Child Maltreatment

Interventions

Evaluating a family’s capacity to care for a child or adolescent is a critical aspect of health supervision. In cases of suspected maltreatment, a comprehensive assessment of both the child or teen and the family is essential. This section provides primary care providers with interventions that can assist with this process.

Health professionals are legally mandated to report any suspected abuse or neglect and should immediately notify the designated child protective service agency. Any medical, psychiatric, or forensic evaluations must be carefully conducted and appropriately documented.

These interventions are presented in the context of the child or teen, family, and community.

Child or Adolescent more information

  • If maltreatment is suspected, try to talk with each parent and the child or teen privately when gathering health and family histories.
  • If evidence of abuse or neglect is present, take immediate steps to protect the child or teen once he or she has been medically evaluated and stabilized.
    • Health professionals are legally mandated to immediately report any suspected abuse or neglect to their designated child protective service agency.
    • If it appears that the child or teen is not safe at home, the primary care provider should request an emergency out-of-home placement when making the mandated referral to the protective service agency.
  • If evidence of neglect is present, assess its severity. If it appears that the child or adolescent is at significant risk, notify child protective services.
  • Primary care providers need to consider safety issues in the medical setting.
    • Ask other staff members to stand by and consider asking your health center’s security force or the local police to be present if you anticipate that a parent may become upset or agitated when he or she is told that the child or teen cannot go home or that a protective agency referral has been made.
    • If maltreatment by a parent is suspected, do not leave the parent and the child or teen alone together in the exam room or waiting room.
  • When discussing a protective services referral with a parent, the following approaches may be helpful:
    • Calmly review the objective indications for the referral without ascribing blame (e.g., “I am legally required to report this type of fracture, because this injury is sometimes seen in children who have been abused”).
    • Highlight your concern for the child or teen and the family as the main reason for the referral (e.g., “We want to make sure that everyone in your family is safe”)
    • Explain that you will continue to work as an advocate for both the child or teen and the family.
  • Children or adolescents who have been sexual abused can be extremely afraid to disclose the abuse. They may be able to talk about the abuse only after a significant effort has been made to help them feel safe. It is also possible that a child or teen will recant her disclosure.
    • The child or teen who discloses sexual abuse should have a timely and comprehensive medical and psychological assessment by health professionals with expertise and experience in treating sexual abuse.
    • Prompt evaluation and treatment of the child or teen and the family is the best way to avoid or minimize the serious problems that can result from sexual abuse.
    • If a child or teen says that she has been sexually abused, parents or other caregivers and the primary care provider should help the child or adolescent understand that what happened was not her fault.
  • For any child or teen who has not had adequate nurturing (including children and adolescents who have not suffered overt abuse or neglect), primary care providers should consider the following interventions:
    • During office visits, provide opportunities for the child or teen to talk openly about his feelings and experiences in the family.
    • Look for difficulties in the following important areas:
      • General mood and behavior, including
        • Inhibition, withdrawal
        • Aggression or anger
        • Overt passivity, compliance, or dependency
        • Attachment difficulties
        • Demanding behavior and oppositionality
        • Role reversal (child or teen takes on adult responsibilities)
      • Relationships with family members
      • Relationships with peers
      • School functioning
      • Development
    • For impairment in functioning that persists despite support, guidance, and the child’s or adolescent’s efforts to change, consider a referral to a mental health professional.
    • Encourage relationships between the child or teen and other positive adult role models.
    • Help the child or teen access sources of support (e.g., after-school programs, clubs, sports, faith-based youth groups).
    • Tell the child or adolescent how to contact you between visits.
Screening Instruments and Questionnaires

The following may help primary care providers assess a child’s or teen’s functioning

Family more information

  • Primary care providers should take steps to increase early awareness of and communication about maltreatment issues. Stress that adults are responsible for protecting children. Emphasize that a child or teen is never to blame for an adult’s harmful actions.
    • As part of the initial health supervision visit, preferably the prenatal visit, ask parents if they were ever exposed to maltreatment during their childhoods. Ask about history of or current mental health problems and specifically about substance use problems.1
    • Discuss with new parents the dangers of shaken baby syndrome.
    • Discuss strategies that can help parents cope when they feel overwhelmed or are about to lose their tempers:
      • Take a deep breath and count to 10
      • Take time out and let the child cry alone; in a safe place
      • Call a close friend or family member for emotional support
      • Call the primary care provider's office to see if there may be a medical explanation for why the child is crying
      • Remember that it is never OK to shake, throw, or hit a child
    • Train office staff to be responsive to any telephone calls from distressed parents.
    • Assist parents in finding ways to talk to their child or teen about interpersonal safety.
    • Share with parents the American Academy of Pediatrics' recommendations for preventing their child from being sexually abused. (See resources below)
    • Provide parents with guidelines for preventing child maltreatment, such as Handling Anger and Countering Abuse in the Community. (See resources below)
  • Protecting a victim of child maltreatment involves engaging community support and resources to address sources of stress within the family. These may include:
    • Parental substance abuse; parental mood, anxiety, or personality disorders. Refer parent to mental health services (e.g., substance abuse treatment, individual or family treatment).
    • Marital discord, domestic violence
      • The estimated overlap between domestic violence and child abuse ranges from 30 to 60 percent.2
      • If the home is unsafe, help family members access shelter services and seek police and legal protection.
      • For ongoing marital discord without violence, refer parents for couples counseling.
    • Poverty, inadequate housing
      • Engage social services for referrals to housing and financial services, job training, and educational opportunities.
    • Physical illness or disability in parent or child or teen
      • Engage social services to help all family members access adequate medical care.
      • Refer for respite care or home visiting services.
    • Poor social supports
      • Refer to community support groups.
      • Help parents learn to engage relatives, friends, or neighbors to provide respite child care, to model parenting practices, and to provide social opportunities.
      • Provide numbers for crisis hotlines.
  • Discuss with parents the impact of stressors and risk factors on parenting practices. Strengthen family and community support. Screening tools such as the Parenting Stress Index (PSI) can help primary care providers identify families for further evaluation or possible referral.
  • Discuss basic concepts of child development to help parents form reasonable expectations of their child.
  • For parents at risk for child maltreatment, discuss the benefits of learning about child development, strengthening parenting skills, and learning to manage stress and anger. Help parents access community programs that provide services in these areas. If necessary, work with the designated child protective services agency to ensure successful completion of the referral and continuation of the program.
Resources for Providers and Families

For Providers

For Families

Primary care providers may want to share the following with families:

References

  1. Wilson, C., & Knight, J. (2001). Neglect: The silent cry. In J. R. Knight, C. Frazer, & S. J. Emans (Eds.), Bright Futures Case Studies for Primary Care Clinicians: Child Development and Behavior. Boston, MA: Bright Futures Center for Education in Child Growth and Development, Behavior, and Adolescent Health.
  2. Bragg, H. L. (2003). Child Protection in Families Experiencing Domestic Violence. Children’s Bureau - Office on Child Abuse and Neglect. Washington, D.C.: U.S. Department of Health and Human Services.

Community or School more information

  • Communitywide prevention efforts can help reduce the incidence of child maltreatment. These efforts benefit from the participation of primary care providers.
  • Social disorganization within a community is one of the key characteristics correlated with child maltreatment. Primary care providers are powerful advocates on behalf of children, teens, and families at risk for family violence. Consider suggesting to members of the practice team that they become involved in community-based initiatives (e.g., domestic violence shelters, public housing units, neighborhood centers).
  • Inform parents about their community’s 24-hour support services and telephone hotlines. Develop a list, and give every family a copy.