In my home county of San Diego, school closure has meant some 800,000 children staying home.1 Parents love and are committed to care for their children, but as these parents struggle with food insecurity and mass unemployment, local pediatricians are joining their national colleagues in worrying about rising rates of child abuse.
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Dr. Gwendolyn Wright, a local pediatrician at Scripps Coastal Medical Center, San Diego, explains. “Obviously, it’s easy for tempers to flare,” during this stressful time, “so there is increased risk for child abuse. And there’s no one else with eyes on the kids. Usually, there would be teachers at schools and other childcare workers who would have eyes on the kid. And now there is none of that extra protection.”
2018 data from the National Child Abuse and Neglect Data System showed that in 91.7% of child abuse cases, one or more parent perpetrated the abuse.2 Prior reporting in our county showed that calls to the child abuse hotline went down nearly 60% a week after school closure.3 However, this is not necessarily good news. NCANDS data show that educational personnel report 20% of child abuse cases – far more than the number of cases reported by social services, medical professionals, or family members.2
Teachers, childcare workers, law enforcement, and medical professionals all are mandated reporters, meaning that they are legally obligated to report any suspected cases of child abuse to Child Welfare Services. Accordingly, they receive training on how to spot signs of child abuse.
Sometimes, the signs are obvious, sometimes subtle. Subtle injuries are called “sentinel” injuries. In a landmark study published in Pediatrics in 2013, a “sentinel” injury was defined as “a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible.” Sentinel injuries can be mild bruising or oral injuries in a young infant. These injuries suggest “there may be escalating and repeated violence toward the infant” that can culminate in death.4,5
In this study, severely abused infants were 4.4 times more likely to initially have come to the doctor with a sentinel injury. Of concern, 42% of parents of definitely abused children reported that a medical provider was aware of the sentinel injury. Of these cases, 56% did not show evidence that a professional was worried about abuse. These data show that medical professionals do miss cases of child abuse.
Dr. Sejal N. Parekh
The cost of child abuse is real and lifelong. According to a policy statement from the American Academy of Pediatrics Council on Child Abuse and Neglect, a quarter of kids who suffer abusive head trauma die. Of the survivors, nearly 70% “have some degree of lasting neurological impairment.”5
Given the potentially disastrous consequences of child abuse, we must stay vigilant about child abuse. In our own profession, we must educate trainees and update experienced pediatricians about suspecting child abuse and reporting. For example, child abuse can be suspected and reported based on telemedicine interactions. The burden of proof for reporting child abuse is only “reasonable suspicion,” not “beyond a reasonable doubt.” In our communities, we must engage with local Child Welfare Services workers and educate them about sentinel injuries. And finally, in our practices, we must build families up with awareness, resources, and coping mechanisms to prevent abuse from happening in the first place.
Dr. Helen C. Wang, associate professor of pediatrics at the University of California, San Diego, talks to parents about managing stress early and often. She says, “I start counseling families at the prenatal visit. I do talk to families about what they liked to do before children. What brought you joy? What communities do you spend time with? And what have you been doing now?”
It can be hard to reconcile prior hobbies with the current recommendations of social distancing. “Now it’s more ‘Do FaceTime’ and ‘Do Zoom’ and spend more time with your extended family,” says Dr. Wang.
By caring for themselves, parents can better protect their children from mistreatment and injury. Healthychildren.org, the parent-facing website of the AAP, offers several tips for parenting in times of stress.
In this unusual time of COVID-19, it is more important than ever to provide parents with suggestions and strategies that will help them – and their children – survive this health crisis. By educating ourselves and our communities about child abuse, we as pediatricians can fulfill our mandate in keeping kids healthy and thriving.
Dr. Parekh is a pediatric resident at University of California, San Diego. She has no financial disclosures. Email Dr. Parekh at pdnews@mdedge.com.
References
1. Early childhood age group in California. kidsdata.org.
2. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child Maltreatment 2018.
3. Hong Joe. “School closures lead to troubling drop in child abuse reports.” KPBS. 2020 Mar 27.