Wendy Gwirtzman Lane and Howard Dubowitz
THE IMPORTANCE OF PREVENTION
Preventing child maltreatment fits well with the goals and scope of pediatrics, as expressed by the American Academy of Pediatrics’ commitment to “prevention, early detection, and management of behavioral, developmental, and social problems as a focus in pediatric practice.”1 The prevention of child abuse and neglect has benefits at the level of the individual child, the family, the community, and the society at large. Sparing a child from the physical, cognitive, behavioral, and emotional problems associated with maltreatment2-6 is intuitively and morally preferable to intervening after the fact.
Beyond the individual child, the prevention of child maltreatment has at its heart the goal of strengthening families and enhancing childrearing. Effective interventions may achieve much more than the narrow goal of preventing maltreatment. Additional outcomes may include children’s cognitive, emotional, social, and behavioral gains; improved maternal health and communication with their children; decreased use of public assistance; and decreased involvement in the criminal justice system.7-10 Child maltreatment has significant costs, human and economic, that need to be weighed against the cost of prevention. Although more research is needed, several studies have demonstrated the cost effectiveness of specific child abuse prevention programs.11-13
ROLES OF PEDIATRIC HEALTH CARE PROVIDERS
To date, pediatric practice has focused primarily on the important issues of identifying abuse and neglect, reporting to the public agencies, and facilitating referrals for assessment and treatment. In order to fulfill their responsibility to help ensure children’s health and well-being, pediatricians should also focus on preventing maltreatment. Pediatricians can do so by identifying and helping to manage child and family risk and protective factors, referring families to effective community-based services, and advocating for the development of policies and funding of programs that effectively promote family well-being. Because children and families generally enjoy excellent relationships with primary care pediatricians, pediatricians may play a role that other professionals cannot. Pediatricians are usually perceived as supportive and caring without the stigma often attached to social work and mental health. This rapport can facilitate a remarkable entrée into families’ lives with sharing of much sensitive information.
IDENTIFICATION OF FAMILIES AT RISK
RISK FACTORS FOR MALTREATMENT
The “ecological” framework of child maltreatment posits that physically abusive and/or neglectful behavior derives from the complex set of interactions between the child, parent, community, and society.14Specific patterns of behavior observed within the parent-child dyad can serve as important indicators of possible physical abuse or neglect. Child characteristics, such as difficult temperament or chronic physical or mental health problems, may challenge parents, heighten parental stress, and increase the risk of maltreatment.15,16 The relationship between parent and child in maltreating families may involve harsh, inattentive, and inconsistent parenting.17 Maltreating parents, particularly physically abusive ones, often report feeling “out of control” as parents. They frequently hold an external locus of control orientation, feeling that they have limited control over their actions.17-19 For a more detailed discussion of risk factors, see Chapter 35.
Research has identified strong associations between a number of parental problems and child maltreatment risk as summarized in Table 35-1. In addition to the factors listed that contribute to abuse and neglect, one less easy for pediatricians to assess directly is the quality of social networks in which families’ lives are embedded.20-27
IDENTIFICATION OF FAMILIES AT RISK
Most high-risk families underutilize professional helping systems, such as mental health or social services,28,29 but may be more likely to seek medical care for their children. Health care services provide a critical, near-universal access point for at-risk families to be screened and identified and for preventive interventions to be initiated. Primary care therefore provides a logical starting point for efforts to prevent maltreatment.
Many risk factors are unlikely to be detected unless specific screening efforts are made. For example, parental depression is often not obvious and is frequently not recognized by pediatricians.30 Intimate partner violence (IPV) is usually a well-kept family secret. For these reasons, the American Academy of Pediatrics specifically recommends that pediatricians screen for IPV, parental substance abuse, and other family risk factors.1,31,32 An approach to identify these possible problems is to screen all families at certain pediatric visits (eg, initially and then periodically) with a brief questionnaire, which can be completed while waiting or can be incorporated into the interview at the visit. Relying on clinical judgment as to who, for example, appears “high” will result in many problems remaining hidden.
A number of screening questionnaires exist to identify parental problems such as depression, substance abuse, and IPV.33-41 Given the range of issues to be covered in a pediatric primary care visit and the limited time available, brief tools are critical. Introducing questions in a sensitive manner may make parents comfortable in disclosing information. For example, “We want to make sure all children live in safe environments. There are some problems lotsof families have, so I am asking everyone these questions. If there is a problem, I will try to help. Also, it is okay if you prefer not to answer some questions.” It is useful to begin with some well-accepted safety issues such as bike helmets, smoke alarms, and guns in the home. Building on pediatricians’ long-standing interest in children’s safety, this is a logical transition to areas such as corporal punishment, parental depression, substance abuse, domestic violence, and other environmental hazards. An example of a 1-page screening questionnaire is the Parent Screening Questionnaire (Table 37-1) developed for the SEEK (A Safe Environment for Every Kid) model of pediatric primary care in which pediatricians are trained to screen, assess, and provide initial management for child maltreatment–related risk factors.39
In addition to questions directed to parents, valuable information can be obtained directly from children and teenagers, and pediatricians have an interest in children’s perceptions and history. It is now customary to spend some time alone with adolescents and to obtain a history independently42; this practice can be extended to younger children as well. It is important first to establish rapport by asking general questions such as “What kinds of things do you like to do?” and “Who lives with you?” The physician can then ask how family members get along and what kinds of things the child likes to do with each of them. More sensitive issues can then be raised, such as “All kids sometimes behave badly. What happens when you behave badly?” “Is there anyone at home who gives you a hard time?” and “Whom do you tell when you have a problem?” It is generally a good principle to talk to children alone if possible. If problems are uncovered, it is important to tell the child of the concern and the need to involve the parent(s).
Table 37-1. A Safe Environment for Every Kid (SEEK) Parent Screening Questionnaire (PSQ)
Screening raises several issues pertaining to confidentiality. If information is gathered on sensitive problems, particularly intimate partner violence, it is prudent to assess the problem privately, without the child or partner present. Women may be understandably reluctant to disclose violence in the presence of others, and there is the risk of aggravating the situation. Children may be later coerced to report on what was said during the visit. A child who is present when a parent denies ongoing violence may learn to keep all maltreatment secret. There is also an issue of documentation, given that the partner may have access to the child’s medical record. One approach is to place sensitive information in a separate section of the chart or in a separate, linked chart.
If screening identifies possible risk factors, there is a need for further assessment. It is also important to assess protective factors, which are also crucial in considering the overall situation. Pediatricians can conduct brief assessments to guide the initial management. For example, the initial screen may identify a parent with depressive symptoms. A brief assessment should focus on priority issues such as whether there is a concern regarding suicide, whether the person is currently receiving therapy, and whether the person is interested in receiving help. This assessment could lead to various recommendations depending on illness severity and available resources: Care should be sought immediately in an emergency department, with a mental health professional, or with the parent’s own primary care provider. The brief assessment can be performed by the pediatrician or by another clinical staff member, such as a social worker.
Many families have more than one problem, increasing their risk of child abuse or neglect. Further assessment of one problem may reveal other problems. Ideally, a comprehensive assessment is done, probably by a social worker or another community resource, to understand the family’s needs and strengths. This more comprehensive understanding is key to intervening appropriately. It is also important to know what interventions have been tried, including those by the pediatrician and with what results. Finally, there is a need to estimate the risks and the prospects for intervening successfully. Risk factors for maltreatment are further discussed in Chapter 35.
A critical criterion for screening is that the person benefits from having a problem recognized. It follows that after screening and a brief assessment, there may be a need for further evaluation and intervention. In some instances, pediatricians can provide education and guidance, such as helping a parent manage the child’s challenging behaviors or supporting a parent suffering an emotional loss. Alternatively, an office social worker or psychologist may play this role. In other instances, such as intimate partner violence or substance abuse, pediatricians serve primarily as “gate keepers” by facilitating referrals—a potentially pivotal role.
To provide a child adequate health care and to prevent abuse or neglect, pediatricians must be familiar with the family’s structure; beliefs regarding health care, child rearing practices, and discipline; stresses and strengths; and barriers to care. Rooted in a trusting relationship, this understanding requires time, and it is an ongoing process as circumstances change. While it is often difficult to change others’ behavior, the process of empathy, motivation, and support may sow a seed that the pediatrician cares about the parent’s feelings and experiences, and it may lead to behavioral change months or years later. The following are general principles concerning preventive efforts:
• The needs of parents, children, and families should be considered, following the vision of Bright Futures.43 Effective interventions focus on basic problem-solving skills and concrete family needs,44 provide behavior management strategies, and help address environmental factors. Parents may require attention to their own emotional needs in order to provide adequate nurturance to their children.
• Identification of a family’s strengths and resources is key to comprehending the situation and to intervening. Strengths may include coping abilities, intelligence, determination, and/or religious faith. Resources may include informal supports (ie, family, friends) as well as formal community resources to which the family is already connected. Informal support may be especially useful for families who are resistant to interventions from public agencies or mental health professionals. Formal support through a religious affiliation may be valuable, and professionals too often overlook this important source of support and guidance. However, some fundamentalist religious movements may encourage corporal punishment and may thus exacerbate the risk for physical abuse. It is therefore important to have a sense of the nature of support that is likely from such resources before simply recommending them.
• Risk factors for maltreatment must be identified and addressed (see Figures 36-1, eFig. 37.1 and eFig. 37.2 for examples of approaches to the clinical assessment of positive screening questions on IPV, substance abuse, or depression).
• Be knowledgeable about community resources, and facilitate referrals. Primary care providers serve as an important conduit to community services and are in a good position to encourage reluctant or ambivalent families to accept or try services.
COMMUNITY-BASED PREVENTION PROGRAMS
Pediatricians can consider a number of community referral resources as they aim to address risk factors for abuse and neglect. Resources vary from one community to another, and many community programs have not been evaluated. Following are examples for which some degree of efficacy or effectiveness has been demonstrated.
Home visitation services assign a professional (often a nurse) or layperson to deliver parent education, case management, and sometimes role-modeling, emotional support, and other parent assistance in the home. Whether a professional or layperson, home visitors are trained, receive intense supervision, and follow a structured curriculum. Often beginning during prenatal care or shortly after birth, home visitation programs should include close partnerships with health care providers, helping parents to learn when to seek medical care, assuring medical follow-up, and providing careful monitoring. Home visitors may also assist families by connecting them to services such as public assistance; Medicaid; mental health, substance abuse, and intimate partner violence services; or other community supports. A meta-analysis of home visitation outcome studies conducted by the Centers for Disease Control and Prevention strongly supported the use of home visitation services to prevent child maltreatment.45 However, not all programs have proven effective, and programs with lay-visitors and non-nurse professionals have mostly been less effective than those involving nurses.
The most successful home visiting program in preventing maltreatment has been the Nurse Family Partnership (formerly the Nurse Home Visitation Program) developed by Olds and colleagues. Randomized trials conducted in upstate New York, Memphis, Tennessee, and Denver, Colorado, have demonstrated positive outcomes for intervention families, compared to controls, including fewer reports to child protective services and fewer injuries and ingestions requiring medical care.46-50 The Denver trial compared the efficacy of paraprofessionals to that of nurses; nurse home visitors were found to be more effective in preventing child maltreatment.49 The Nurse Family Partnership had limited effectiveness among families coping with intimate partner violence.51
Healthy Families America leads one of the largest home visiting programs in the United States and may be familiar to community pediatricians. Unfortunately, rigorous evaluations of Healthy Families America sites in Hawaii and Alaska found that the program had no effect on the incidence of maltreatment among participating families.52,53 The Alaska program did, however, lead to improved child development and behavior and quality of children’s home environment.54 Programs at both sites improved children’s access to health care.54,55 There is considerable heterogeneity in Healthy Families America programs; some programs may be more effective than others. Factors that may affect individual program success include staff skill and turnover, intensity of services, family engagement, alignment of family and program goals, severity of family risk, and availability of other community resources and services.56
PARENT TRAINING PROGRAMS
Parent training programs typically aim to address parents’ emotional adjustment and improve parents’ comfort and competence with parenting. Examples include the Triple P program, Sure Start, Family Connections, Parents as Teachers, and Together for Kids.57-60 There is variability in services among these programs, several of which involve home-based interventions. Some have shown improvements in parents’ self-esteem and attitudes toward child rearing.
Several meta-analyses of parent training programs have identified characteristics that may increase program effectiveness.61-64 For example, programs that include multiple modalities, such as office-based and home visitation services or group and individual services, may have better outcomes than more limited programs. This information may be helpful for pediatricians fortunate enough to have more than one available program or for those who are advocating for the development of new programs.
PREVENTION OF ABUSIVE HEAD TRAUMA
Approximately 30 of every 100,000 infants suffer from abusive head trauma (AHT) during their first year of life, and AHT is the leading cause of child abuse–related death.65,66 The observation and later demonstration67 of a temporal association between peak frequency of infant crying and peak incidence of AHT have led to an interest in educating parents of infants about ways to cope with infant crying and to refrain from shaking their babies. One program that has had some success focused on educating parents of newborns during their postpartum hospital stay, using a brochure and video.68 Parents were also asked to sign a commitment statement stating that they had received the AHT information and they understood that shaking is harmful. An evaluation of the intervention showed a decrease in the rate of AHT in the implementation region, while AHT rates in a neighboring state without the intervention were unchanged.68 While these preliminary findings are encouraging, further studies are needed to prove program effectiveness.
PREVENTION OF CHILD SEXUAL ABUSE
Prevention of child sexual abuse has been particularly difficult. Most existing programs are specifically directed at children, teaching them about personal safety, body safety, saying no, and telling a trusted adult. Some include behavioral skills training such as modeling and role playing.69-71 Critics of these child-focused educational programs argue that they unreasonably burden children with the responsibility for preventing sexual abuse rather than targeting those who may abuse children. Parents have also expressed concern that it may be harmful to tell children that someone close to them could possibly abuse them.
Evaluations of specific programs have demonstrated improvement in children’s safety skills, increased knowledge about sexual abuse, increased rates of disclosure, and decreased self-blame if abuse occurs after the training. However, assessing the direct effect of a program on the rate of sexual abuse is methodologically difficult and therefore has generally not been done. One study that did demonstrate effectiveness was a retrospective study in which college students were asked about their participation in school-based sexual abuse programs and their history of possible sexual abuse.72 Rates of abuse were significantly higher in the group that reported no participation in prevention programs. This study, several program evaluations, and documentation of a decline in the incidence of sexual abuse over the past 20 years have led one expert to support the continuation of high-quality prevention-education programs.73
Little or no data are available regarding effective primary care–based interventions to prevent child sexual abuse. However, pediatricians can provide children and parents with basic information about sexual safety. Following are some examples of safety messages:
• During the genital examination, the pediatrician can point out to the child that only their doctor and specific adult caregivers should be allowed to see their “private parts.” Parents can be engaged in this conversation by asking them to clarify which caregivers are permitted to do so.
• Pediatricians can counsel parents on how to maintain open channels of communication with their children, including informing the parent if anyone makes them feel bad. At the same time, the pediatrician can encourage children to talk with their parents when something is troubling them.
• Parents can be given information on how to minimize the opportunity for perpetrators to access children (eg, limiting 1-adult/1-child situations), how to discuss issues of sexual abuse with children, and how to recognize potential behavioral and medical signs of sexual abuse. The Stewards of Children program, developed by the Darkness to Light Foundation, offers educational materials to address these issues (http://www.darknesstolight.org).
Pediatricians can be advocates for the prevention of child maltreatment on different levels, including that of the child, parent, family, community, and society. Helping parents meet their children’s needs is advocacy on behalf of children unable to express or meet their own needs. Acknowledging the stress a parent may feel and facilitating help is also advocacy, and knowledge of effective resources helps make appropriate referrals. While most pediatricians will not have direct involvement in community-based prevention programs, they can advocate individually or through their state’s American Academy of Pediatrics chapter to start abusive head trauma prevention programs in their hospital newborn nurseries or to develop home visitation programs in their communities. Enhancing access to health care represents advocacy at the broadest societal level. Each of these examples of advocacy is valuable in helping prevent child abuse and neglect.