Child Abuse: Why It’s So Hard to Determine Who’s at Risk
By Bonnie Rochman
Prevention is nearly always preferable to treatment when it comes to our health, and the stakes are even higher in cases of child abuse. But is it even possible to identify children at risk of abuse before it’s too late? That’s the question the U.S. Preventive Services Task Force (USPSTF) addressed, in a comprehensive review of the available data on ways to detect maltreatment of children.
The task force is a government-funded group of independent experts that considers all the available evidence on a range of health topics, then grades studies on their reliability and validity before making recommendations based on the quality of those results. In recent years, its review of the benefits of mammography in preventing breast cancer and prostate specific antigen (PSA) testing in detecting prostate tumors caused controversy when it recommended that men skip regular PSA screening altogether, and that women wait until they reach 50 to begin routine mammogram testing — a full 10 years later than previous advice.
When it came to deciding whether pediatricians should implement wholesale interventions to prevent child abuse, the task force enlisted researchers at Oregon Health & Science University (OHSU) to scrutinize a decade of existing literature.
In a sobering acknowledgement, the USPSTF believes that there is not much that can be done to detect cases of child maltreatment that aren’t glaringly obvious. There’s simply not enough research to make a case for advising physicians to take specific actions during well-child visits, for example, to help determine which children are at risk. In 2010, nearly 700,000 children were victims of abuse and neglect; 1,537 of them died.
“Obviously children who present with multiple bruises, you already have a high level of suspicion and will immediately launch into questions,” says Dr. David Grossman, a pediatrician who is one of the 16 members of the task force and a senior investigator at Group Health Research Institute in Seattle. “But for kids who don’t have symptoms, do we have methods to determine which children are at high risk and are currently being maltreated? We don’t, and that is disappointing. We would love to be able to add some tools to the toolbox for primary care clinicians.”
The researchers at OHSU analyzed 11 studies that evaluated the effectiveness of child abuse and neglect prevention programs or interventions that took place in clinics — such as meetings with a social worker, for example. They gave parents questionnaires that assessed such risk factors as substance abuse, depression, stress and attitudes toward physical punishment — as well as noting whether parents were concerned that their child may have been physically or sexually abused. Doctors discussed the risk factors with parents and referred them to social workers if needed. After three years, researchers found that parents who took part in risk assessments and received social work referrals, if necessary, had decreased incidences of abuse, fewer reports to Child Protective Services (CPS) and better adherence to immunization schedules.
But the studies’ results were not persuasive enough to warrant new recommendations for physicians, says Dr. Heidi Nelson, senior author of the study analysis published in Annals of Internal Medicine and a research professor in medical informatics, clinical epidemiology and medicine at OHSU. “This is not about identifying kids who are being abused,” says Nelson. “This is about determining if a family in front of me is at risk for abuse in the future.”
A major challenge with determining who is at risk for child abuse is how — and to whom — to pose questions. If the parents who bring a child to a check-up are mistreating that child, says Grossman, it’s not likely they will volunteer that information. “You are potentially asking the perpetrators if there is a problem,” he says.
While evidence underpinning the effectiveness of screening questions is scanty, home visits seem to have had more success. Last year, a study in the Journal of the American Medical Association (JAMA) found that home visits can cut child maltreatment cases by up to half. States determine eligibility for home visits in different ways, but poor moms, single moms, homeless moms, teen moms and those with a history of domestic violence typically top the list. Home visitors serve as a sounding board and support system, educating moms about normal infant behavior, cautioning them against shaking crying babies and offering suggestions for stress relief and interacting with their babies. Parenting can be overwhelming even for educated, well-to-do women, but those who are less fortunate stand to benefit even more from having someone help them navigate the challenges of child-rearing. In fact, when researchers evaluated the effect of home visitations, they found that those babies whose families were visited by nurses were less likely to die of all causes by age 9 than other children. Some studies showed that children who benefited from home visits had less contact with CPS and fewer trips to the hospital.
But other studies on home visits have shown mixed results, leading the task force to stop short of issuing a blanket recommendation for primary-care clinics across the U.S to adopt the program for families they perceive to be at risk. “It’s one thing to say that it’s a good idea, but it’s another to say that we have definite proof,” says Nelson.
The task force last took up this issue in 2004; it will take another look at any new studies that have emerged five years from now to see if things have changed. In the meantime, for the next 30 days the public is welcome to submit comments on the task force’s preliminary recommendations. “We are looking to see if we missed any key pieces of evidence,” says Grossman.
Some may point out that the criteria the task force apply to data may be too rigid, and could miss some valuable information about the forces behind child abuse that may not be captured in a quantifiable way. Dr. Bob Block, a retired pediatrician who specialized in cases of child abuse, and the past president of the American Academy of Pediatrics, says relying on blinded and controlled studies is not the only way to figure out what works. “The task force doesn’t accept clinical anecdotal information, and we do have some interventions that have been shown to be effective — nurse home visiting and teaching methods we use in the hospital to help teach parents not to shake their baby,” says Block.
Studies about the effectiveness of shaken-baby teaching videos have been mixed, but some parents clearly benefit. “If I have a video that helps parents remember that crying babies are normal, I’m going to use that,” says Block. “There is no downside. There are two parts of medicine: the research end and the clinical end where you apply what has worked for you or others.”
Yet, despite the lack of scientific evidence that they can reduce child maltreatment, home visits, for example, are widely embraced in other countries. “It would be ideal to do this for everyone,” says Block. But lack of funding means it’s often limited to first-time, low-income, younger moms — if it’s available at all.
Even some child-abuse experts agree, however, with the task force’s caution about endorsing home visits. The best home-visiting programs set specific criteria for those who qualify, says Dr. James Anderst, director of the Division on Child Abuse and Neglect at Children’s Mercy Hospitals and Clinics in Kansas City, Mo. “We can’t have a situation where a doctor is worried and all of a sudden a home visitor just shows up at someone’s home,” says Anderst.
He and others recognized that home visits could amount to a type of profiling of parents. Because there’s not unlimited funding, the programs often rely on certain criteria, such as household income, single parenthood and a mother’s age to determine whether a child is likely to be abused or mistreated. Not all of the parents who meet these conditions will mistreat their children, so targeting them could potentially be perceived as unfair and insulting.
That doesn’t mean pediatricians’ hands are tied when it comes to pre-empting potential abuse. “I don’t think this means that pediatricians should do nothing,” says Anderst. “We should just continue to do what we’re probably doing already – counseling parents about appropriate behavior techniques, teaching them about what kids need. Most primary care physicians say, I’m going to teach these people how to be good parents and hope they will do this when they go home.”