In this issue of Pediatrics, Dr. Pinto Pereira and colleagues1 describe important associations between maltreatment experiences in childhood and work–life circumstances in adulthood. The strength of this work lies in a unique British birth cohort followed over 50 years. Using exposure variables collected both prospectively (child neglect) and retrospectively (child abuse and emotional neglect), the authors identify differences in employment, financial stability, social class, and social mobility at 23 and 50 years of age after adjustment for early-life confounders. The authors go on to explore how mental health and cognitive capacities in adolescence may serve as mediating factors between these childhood experiences and adult socioeconomic outcomes.
The findings, particularly those prospectively collected on neglect, add to growing evidence that child maltreatment contributes significantly to the trajectory of a child’s life.2–5 As the literature of child maltreatment, adverse childhood experiences, and social determinants of health expands, however, it is worth critically examining the measures used to define these childhood experiences. In their work, Pinto Pereira and colleagues1 rely on parent and teacher reports of limited parental engagement and unkempt child appearance to define neglect at 7 and 11 years of age. Emotional neglect is identified with recollections of poor parental affection during childhood by 45-year-old participants. Abuse, in all forms, reflects physical and sexual maltreatment by a parent recalled by that same 45-year-old adult.
Although few would argue that these experiences reflect positive childhood experiences, many will also recognize that these measures are likely to both over- and undercount experiences that would be recognized as child maltreatment. Definitions of physical or sexual abuse that exclude injuries inflicted by a child’s uncle or a mother’s boyfriend clearly miss important events that we count as child maltreatment. On the other hand, definitions of child neglect may capture much more than child maltreatment. Does a child’s “scruffy or dirty” appearance reflect child neglect or household poverty? Similarly, do rare outings with a parent indicate neglect or unsafe neighborhoods? Finally, does a lack of parental interest in education indicate neglect, or the reality of work hours that do not accommodate parent–teacher meetings or illiteracy that makes helping with homework a futile and humiliating experience?
As professionals working to strengthn the culture of health around children, we recognize that bad things happen to far too many of our kids: child maltreatment, adverse childhood experiences, toxic stress, social determinants of health. How much does it matter what we call these things? As professionals working across disciplines, we argue that this choice is not simply an issue of semantics. Our words matter.
Words matter because they shape our practice. For US readers, experiences defined as child maltreatment trigger a mandated referral to child welfare agencies in the community. For some families, this referral is absolutely appropriate and can provide critical resources and support to protect the physical and emotional wellbeing of a child. When we begin to see every childhood adversity as a form of child maltreatment, however, we are failing our children and their families.6 A referral to child welfare may simply pass an under-resourced family from the clinic to a caseworker, who has no more ability to fix social inequities than does the referring physician. Framing those childhood adversities associated with household poverty, poor education, and parental mental health as social determinants of health, rather than forms of child maltreatment, returns them to the medical setting, where emerging research suggests that well-designed interventions can improve health and reduce risk for future child welfare involvement.7–9
Words matter because they shape our policies. In their final paragraph, Pinto Pereira et al1 note that their findings on “the full costs of child maltreatment” should help refine policy priorities. Policy priorities change, however, if the true exposure is not child maltreatment, but is household poverty, neighborhood safety, or parental mental health. Policies that simply ask more of our colleagues in often underfunded child welfare agencies because of ever widening definitions of child maltreatment help no one. We should all work toward effective, evidence-based policies to address child health, and that begins by not collapsing the full spectrum of social determinants of health under one umbrella term: child maltreatment.
- Accepted October 20, 2016.
- Address correspondence to Kristine A. Campbell, MD, MSc, Department of Pediatrics, University of Utah, Primary Children’s Hospital Center for Safe and Healthy Families, 81 North Mario Capecchi Dr, 4E-200, Salt Lake City, UT 84113. E-mail:
The opinions reflected in this commentary reflect the opinions of the authors, and do not reflect official opinions or positions of the University of Utah or of the Utah Division of Child and Family Services.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: Dr Campbell’s institution receives financial compensation for expert witness testimony provided in cases of suspected child abuse, for which she is subpoenaed to testify. Drs Myrup and Svedin indicate they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-1595.
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- Copyright © 2017 by the American Academy of Pediatrics