PEDIATRICS Vol. 122 No. 3 September 2008, pp. 654-655 (doi:10.1542/peds.2008-1550)
COMMENTARY |
Child Abuse and Neglect: A System That Still Needs Pediatric Leadership
District I Chairperson, American Academy of Pediatrics, Elk Grove Village, Illinois
Abbreviations: CARES, Child Abuse Reporting Experience Study • AAP, American Academy of Pediatrics • CARRET, Child Abuse Recognition, Research, and Education Translation • SOCAN, AAP Section on Child Abuse and Neglect
Four decades ago, a group of pediatricians published landmark research that substantiated abuse and neglect as an issue worthy of society's attention, providing the catalyst for cultural change and milestone legislation.1 Although a generation of child advocates has made remarkable progress, children remain at risk, and pediatricians must remain leaders in protecting vulnerable children. Every year in the United States, an estimated 900000 children are determined to be victims of child maltreatment, and more than 1500 die secondary to abuse and neglect. To ensure their safety, every year 800000 American children spend time in foster care. In addition, although the $100 billion annual cost of child abuse and neglect to US society is insignificant when compared with the measure of human suffering, it is not a trivial sum.
Included in the August and September issues of Pediatrics are 2 articles about the child abuse identification and reporting behaviors of pediatricians.2,3 The Child Abuse Reporting Experience Study (CARES), conducted by the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings (PROS) Network, has provided evidence-based confirmation of the perceptions of professionals who have spent entire careers evaluating cases of suspected abuse and neglect. CARES investigators found that health care providers do not report all cases of suspected abuse, in large part because of concerns over best outcomes, given a system perceived as dysfunctional.
Previous research has suggested that the results of the CARES, although certainly unsettling for pediatricians, seem to be part of a larger and consistent picture of child abuse reporting (or the lack thereof) by professionals who are mandated to report it. For example, in 1994, Tilden et al4 surveyed a wider variety of professionals (ie, dental hygienists, dentists, nurses, psychologists, physicians, and social workers) and asked about their typical response when child abuse is suspected. Only physicians and social workers selected "reporting to child protective services" as their most typical response.
Literature exists that suggests varying interpretations of the criterion for "reasonable suspicion." The system that exists for the reporting of cases is complex and often underresourced. Some practitioners may believe that in such an environment, an alternative strategy will yield a better outcome for the family. Indeed, the Jones et al3 article validates these notions, noting that many practitioners who did not report a child to child protective services instead used alternative management strategies with the intent of seeking better outcomes for possibly victimized children. The decision to report is both multifaceted and difficult. Overall, the results of the Jones et al study clearly point to a system that should be improved.
Toward the goal of system improvement, the AAP gathered relevant stakeholders from health care, social work, and child protective services in January 2007 to translate the CARES findings into definable action to better improve outcomes for children. As a general pediatrician with significant experience in the area of abuse and neglect and a member of the AAP Board of Directors, I attended the Child Abuse Recognition, Research, and Education Translation (CARRET) Conference. Conference participants prioritized several strategies to save children's lives, which are identified in the conference proceedings published by Pediatrics as an electronic supplement to this issue.5 Taking a pragmatic approach, the group adopted the following general recommendations:
- to work to improve relationships, communication, and collaboration among health care providers and criminal justice and human service agencies;
- to encourage the development of centers of excellence to act as resources for communities or regions and to support research and training; and
- to work at the medical student and resident levels to increase awareness and improve training regarding the prevalence, identification, and evaluation of children who are at risk.
This conference serves as evidence that collaboration among the various disciplines involved in addressing child maltreatment is possible and that finding common ground can happen. After reading this supplement, we hope you will see that you are not alone; the AAP is here to support the pediatric community.
For more than 25 years, the AAP Committee on Child Abuse and Neglect (COCAN) has focused on creating policy and clinical guidance and using them as a foundation for advocacy efforts. Since 1990, the Section on Child Abuse and Neglect (SOCAN) has served as an educational forum for the discussion of child-maltreatment prevention, identification, reporting, and management. The SOCAN continues to propose and sponsor sessions that focus on the identification and reporting of child abuse and neglect at the AAP National Conference and Exhibition and other live continuing medical education events. Furthermore, the SOCAN will be sponsoring a multiday continuing medical education course dedicated solely to child abuse and neglect in July 2009, which will be open to all pediatricians and other clinicians. SOCAN members have participated in the development of many resources for our members that are available through the AAP bookstore, such as the excellent Visual Diagnosis of Child Abuse on CD-ROM, which has been revised and includes more than 300 new diagnosis slides, a lecture series based on the third edition of Child Abuse: Medical Diagnosis and Management, and other resources. In addition, the SOCAN maintains a comprehensive Web site that includes links to all AAP child abuse policy statements, provides information on forthcoming child-maltreatment conferences and training opportunities, and incorporates a state map of child abuse centers across the United States and Canada that pediatricians may use for referral and additional support (www.aap.org/sections/scan/default.cfm).
Both the committee and section regularly work together with partner organizations to bring national attention and resources to support pediatricians in identifying and addressing child maltreatment. The American Board of Pediatrics recently approved creation of a Certificate of Special Qualification in Child Abuse Pediatrics, which will ensure development of a cadre of certified experts to whom general pediatricians can refer complicated cases. We hope that this pediatric subspecialty will inspire other medical licensing and certifying bodies to follow suit and require a broader range of courses at all levels of graduate and postgraduate medical education and training. An additional activity of great significance is the proposal to develop a Health CARES (Child Abuse Research, Education, and Services) Network. Modeled after the decades-old federal investment in the national network of University Centers of Excellence in Developmental Disabilities Education, Research, and Service, the proposed Health CARES Network would consist of regional consortia, each comprising multiple institutions that bring together expertise in health care research, training, and services to prevent, identify, and treat child abuse. The AAP is working closely with cosponsors including the National Association of Children's Hospitals and Related Institutions (NACHRI) and the American Association of Child and Adolescent Psychiatry (AACAP) to advocate for federal dollars to support this system.
Clearly, despite the significant resources and advocacy efforts of the AAP, substantial challenges and opportunities still lie ahead, but the AAP remains highly committed. After the CARRET Conference, a subset of participants from multidisciplinary fields agreed to form an action group to explore how the prioritized strategies can be fulfilled. Specific activities undertaken by the group are detailed in the conference proceedings5 and include developing guidance that outlines the roles and responsibilities of each professional involved in evaluating, investigating, and addressing child maltreatment, as well as creating a statement to clarify the implications of the Health Insurance Portability and Accountability Act (HIPAA) for sharing information among professionals who work on child-maltreatment cases.
Although the focus of the CARES project and the ensuing CARRET Conference was on the identification and reporting of child maltreatment, no discussion of the topic would be complete without a comment regarding prevention. To help stem the tide of abuse and neglect, we must expand our vision and develop and establish interventions that immunize children and families against harm. Early intervention strategies work, as do strength-based family initiatives. Although new programs require social investment, the value of such strategies would be enormous.
Four decades ago, pediatricians were the professionals who led the way in turning a sharp public light on child abuse. Four decades later, we find ourselves in a position to again assume a leadership role, this time in addressing the complexities of a sometimes dysfunctional multidisciplinary child abuse–reporting system. The AAP is committed to having a prominent role in seeking solutions.
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FOOTNOTES |
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Accepted May 27, 2008.
Address correspondence to Edward Bailey, MD, NSMC/North Shore Children's, 57 Highland Ave, Salem, MA 01970. E-mail: enbailey{at}partners.org
The author has indicated he has no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
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REFERENCES |
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 TOP REFERENCES |
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- Helfer RE, Kempe CH, eds. The Battered Child. Chicago, IL: University of Chicago Press; 1968
- Flaherty EG, Sege RD, Griffith J, et al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. The Child Abuse Reporting Experience Study Research Group.
Pediatrics. 2008;122
(3):611
–619
[Abstract/Free Full Text] - Jones R, Flaherty EG, Binns HJ, et al. Clinicians' description of factors influencing their reporting of suspected child abuse: a report of the Child Abuse Reporting Experience Study Research Group.
Pediatrics. 2008;122
(2):259
–266
[Abstract/Free Full Text] - Tilden VP, Schmidt TA, Limandri BJ, Chiodo GT, Garland MJ, Loveless PA. Factors that influence clinicians' assessment and management of family violence.
Am J Public Health. 1994;84
(4):628
–633
[Abstract/Free Full Text] - Flaherty EG, Sege RD, eds. Translating child abuse research into action: improving primary care recognition and collaboration. Pediatrics. 2008;122 (3)(suppl). Available at: www.pediatrics.org/cgi/content/full/122/3/S1
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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