by Greg Lopez, MD (’24)
A child abuse rotation is an unorthodox way to start residency. On my first rotation, I had the privilege to learn from the experts in the Aubin Child Protection Center about how to respond to this unfortunate aspect of our field. It was reassuring to learn how to support children following the maltreatment they experienced, but I also found myself wondering what resources and strategies are available to prevent maltreatment before it happens.
Though each case stems from its own unique set of circumstances, there are numerous risk factors for child maltreatment that serve as valuable targets for preventative interventions. These risk factors can be broadly categorized into three groups — child risk factors (prematurity; long-term disability or medical condition), caregiver risk factors (teenage or single caregivers; lack of preparation or support; history of mental health issues, substance use, domestic violence), and community risk factors (high rates of poverty and unemployment; lack of social services).
As providers, our prevention strategies often target caregiver risk factors, as they are most able to be directly addressed with an individual family in a clinical encounter. Screening for risk factors and providing anticipatory guidance to let families know what to expect in normal child development allows us to address stressors and potential incidents of maltreatment before they occur. Community organizations take a similar approach, focusing on identifying families with risk factors of child maltreatment. One such group is the Nurse-Family Partnership (NFP), which targets low-income, first-time mothers and offers prenatal care, anticipatory guidance, and assistance with financial planning. Randomized controlled trials have demonstrated that families working with the NFP have significantly lower rates of child maltreatment.
Despite the benefits that these interventions provide, there are drawbacks to a targeted, caregiver-focused approach. While screening systems may be robust, some families will inevitably slip through the cracks and miss out on available resources. It can be difficult for caregivers to respond truthfully to screening questions about their needs if they feel a stigma attached to being labeled “at risk” or that they may be looked at as unable to provide for their children. Caregivers who work multiple jobs or who do not have access to reliable transportation may have more difficulty scheduling and attending well-child visits for their children, which means they may not be screened in the first place. And though community organizations can provide significant benefits, this requires active participation from caregivers, which places increased responsibility on families that are likely already stretched too thin.
Ultimately, the most significant drawback to targeting caregiver risk factors is that it still leaves the overarching community risk factors untouched. We can provide caregivers with all the emotional support and guidance in the world, but if the family remains in poverty, in unsafe housing, in an unsafe neighborhood, those risk factors and increased cumulative stress still lead to greater risk of child maltreatment. As we consider other ways to address child maltreatment, we must think upstream and take a public health approach to address the broader socioeconomic risk factors that put these families at risk. Rather than target specific families, the goal of this approach is to provide universal support to ensure that fewer families are at risk to begin with.
The Centers for Disease Control and Prevention (CDC) has adopted this public health lens to child maltreatment, with an effort to change the scope of the conversation. When individual families become the focus of prevention, the tendency is to view child maltreatment as someone else’s problem and an issue affecting “bad” families. The CDC utilized a different framework for their messaging, describing their efforts as working to ensure that all children had “safe, stable, nurturing relationships and environments.” In surveys comparing the two approaches, respondents were more likely to support preventative measures when described using the latter, more universal narrative.
The California Essentials for Childhood Initiative, which involves a partnership between the Office of Child Abuse Prevention and the Safe and Active Communities Branch of the California Department of Health, has successfully advocated for an increased minimum wage, improved family leave policies, increased subsidized childcare, and expansion of the state’s Earned Income Tax Credit. When child abuse experts and public health experts worked together to address the issue of maltreatment through universal prevention, they were able to achieve tangible financial and social benefits for families, which directly address the community risk factors of child maltreatment.
If we can identify community risk factors that contribute to higher rates of child maltreatment, we do our kids a disservice if we do not actively confront those issues. Thinking upstream widens the scope of possible solutions, as any approach that seeks to reduce poverty or make communities safer becomes viable. Advocating for causes like universal healthcare, increased wages, and more affordable housing would all directly impact risk factors of child maltreatment by providing socioeconomic benefits to families and communities. These broader efforts, in conjunction with existing targeted interventions, provide a truly comprehensive approach to addressing child maltreatment and ensure that we are doing everything we can to keep kids safe.
Bethea L. Primary prevention of child abuse. Am Fam Physician. 1999 Mar 15;59(6):1577-85, 1591-2. PMID: 10193598.
Kairys S. Child Abuse and Neglect: The Role of the Primary Care Pediatrician. Pediatr Clin North Am. 2020 Apr;67(2):325-339. doi: 10.1016/j.pcl.2019.11.001. PMID: 32122563.
Ashraf IJ, Pekarsky AR, Race JE, Botash AS. Making the Most of Clinical Encounters: Prevention of Child Abuse and Maltreatment. Pediatr Clin North Am. 2020 Jun;67(3):481-498. doi: 10.1016/j.pcl.2020.02.004. Epub 2020 May 4. PMID: 32443988.
Jack SM. The role of public health in addressing child maltreatment in Canada. Chronic Dis Can. 2010 Dec;31(1):39-44. PMID: 21176413.
Klevens J, Alexander S. Essentials for Childhood: Planting the Seeds for a Public Health Approach to Preventing Child Maltreatment. Int J Child Maltreat. 2019;1(2):10.1007/s42448-018-0009-8. doi:10.1007/s42448-018-0009-8
Abbott, Marissa & Wirtz, Steve. (2019). California Essentials for Childhood Case Study: Collective Impact Through Strategic Opportunities. International Journal on Child Maltreatment: Research, Policy and Practice. 1. 1-20. 10.1007/s42448-018-0012-0.