevention of child maltreatment. With the recognition of social determinants of health and ACEs, targets of prevention have shifted from individual family characteristics to local, regional, and national systems that may influence risk of child maltreatment via social determinants of health and ACEs. Most notable was work that demonstrated the effectiveness of targeting social determinants of health at a national level in reducing child maltreatment. Dr. Henry Puls et al compared the cumulative spending on benefit programs and rates of child maltreatment by state to determine if there was an association between the two.¹⁰ He found that in states with higher spending on benefit programs, there were reductions in child abuse reporting, the number of reports that substantiated child abuse, foster placements, and child fatalities. This type of upstream, systemic mitigation of social determinants of health holds promise for the reduction of child maltreatment.

The pages of Pediatrics provided a large amount of opportunity to highlight how the field of child abuse pediatrics has grown over the past 75 years. The role of the pediatrician and the evolution of how prevention was understood stand as clear examples of that growth.

References

1. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA. 1962;181(1):17-24
2. Committee on Infant and Pre-School Child. Maltreatment of children: the physically abused child. Pediatrics. 1966;37(2):377-382
3. Child Maltreatment 1995: Reports From the States to the National Child Abuse and Neglect Data System. Washington, DC: US Department of Health and Human Services; 1997. Available at https://www.acf.hhs.gov/sites/default/files/documents/cb/child_maltreatment_1997.pdf
4. Brem J. Child abuse control centers: a project for the Academy [letter]? Pediatrics. 1970;45(5):894-895
5. Dubowitz H. Child abuse programs and pediatric residency training. Pediatrics. 1988;82(3):477-480
6. Krugman RD. Landmarks in child abuse and neglect: three flowers in the desert. The whiplash shaken infant syndrome, by J. Caffey, Pediatrics, 1974; 54: 396–403; Covert video recordings of life-threatening child abuse: lessons for child protection, by David P. Southall et al, Pediatrics, 1997; 100: 735–760; Preventing child abuse and neglect: a randomized trial of nurse home visitation, by David L. Olds et al, Pediatrics, 1986; 78: 65–78. Pediatrics. 1998;102(suppl 1):254-256
7. Giardino AP, Hanson N, Hill KS, Leventhal JM. Child abuse pediatrics: new specialty, renewed mission. Pediatrics. 2011;128(1):156-159
8. Helfer RM. The etiology of child abuse. Pediatrics. 1973;51(4):777-779
9. Olds DL, Henderson Jr CR, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics. 1986;78(1):65-78
10. Puls HT, Hall M, Anderst JD, Gurley T, Perrin J, Chung PJ. State spending on public benefit programs and child maltreatment. Pediatrics. 2021;148(5)