Role of the Pediatric Health Care Provider in Identifying and Preventing Child Abuse During COVID-19 and Beyond

AUTHORS:
Andrea Repine, MSN, APRN, CPNP¹ • Jennifer Macaulay, MSW² • Stephanie Anne Deutsch, MD, MS¹

AFFILIATIONS:
¹Department of General Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
²Department of Social Work, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware

CITATION:
Repine A, Macaulay J, Deutsch SA. COVID-19 and child abuse: practical steps to address child safety. Consultant. 2021;61(9):e1-e6. doi:10.25270/con.2021.03.00010

Received September 4, 2020. Accepted December 28, 2020. Published online March 15, 2021.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Andrea Repine, MSN, APRN, CPNP, Department of General Pediatrics, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803 (andrea.repine@nemours.org)

The COVID-19 pandemic has changed the lives of the children and families we serve. In 2020, many states and counties across the nation ordered shelter-in-place and social distancing measures, which included nonessential business shutdowns, school closures, public park and recreational facility closures, and elective health care visit cancellations. Daily life and routines for most children and families were dramatically disrupted. Unfortunately, a year later, pandemic-related conditions persist, and many families continue to face issues of economic insecurity, juggling work demands, tending to childcare needs, and providing educational supervision for children tasked with learning remotely, all while social distancing recommendations remain in place. The "new normal" continues to stress the US population, and most of us are still mostly spending time at home

Unfortunately, acute and chronic stress can lead to unintended consequences and impact child safety in the home. It can diminish one’s ability to control or manage mood and behavior, which, for parents/caregivers, may create or exacerbate an abusive dynamic when interacting with children.¹ Historically, stressors like economic uncertainty have precipitated spikes in child abuse, use of spanking as a parenting behavior, and abusive head trauma diagnosis.^2,3,4 Importantly, social isolation is also a primary risk factor for abuse.⁵ Social distancing measures, in an early cross-sectional study, have also been shown to heighten risk for abuse, exacerbating underlying mental health conditions such as anxiety and depression, and creating limited opportunities for caregivers to physically go outside to destress in the community. This can incite parental frustration and lead to inappropriate discipline measures or other acts of physical violence.⁶

In particular, concerns for family-level violence have persisted during the pandemic, and several major media outlets and opinion articles written by advocates and providers have reported an uptick in intimate partner violence, both nationally and internationally.^7-10 Early in the pandemic, the United States alone reported domestic violence incidents increased an average of 30%, with many other countries reporting similar numbers.¹¹ Violence between intimate partners is often codirected toward children.¹⁰ According to Prevent Child Abuse America, there is a known, well-established association between domestic, intimate partner violence and child abuse.¹² In fact, 30% to 60% of children from homes where violence occurs also experience abuse.^12,13,14 Stressed parents who experience violence from their partner are at an increased risk of neglectful or abusive parenting directed toward their children, and partner violence in the home constitutes the single, greatest risk factor for child abuse-related fatalities.^10,12,15,16

Chronic future uncertainty and frustrations surrounding the “new normal” of home and work life have the potential to create negative dynamics, resulting in unsafe havens at home for many children abused or neglected by those responsible for their care. Early in the pandemic, startling trends emerged; the Childhelp National Child Abuse Hotline reported 31% more calls and messages in March 2020 compared with March 2019,¹⁷ and the National Sexual Assault Hotline reported 50% of users of its services during that timeframe were minors.¹⁷ Of those with concerns related to COVID-19 and the shelter-in-place orders, approximately 79% of those reaching out to the National Sexual Assault Hotline were living with their abuser.¹⁷ More recently, published data suggest that while emergency department visits for pediatric health conditions across the country generally have decreased, the proportion of hospitalizations directly related to child abuse and neglect have increased, with hospitalized children having sustained more severe injuries.^18,19

Being "stuck at home" potentially poses an added risk for children, who may experience abuse and neglect from their caregivers.²⁰ This added burden is primarily related to lack of visibility. Historically, federal data have shown that most abusers are direct, intimate caregivers (such as parents),²¹ and with social distancing measures in place there exist added challenges to child abuse detection. Federal data show that most abuse-related hotline reports are filed by professionals who have contact with children as part of their jobs²¹ including teachers, social workers, and health care providers. To abide by social distancing recommendations, many schools nationally initially closed and converted to hybrid, distance-learning models, leaving teachers and other school and community personnel with limited ability to directly interact with children or serve as confidants or safe zones for those experiencing abuse or neglect. Despite more recent liberalization of recommendations allowing many students to engage more directly with learning programs back in school buildings, in-person time with teachers and other school professionals remains limited.

If history is any indication, the situational factors of the pandemic potentially pose a safety threat to children and will likely compromise the detection of maltreatment. What can pediatric health care providers do about it? Pediatric health care providers play a unique role in supporting healthy and safe childhoods and are uniquely positioned to prevent child abuse and neglect. The following outlines practical guidance that can be implemented in everyday practice for detecting child safety concerns during times of social distancing and beyond.

Identify Child Safety Concerns during Telehealth Visits

Early in the pandemic, many routine and well-child examinations were cancelled to limit infectious spread; while some restrictions around in-person visits have been limited, many health care providers continue to routinely utilize virtual platforms via telehealth for safety and convenience purposes. While routine use of virtual platforms is beneficial for increasing access to health care, it limits health care provider opportunities to engage in person with children and families. Telehealth does, however, uniquely offer an opportunity to better understand the lives of those the pediatric health care providers serve.²³ Most importantly, while other supportive relationships (ie, teachers, coaches, faith-based engagement) may have been disrupted, telehealth can assess and address child safety concerns regardless of the chief report or reason for the visit. For example, health care providers may identify physical findings concerning for abuse, such as an ear bruise on an infant or a patterned burn on the arm of an older child during the visit. Alternatively, pediatric health care providers may witness partner violence or worrisome living conditions in the background of a visit; all of which present an opportunity to intervene for safety and enhance abuse detection. Therefore, it is important to be observant when conducting telehealth visits and take note of the interaction between the child and caregiver while taking history of the chief report. Does the caregiver appear supportive and nurturing toward the child? Does the child appear unkempt or alone, with no supervising caregivers around? Children who appear alone, unsupported, or unkempt may be victims of neglect. Is the child exhibiting any unusual behavioral changes? When physically assessing the child, take note of the child’s appearance. Does the child have any physical findings suggestive of abuse? Even minor injuries, such as slight bruises on young infants, can have major significance. These sentinel injuries are often warning signs of future catastrophic injuries, especially in infants and toddlers.²⁴ Bruises are the most common and readily visible injuries due to physical abuse but are often missed, misdiagnosed, or their significance minimized.^5,24 Management of minor injuries can aid jurisdictional child protection agencies in proper intervention to help protect vulnerable children.⁵ 

The following findings identified during telehealth visits should raise concern for inflicted injury and child physical abuse:

• Skin bruising or mouth injuries to pre-ambulatory infants
• Injuries or bruises not over bony prominences (such as on the torso, ears, upper arms, and legs or neck)
• Injuries in multiple stages of healing or on multiple planes of the body
• Patterned injuries that may represent the use of an object such as a loop mark from a belt or linear marks from a hand
• Burn marks that are inconsistent with the history or that are patterned, such as with the use of a hot iron or cigarette burn⁵ 

Bite marks should also raise concern for child safety, although bite marks may be difficult to assess via telehealth and can occur from both adults and other children. Bites will often have an oval pattern and size, and imprint characteristics can help determine the source of injury.⁵ Children with recent skeletal injuries are symptomatic and may have associated crying, visible swelling or deformity of the injured area, or refusal to use the affected limb, bear weight, or engage in normal play activities.⁵ Head trauma is the leading cause of pediatric physical abuse mortality and is most common among infants younger than 2 years.^5,25 Many infants with abusive head trauma present with vague or nonspecific symptoms such as fussiness, spit-ups or feeding intolerance, or altered sleep or feeding patterns. Therefore, it is important to consider abusive head trauma in the differential diagnosis of any fussy infant, as subtle signs may be the only clinical clue. Abdominal injury is another form of abuse and the second leading cause of abuse-related mortality.^4,25 Signs related to abusive abdominal injury may include peritonitis or shock, including vomiting and hypotension.^5,26

Children experiencing suspected physical abuse require urgent evaluation, and if you suspect abusive injury, evaluate the child in person. Children younger than 2 years require ancillary studies to identify occult injury. Skeletal examinations, laboratory studies, and neuroimaging are performed for infants suspected of being abused.⁵ Referral to the local emergency department for urgent assessment should be considered to ensure injuries are thoroughly assessed, any occult findings are identified, and referrals are made to ensure the child’s safety (ie, mandated reports to child protective services and involvement of law enforcement). At a minimum, infants and children whose presentations raise concern for physical abuse should be assessed in person in the office or more frequently over telehealth if otherwise impossible.

Although telehealth can identify physical maltreatment, children affected by sexual abuse may not show visible signs or symptoms of abuse. School-age children and adolescents are at the highest risk for sexual abuse. Risk factors for child sexual abuse often include environments of high stress, high poverty, low parental education, absent or single parenting, parental substance abuse, or domestic violence.^27,28 Of those affected by child sexual abuse, 90% know their abuser and 30% of abusers are family members.²¹ Children most at risk for sexual abuse are those with physical disabilities, mental health conditions, or who are emotionally vulnerable. Victims of child sexual abuse may have psychological symptoms of trauma, such as depression or anxiety, which are easily confused with other mental health conditions.²⁷ These may be difficult to distinguish from poor coping or other natural reactions to social isolation measures during the COVID-19 pandemic. Concerns for suspected sexual abuse should warrant a detailed physical examination, which may be difficult via telehealth without the properly trained professional.²⁸ Individuals experiencing sexual abuse should go to a local pediatric emergency department or sexual assault resource center for immediate evaluation, as forensic evidence collection, testing for sexually transmitted infections, or prophylactic medication administration may be required. Timeframes and clinical planning may vary based on jurisdiction and pubertal status of the child or adolescent. Thus, consulting local resources is recommended. Finally, it is important that if the child or caregiver raises concerns for physical symptoms such as genital discharge, bleeding, or rash, the visit should be completed in a safe, in-person format in a medical office. Providers should avoid examining the anogenital area of a patient via telehealth. 

Information provided during the telehealth visit is limited to those engaging in the appointment, which poses potential challenges. If a provider raises concerns about suspected abuse during an appointment, a thorough history should be obtained by asking open-ended questions. For example, if the health care provider identifies an injury or concerning symptom, he or she should ask the caregiver how and when that injury occurred and correlate that information with the child’s developmental status. For children with complex medical needs, this can be a tedious task and presents difficulties for clinicians to obtain an accurate assessment. However, telehealth also allows for more frequent contact with medically complex patients. This may facilitate “laying continuous eyes” and identifying concerns sooner, leading to a decrease in abuse.^29,30 If a clinician identifies concerns of abuse or neglect via telehealth, an honest conversation should be had with the caregiver. Explain to the caregiver the concerns identified during the assessment and the next steps that should take place. Openly discuss the differential diagnoses. However, if abuse remains on the differential, inform the caregiver that a report will be made to local child protection services, as medical providers are mandated reporters by the state in which they work. The clinician should never assume who the abuser is, even if a caregiver identifies an individual. Determining the abuser or neglector is the role of the investigating agencies. Making statements such as, “I have a concern about your child and your child’s safety,” will often help alleviate negative feedback from caregivers.³¹

Child neglect is the most common form of child maltreatment and is defined as failure to provide medical, emotional, educational, and basic physical needs for the child’s development.³² Risk factors for child neglect align with other types of child maltreatment, including domestic violence, social isolation, and low socioeconomic status; all have been exacerbated during the COVID-19 pandemic.³³ Childhood neglect may have lifelong effects on normal development lasting into adulthood. As health care providers, we may see these children before, during, and after these neglectful events. While it is more difficult to assess a child via telehealth vs in person, pediatric health care providers can identify many forms of child neglect during telehealth visits. Signs of medical neglect include a child presenting via telehealth for a well-child visit but the child appears ill and in some type of distress where a notable delay in seeking care likely compounded the initial presentation and caregivers failed to pursue care in a timely manner. For example, the pediatric health care provider may identify a child with significant cellulitis who needs hospital admission and intravenous antibiotics related to lack of care of a skin injury. Another example is a toddler with poor weight gain that persists despite explicit instructions provided to the caregiver on nutritional supplementation. Physical neglect involves failure to provide basic needs such as food, shelter, and clothing. Health care providers should be mindful of the child’s living conditions during the telehealth visit. Does the house appear to be clean, or is there a visible sanitation issue? Inquire about how the child is feeling, how his or her diet has been, and whether the family is struggling with finding adequate amounts of food or formula.³⁴ If one identifies concerns, consider scheduling more-frequent telehealth visits to reassess potential circumstances of neglect or in-person medical office appointments to assess the child who may be experiencing neglect.

Many forms of maltreatment and violence can occur within the family, but the shift to online and telecommunications for work, school, and socialization increases the risk of perpetration via the internet by individuals external to the household.³⁵ Children and adolescents are at a higher risk for perpetration and victimization when engaging in increased inappropriate online usage. Engaging in online gaming involving violence and other high-risk internet behaviors, such as participating in chat rooms or sexual solicitation, increases the risk of perpetration. With increased use of the internet for everyday life, risk increases.³⁶ Clinicians should alert caregivers to check their child’s internet, social media, and mobile device use, as children are using these formats more often during times of social distancing. It is important to ensure that children and adolescents are staying safe by offering actionable steps that caregivers can take. First, educate families about the potential dangers of increased, unfettered online use and advise caregivers to supervise children’s internet use through modeled behavior. Put the computer or mobile device in a common living space to monitor use or activate parental controls or an online protection program that limits what children can access.³⁵ For adolescents, caregivers should have an open conversation about safety and interacting with individuals online, including avoidance of exchanging digital images (ie, “sexting”) or meeting in person with strangers encountered online. Caregivers should be mindful of signs of unsafe internet use, including adolescents staying up late or for long periods of time to be online, having contact with individuals they do not know, or receiving unsolicited gifts.³⁵ Praise parents for having an active involvement in their child’s new form of “normalcy” and encourage children and adolescents to allow their caregivers to monitor their safety. 

Whether in person or during a telehealth appointment, further assessment of imminent safety risks can be achieved by asking, “Do you feel safe at home?”²⁸ This simple question can assess for safety regardless of the maltreatment concern and offers an open-ended and neutral opportunity for disclosures.   

Mandatory Reporting Obligations

If a clinician suspects child maltreatment during a telehealth visit, a report must be made to the appropriate child protection agency. Early detection of abuse can lead to interventions that provide safety to all children with whom the abuser comes into contact. Mandatory reporting laws do not require absolute certainty, only reasonable suspicion. Failures to report or delays in reporting to child protective services can result in civil or criminal penalties and additional or fatal injury to the child.⁵ If immediate and imminent intervention is necessary during a telehealth visit (such as witnessing domestic violence perpetration in the background of a virtual visit), emergency medical services should be contacted, and the clinician should remain on the line or in the telehealth appointment until emergency responders contact the child or family. 

As pediatric health care providers, an ethical and legal duty exists to protect children, and it may be necessary to have difficult conversations with caregivers and children about abuse-related concerns. Health care professionals often worry that reporting to child protective services will ruin the provider/family relationship. However, this fear should never pose a barrier to the responsibility of reporting suspected abuse.²⁸ Clinicians can maintain the relationship through honest communication about concerns and expectations. Concerns about retaliation, either against the child or the provider making the abuse-related report, should be voiced to investigative authorities at the time the report is made. 

Linkage to Mental Health and Other Support Services

During this time of isolation, children may experience tantrums or other changes in behavior related to disruption of routine. This may be exacerbated among children with emotional, developmental, or other complex behavioral needs who may experience gaps in established therapeutic interventions. Problematic child behaviors may precipitate caregiver frustration and inappropriate discipline methods, leading to abuse. The pediatric health care provider can use telehealth to discuss behavioral concerns with parents or caregivers and offer positive parenting advice and strategies, including praising positive behaviors, ignoring negative behaviors, and re-establishing structure and routine.

Once a child has been identified as experiencing abuse, it is important that children who are experiencing emotional distress related to child maltreatment have access to mental health services.²⁸ Many pediatric mental health clinicians provide outpatient services through telehealth to allow for ongoing care and new patient assessments. It is beneficial to refer children and caregivers to appropriate mental health services when safety or maltreatment concerns arise. Mental health care provides interventions for acute symptoms related to the maltreatment/trauma and mitigates feelings of isolation, frustration, and worry. Some children and caregivers may feel uneasy about conducting a therapy visit via telehealth. Thus, medical providers should discuss the importance of mental health care with the child and caregiver and encourage them to schedule a visit. Social distancing requirements are temporary, and the therapy can transition to an in-person format when it is safe to do so. 

Telehealth offers pediatric health care providers an opportunity to help prevent abuse by fostering emotional connection and linking families with needed resources. Avoid rushing through the visits and consider providing information about positive parenting techniques to all patients and anticipatory guidance about safety. Providers may also screen for other areas of social determinants of health, like food or housing insecurity, or untreated mental health conditions. These may be risk factors for future involvement with child welfare agencies and even abuse. Timely intervention for some of the most basic human needs may prevent some forms of child maltreatment. To meet these identified needs, clinicians should utilize their internal practice resources such as care coordinators or social workers. If these professionals are not available, connect families to a local community agency. Most child protection agencies are offering resources during the pandemic as a method of maltreatment prevention, and many communities have established creative methods of supporting family needs. It is helpful to have a list handy of local agencies providing counseling or crisis support for mental health needs, shelters, food banks, or distribution sites, as well as the hotline number for your jurisdictional child welfare agency.  

Positive Parenting Tips

Pediatric health care providers can play a fundamental role in boosting family resiliency throughout the stressful pandemic time period through positive praise and encouragement. Parenting is stressful on a normal day, but it is even more so during the pandemic. Encourage your patients and their families to take joy in their small victories and celebrate their success. Simple steps, like encouraging families to go for walks outside and get active, can help relieve tension and stress. Creative activities like planning a nature scavenger hunt or taking a family front-stoop portrait are ways to divert attention from future uncertainty. Connecting with family and friends through virtual electronic platforms like Skype or Zoom could be encouraged as well.

Remind parents or caregivers to check in emotionally with their children as well. Many children and adolescents are nervous or scared, and those emotions can escalate when they witness caregiver stress. Asking simple questions like, “What do you look forward to when this is over?” or “What was the best part of online schooling today?” can provide opportunities for children and adolescents to voice concerns about the COVID-19 pandemic and enhance coping.

Clinicians should also remind parents or caregivers to establish routine, because children thrive when there is structure. Improvements in behavior (however slight) may occur if children follow a regular schedule around meals, learning, and play. Positive parenting tips may also be effective abuse-prevention strategies. For example, to help normalize the experience and prevent potential abusive perpetration, reinforce to new parents with young infants who are socially isolated during the pandemic that it is alright to feel frustrated when infants cry and that it is alright to put the infant down in a safe place and walk away for a few minutes. Positive and supportive messaging should be tailored to the individual circumstance and family, but words of encouragement and support can make a difference.^37,38

The COVID-19 pandemic has created a level of uncertainty that many have felt for the first time, and never will feel again, in their lifetimes. Communities and families coming together in unprecedented ways to support each other shows the incredible resiliency of society. Mask-making efforts and sidewalk chalk art for health care providers are two illustrations of a greater-good sentiment. Pediatric health care providers are fortunately deemed “essential personnel” who can and should remain connected to children and families to prevent child maltreatment and family violence—and intervene when others may not do so.   

References

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