Family Matters

Child Abuse: Why It’s So Hard to Determine Who’s at Risk

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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.”

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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.

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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.”

MORE: The Shaky Science of Shaken Baby Syndrome


I think one problem is sometimes people refuse to see some things as abuse because they fazil to understand that just because someone has always been that way or has worked certain amount of years in the teaching world IT DOES NOT mean they should be allowed to treat children certain way s and get away with it...especially whe it happens time and time again....


"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."  This type of thinking ... that those who have more money make better parents is one of the biggest problems in child protection today.  The statistics that back of this type of misguided thinking are stats based on those poor parents accused and dragged through our draconian family courts with no money to hire an attorney to aggressively defend their civil rights.  Essentially what we have created is a system of harvesting the children of the poor for profit.  These families cannot protect their children from those who take them away on the basis of suspicion and accusation alone.  They are forced to watch while their children are drugged, abused, shuffled from foster home to foster home, and sometimes murdered in the custody of the state.  The fact is that a well-educated, wealthy parent is just as capable of child abuse and neglect as a person who has less education and less income.  Parenting is more instinctual than people realize.  So, don't blindly judge those who have less as automatically being potentially bad parents.  This is discriminatory and racist thinking and needs to be squashed.  The children of the poor don't need mandated reporters in our hospitals and schools interrogating and strip searching them.  Children need to know that even though they are poor, they are still loved and accepted.  Child protection was an extremely bad agenda and millions of children and their families have lived through hell as a result of it.  How many children have been murdered as a result of this agenda in foster homes and adoptive homes?  You can't help people by hurting them.  Help is something you can offer, not order.  For the crime of child abuse, like any other crime, we should dial 911.  We don't need a system that preys on families.  It's a disgraceful legacy and it needs to end.


“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 ... Here is a doctor who will target the parents of vigorous, active, healthy children.  Healthy, vigorous, active children will suffer as a result of this doctor's take on childhood.  Perhaps he was never allowed an active childhood and simply doesn't understand how physical some kids are.  He should not be allowed to participate in this kind of decision-making, nor should others like him. 


@JulienHolderbaum The sentence you quote has no mention of race, nor does the rest of this article if you are associating low income families with a particular race, then concluding that the author is racist, you should perhaps review your own preconceptions. I think the issue you particularly refer to could have been better explained in this article. I understand it to be that families with more resources (money, support systems, access to community services etc...) are more likely to use those supports and avoid hitting the breaking point (which leads to abusing or neglecting their children.) In the context of assessing risk, having fewer supports of any type increases risk. In no case does any particular set of circumstances (like poverty) mean that a parent will abuse  a child, as likely the majority of parents of any classification probably do not (an exception might be alcohol or dug addicts, but I wouldn't even feel sure of that without looking at some research) Its a fair assumption to research though that poverty/having little access to any supports or resources, places children at greater risk of abuse or neglect. 

As to your allegation that the child welfare system has a for profit agenda of "harvesting children". Show me where the money is, because after almost 20 years in this field, I have yet to see it.


@JulienHolderbaum As much as I agree to a point that class is not always the issue in child abuse, I don't think it entirely fair to lump these cases together under the idea that these poorer families are targeted without reason.  I worked in residential treatment for teenage girls often suffering from mental illness and an overwhelming majority were abused physically, sexually, or psychologically. Often times it was all three.  They came from varying backgrounds and sadly a lot did come from poor homes.  I don't think the state was evil and targeting these kids as they were mistreated for often years until there was any investigation.  For a child that was raped by 3-4 members of her family I just wished the state had intervened sooner.  I agree that the foster care system is often broken and I also understand how difficult it is to place children with such terrible backgrounds in good homes as they have often developed some serious behavior issues as a result.  

One girl came from a poor home where her mother was addicted to meth, hardly fed her, and had boyfriends over who molested her on a near constant basis.  They moved her in with loving relatives only to have her sexually abuse their young children shortly after.  We dealt with cases like this all the time but you seem to argue that these families are better left alone.  I couldn't disagree more.  There are no simple solutions but I don't know where you're getting the idea that the state or someone else financially benefits from removing these kids from their homes and placing them elsewhere. On the contrary, there are constant cuts made to these programs.  At our facility our referrals went way down not because of a lack of need for our services but because of budget cuts.  We started receiving kids who really needed a higher level of care we could provide as many mental wards accepting minors closed down across the state.  It's something we need to fund more and do so more efficiently but the idea that these children should continue to suffer as they come from toxic homes (regardless of their income) we should continue to intervene.  And to be honest, these are very difficult kids to works with through little fault of their own.


@JulienHolderbaum there are specific types of bruising that are indicative of abuse, versus kids who are very active.  Brusies along the shins and elbows, for example, raise less concern than bruises along the spine and in particular the lower back. Bruises on the wrist are of concern as well.  Bruises ont he face require questions to determine what caused them. Your judgemental attitude is no different that what you are accusing the Dr's of having.