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Child Maltreatment: Screening and Anticipatory Guidance
ARTICLE
Continuing Education
Child Maltreatment: Screening and Anticipatory Guidance Gail Hornor, DNP, CPNP
ABSTRACT Child maltreatment is a problem of epidemic proportions in the United States. Given the numbers of children affected by child maltreatment and the dire consequences that can develop, prompt identification of child maltreatment is crucial. Despite support of the implementation and development of protocols for child maltreatment screening by professional organizations such as the National Association of Pediatric Nurse Practitioners and American Academy of Pediatrics, little is available in the literature regarding the screening practices of pediatric nurse practitioners and other pediatric health care providers. This Continuing Education article will help pediatric nurse practitioners incorporate this vital screening intervention into their practice. Practical examples of when and how to incorporate screening questions and anticipatory guidance for discipline practices, crying, intimate partner violence (domestic violence), physical abuse, and sexual abuse will be discussed. J Pediatr Health Care. (2013) 27, 242-250.
KEY WORDS Child maltreatment, screening, guidance
Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children’s Hospital, Center for Family Safety and Healing, Columbus, OH. Conflicts of interest: None to report. Correspondence: Gail Hornor, DNP, CPNP, Nationwide Children’s Hospital, Center for Family Safety and Healing, 655 East Livingston Ave, Columbus, OH 43205; e-mail: Gail.hornor@ nationwidechildrens.org. 0891-5245/$36.00 Copyright Q 2013 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2013.02.001
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OBJECTIVES Based on the content of the article, you will be able to: 1. Identify negative consequences to children resulting from child maltreatment. 2. Describe when and how to provide screening and anticipatory guidance related to discipline, infant crying, intimate partner violence, sexual abuse, and physical abuse. 3. Recognize the impact on children of witnessing intimate partner violence. 4. State when to report a concern of suspected child maltreatment to child protective services. 5. Recognize the link between corporal punishment use and physical abuse. 6. Identify historical indicators of physical abuse.
Child maltreatment is a problem of epidemic proportions in the United States. During 2010, approximately 754,000 children were victims of child maltreatment (U.S. Department of Health & Human Services, 2012). An estimated 1,560 children die nationally each year because of child abuse or neglect, a rate of 2.07 deaths per 100,000 children. Reports indicate that in 2010, 78.3% of victims suffered neglect, 17.6% were physically abused, 9.2% experienced sexual abuse, and 8.1% were psychologically maltreated. Additionally, 3.3 to 10 million children witness domestic violence each year. In nationally representative samples of 2,030 children and 4,053 children, Finklehor, Ormrod, and Turner (2007) and Turner, Finkelhor, and Ormrod (2010) found that 69% and 66% of the children, respectively, had experienced more than one form of child maltreatment. Given the numbers of children affected by child maltreatment and the dire consequences that can develop, Journal of Pediatric Health Care
prompt identification of child maltreatment is crucial. Health care personnel were responsible for only 8.2% of the estimated 3.3 million referrals to child protective service agencies in 2010 (U.S. Department of Health & Human Services, 2012). The importance of early identification of child maltreatment led the National Association of Pediatric Nurse Practitioners (NAPNAP) to issue a position statement that supports the implementation and development of protocols for child maltreatment screening (NAPNAP, 2011). When developGiven the numbers ing protocols for child of children affected maltreatment screening, it is important to by child realize that any one maltreatment and form of child maltreatthe dire ment rarely occurs in isolation. If only one consequences that form of child maltreatcan develop, ment is assessed, proprompt viders may fail to recognize the full buridentification of den of victimization child maltreatment and leave children is crucial. unprotected and inadequately treated. Despite the recognition of the need to identify and intervene in cases of child maltreatment as soon as possible to decrease trauma to children, little is available in the literature regarding the screening practices of pediatric nurse practitioners (PNPs) and other pediatric health care providers, screening for child maltreatment, and psychosocial risk factors for maltreatment, including intimate partner violence. This article will help PNPs incorporate this vital screening intervention into their practice.
REVIEW OF LITERATURE Consequences Consequences of child maltreatment can be physical and/or psychological, and short-term and/or longterm. Immediate consequences of physical abuse can range from minor cutaneous injuries such as abrasions or bruises to more severe injuries such as fractures, abdominal trauma, inflicted head injury, or death. Longterm consequences of physical abuse include residual mental and/or physical disabilities resulting from the initial injuries and psychological problems related to experiencing trauma such as posttraumatic stress disorder, anger, and aggression. Springer, Sheridan, Kuo, and Carnes (2007) and Greenfield (2010) found child physical abuse to be associated with negative health outcomes in adulthood, including an increased likelihood of reporting more diagnosed illnesses such as heart disease, stomach ulcers, and hypertension. Adults who experienced physical abuse were also found to rewww.jpedhc.org
port more physical symptoms, along with anxiety, anger, depression, and drug/alcohol abuse. Sexual abuse has been linked with a variety of behavioral concerns, including sexualized behaviors in young children, symptoms similar to attention deficit disorder, and violent behaviors (Hornor, 2010). Child sexual abuse can also result in the development of posttraumatic stress disorder, depression, suicide, substance abuse, and adult revictimization. Furthermore, exposure to domestic violence can have negative physical, developmental, and psychological effects on children (Hornor, 2005). Children who witness domestic violence are at risk for the development of behavioral and mental health consequences such as posttraumatic stress disorder, anxiety, depression, withdrawal, attention problems, and aggression (Thackeray, Hibbard, & Dowd, 2010). Experiencing corporal punishment (CP) has been linked to a number of negative consequences for children. The use of CP has been linked to increased risk of physical abuse (Sanapo & Nakamura, 2011). Physical abuse often begins as an act of discipline that morphs into abuse at the hands of a frustrated caregiver who loses control of himself or herself. Higher rates of externalizing behavioral problems are seen in children who are spanked (Mackenzie, Nicklas, Waldfogel, & Brooks-Gunn, 2012). Decades of research have implicated CP in the etiology of criminal and antisocial behavior in children and adults (Gershoff, 2002). Children who are spanked demonstrate slower development of receptive verbal capacity (Mackenzie et al., 2012). Experiencing any form of child maltreatment can have negative affects on future parenting ability (Currie & Widom, 2010; Hornor, 2010). Experiencing childhood physical abuse and/or exposure to domestic violence has been linked with perpetrating physical abuse as an adult. A parent who has experienced child sexual abuse is at increased risk to have a child who is sexually abused, not by sexually abusing the child themselves, but by placing the child in high-risk situations and exposing him or her to persons who are likely to abuse. Risk Factors for Child Maltreatment Child maltreatment crosses all economic, ethnic, racial, and religious boundaries. However, certain psychosocial factors place a parent at increased risk of perpetrating child maltreatment and place a child at increased risk for victimization. Parental risk factors include poverty, a childhood history of abuse/neglect, social isolation, being an adolescent or young parent, having unrealistic developmental expectations, having poor impulse control, substance abuse, domestic violence, mental illness/depression/mental retardation, and previous involvement with child protective services or law enforcement (Hornor, 2005; Sidebotham & Heron, 2006). Factors placing children at increased risk include young age (for physical abuse), developmental delay, July/August 2013
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prematurity, congenital anomalies/medical condition, behavior problems, and female gender (for sexual abuse). Corporal punishment and child physical abuse are often linked (Knox, 2010; Zolotor, Theodore, Chang, Berkoff, & Runyon, 2008). Child Maltreatment Screening Practices The role of pediatric health care providers in child maltreatment has primarily focused on the issues of identifying abuse and neglect, reporting it to the appropriate agencies, and facilitating referrals for assessment and treatment (Dubowitz, Feigelman, Lane, & Kim, 2009). However, Dubowitz and colleagues (2009) also discuss the role of the pediatric health care provider in the prevention of child abuse and neglect. Universal or primary prevention efforts can target all children receiving primary care with the intent of screening children and families for known risk factors for child maltreatment (Sidebotham & Heron, 2006), as well as exposure to sexual abuse and/or physical abuse. Leder, Emans, Hafter, and Rappaport (1999) used a qualitative research design to describe barriers to inquiry about sexual abuse by pediatric health care practitioners. Six Maternal and Child Health Bureau– sponsored collaborative office rounds (COR) groups participated in a focus group interview. These COR groups, consisting of pediatric primary care providers (6 to 17) and at least one child psychiatrist or psychologist, were formed in 1989 to promote positive psychosocial development in patients and families. Some COR participants reported giving anticipatory guidance to their patients regarding sexual abuse; however, many reported inconsistencies in their practice. Barriers to inquiry included lack of time, loss of rapport with family, lack of training in sexual abuse, discomfort with discussing sexuality, uncertainty about what to do if sexual abuse is disclosed, lack of appropriate referral services, and belief that child protective services are inadequate. A survey of 542 pediatricians regarding counseling behaviors about inappropriate sexual touching, internet safety, media issues, sexual harassment, and domestic violence was conducted by Hurley, Kellogg, O’Connor, and Baker (2008). Few pediatricians reported routine discussions of inappropriate touching (40%), sexual harassment (14%), and domestic violence (13%) during well-child visits. The opinions of parents and pediatricians in relation to effective anticipatory guidance regarding corporal punishment were elicited by Sege, HatmakerFlanigan, DeVos, Levin-Goodman, and Spivak (2006). Forty-nine parents and 26 pediatricians participated in the facilitated focus groups. Very few parents stated that they used corporal punishment as their primary means of discipline; however, they would use corporal punishment if other means of discipline failed. Many 244
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parents recognized a connection between physical abuse and corporal punishment. Pediatricians reported time constraints as a barrier to providing anticipatory guidance related to corporal punishment. Regalado, Sareen, Inkelas, Wissow, and Halfon (2004) examined the use and predictors of discipline practices by parents of children from the ages of 4 to 35 months. A telephone survey of 2,068 parents was conducted by the National Center for Health Statistics. The survey included questions regarding the use of the following discipline practices: yelling, spanking, time out, toy removal, and explanations. Spanking as a form of discipline increased with age. Parents of children aged 4 to 9 months reported the use of spanking often (0%); sometimes (2%); rarely (4%); and never (94%). However, parents of children aged 19 to 35 months reported the use of spanking often (2%); sometimes (24%); rarely (38%); and never (35%). More adolescent and black parents reported spanking their children. More than half of the parents surveyed denied discussing discipline with their physician at a health visit in the past year. The effectiveness of domestic violence or interpersonal violence (IPV) screening in health care settings in reducing subsequent violence and improving quality of life was examined by MacMillan and colleagues (2009). More than 6,000 women (6,743) were recruited from 12 primary care sites, 11 emergency departments, and three obstetric/gynecology clinics in Ontario, Canada. All participants were adult women seeking medical care for themselves. Participants were randomly assigned to a screening for IPV group and a nonscreening group. Women in both groups were followed up for 18 months. Both groups completed IPV screening tools, the difference being that for the women who screened positive in the screening group, their medical provider was informed; in the nonscreening group, their medical provider was not informed. Women in both the screened and nonscreened groups exhibited reductions over time in IPV, posttraumatic stress disorder symptoms, and alcohol problems, and also reported improvements in quality of life, depression, and mental health. There was no indication that screening for IPV resulted in harm to the women. A serious limitation to the study was that nearly half (42%) of participants were lost to follow-up. MacMillan and colleagues (2009) concluded that there was not sufficient evidence to support IPV screening in health care settings. Little research has been conducted on the effectiveness of screening and intervention in the primary care setting in preventing child maltreatment and IPV. The U.S. Preventive Services Task Force (USPSTF, 2004) found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children or women for IPV. However, the USPSTF states that all clinicians Journal of Pediatric Health Care
BOX 1. Psychosocial assessment 1. Previous or current familial involvement with child protective services 2. Previous or current parental involvement with law enforcement 3. Parental employment/financial stressors 4. Parental drug/alcohol use 5. Interpersonal violence/domestic violence 6. Parental mental health concerns a. Mental retardation/low functioning b. Anxiety c. Depression d. Other diagnosis e. Mental health/psychiatric medications 7. Maternal/paternal a. Sexual abuse as a child b. Physical abuse as a child c. Child protective service involvement as a child 8. Support systems
examining children should be alert to physical and behavioral signs and symptoms associated with child maltreatment or neglect. The USPSTF found fair to good evidence that once child abuse or neglect has been assessed, interventions reduce harm to children. The American Academy of Pediatrics (AAP, 2002) supports the promotion of healthy sexuality in children by encouraging the education of children regarding private parts and that no one should touch their bodies inappropriately. Children should be encouraged to tell a trusted adult if anyone touches them inappropriately, and parents should be encouraged to be supportive of children if they do disclose (AAP, 2002). The American College of Obstetricians and Gynecologists (1995) and the American Medical Association (1992) recommends that physicians routinely ask women direct and specific questions about abuse. The AAP Committee on Child Abuse and Neglect supports assessment for IPV in either a universal or case-finding manner (Thackeray et al., 2010). IMPLICATIONS FOR PRACTICE Early identification of child maltreatment coupled with appropriate intervention leads to better outcomes for victims of child maltreatment. A thorough psychosocial assessment provides invaluable information when screening for child maltreatment, as well as when providing pediatric care for any concern. At the initial health care visit, a complete psychosocial assessment should be completed and updated annually. At interval health care visits, parents/caretakers should be asked if there are any changes in the home or family since the last visit, especially those that could be affecting the child. www.jpedhc.org
A thorough psychosocial assessment allows the provider to better understand the family’s challenges and strengths. Begin by drawing a family tree that provides a visualization of the persons present in the child’s life. The names and ages of the mother and father, as well as children they have together and with other partners, should be included in the family tree. Include in the family tree all individuals living with the child; a circle can be drawn around the persons living together. When pertinent, include the child’s visitation schedule with a noncustodial parent or the names of other relatives and individuals living in the home of a noncustodial parent. Next, complete a brief psychosocial screening. Explain to the parent/caregiver that you ask all of your families these questions to provide care that addresses all of their child’s needs. See Box 1 for a list of psychosocial characteristics to assess. DISCIPLINE The negative effects of CP have been well documented, yet many American parents continue this practice (NAPNAP, 2011). All well-child visits beginning in infancy should include a discussion of discipline practices with encouragement of the use of nonphysical methods. Provide education to parents regarding the potential negative consequences to children All well-child visits experiencing CP. Chilbeginning in dren as young as 3 or infancy should 4 years of age should be asked, ‘‘What hapinclude pens when you get in a discussion of trouble?’’ See Box 2 discipline practices for questions to ask both children and parwith ents regarding disciencouragement of pline. Assessment of the use of discipline practices is especially important nonphysical when a child presents methods. with an injury of concern for inflicted injury/physical abuse, such as a patterned bruise consistent with being struck with an object. Parents do listen to pediatric health care providers when considering discipline practices, as demonstrated by a study that involved a telephone survey of 500 parents in an urban southern American city (Taylor et al., 2011). Interestingly, these investigators found that the strongest predictor of parents’ positive attitudes towards CP was their perception that the professional they were most likely to turn to for advice about child discipline approved of CP. The professionals the parents stated that they were most likely to turn to for advice were pediatricians (48%), religious leaders (21%), and mental health professionals (18%). Be cognizant of your July/August 2013
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BOX 2. Discipline/corporal punishment screening questions Parents 1. How do you discipline your child? 2. Do you or anyone else ever spank your child with your hand? a. Where on their body? b. How often? c. Has it ever left a mark? 3. Do you or anyone else ever hit your child with an object? a. What object? b. Where on their body? c. How often? d. Has it ever left a mark? 4. Do you ever use other physical means of discipline? a. Pinching/kicking/pulling hair 5. Do you ever use nonphysical means of discipline? a. Time out b. Stand in corner c. Take away privileges d. Grounding/send to room
Child 1. 2. 3. 4.
What happens when you get in trouble? What does Mommy do when you get in trouble? What does Daddy do when you get in trouble? Does anyone ever hit/whoop/or spank you? a. What do they hit you with? b. Where on your body do they hit? c. Who hits you? d. How often do you get hit? e. Does it ever leave a mark on your body?
personal attitude and beliefs related to CP. A study of primary care physicians in Ohio found that 59% of pediatricians and 70% of family practice physicians supported the use of CP (McCormick, 1992). Another study found that 39% of academic pediatricians specializing in child abuse thought that CP was sometimes appropriate and only 29% taught residents how to address parents regarding the use of CP (Farason, Chernof, & Socolar, 1996). Although both studies are more than a decade old and most likely physician attitudes regarding CP have changed, it raises concern regarding the message that pediatric health care providers are sending to parents regarding discipline. CRYING Infant crying is a primary risk factor for abusive head trauma and other forms of physical abuse. Anticipatory guidance beginning at the newborn visit must address infant crying and assess parental stress and coping mechanisms. Inform parents that crying typically peaks between 2 and 4 months and excessive crying is a normal phase of infant development (National Center on Shaken Baby Syndrome, 2011). Reinforce that crying 246
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does not mean they are a bad parent or that their baby does not like them. Discuss measures to comfort a crying infant, such as checking for signs of illness, changing the diaper, and feeding. Parents need to be informed that sometimes the baby will continue to cry despite exhausting all efforts to calm the baby, and that it will not hurt the baby to cry. Crying can be very frustrating; parents should be told that this frustration is normal but that it is important to recognize when they are frustrated and to take a break. Educate the parent to place the infant somewhere safe, like in a crib on his or her back, and walk away, checking on him or her every 5 to 10 minutes. Reinforce that infants should never be shook and that shaking can result in serious permanent injury and even death. INTIMATE PARTNER VIOLENCE IPV or domestic violence negatively affects many American children. IPV screening and anticipatory guidance should occur at the initial health care visit, subsequent well-child visits, whenever a child presents with an injury of concern for nonaccidental trauma (recognizing the strong association between IPV and child physical abuse), and when a child presents with an emotional/psychological concern (recognizing the association between living in a violent home and the development of emotional/psychological problems). Caution should be practiced when screening for IPV. If both parents or caregivers are present, they should be separated to ask questions regarding violence, because disclosure is unlikely in the presence of the perpetrator or could result in placing the victim at increased risk. Children should also be questioned regarding the witnessing of violence in their home. See Box 3 for questions to ask both parents and children. Parents disclosing IPV should be educated regarding potential negative consequences to children exposed to the violence. Inform parents that children are typically much more aware of the violence going on in their homes than the parent may think. Provide the parent victim with local domestic violence counseling and shelter information. Recognize that disclosing IPV is only the first step in the process of removing oneself or addressing the situation. The IPV victim must decide his or her own path. Snider, Webster, O’Sullivan, and Campbell (2009) recommend asking five additional questions when IPV is disclosed to determine risk: Has the physical violence increased in frequency or severity during the past 6 months? Has a weapon been used or threatened? Do you believe he or she is capable of killing you? Have you ever been beaten when you were pregnant? Is he or she violently and constantly jealous of you? The PNP, as a health care provider for children, must assess the safety of his or her patient and any other children in the home. A referral to child protective services may be necessary to Journal of Pediatric Health Care
BOX 3. Interpersonal violence screening questions Parents/Dating Teens 1. Have you ever been hit, kicked, punched, or hurt by a partner/spouse/boyfriend or girlfriend, or have they ever threatened to hurt you? 2. Do you feel safe in your current relationship? 3. Do you have a past relationship where you did not feel safe or were afraid? 4. Is there a partner/spouse/boyfriend or girlfriend from a past or current relationship who is making you feel afraid or unsafe? 5. Has a partner/spouse/boyfriend or girlfriend ever made you feel ashamed, embarrassed, or hurt emotionally? 6. Have you ever been forced to have sex? 7. Have weapons ever been used against you?
Child/Teens 1. What happens when Mommy and Daddy fight? 2. Have you ever seen anyone hit/push/hurt Mommy? 3. Have you ever seen anyone hit/push/hurt Daddy?
protect the children. Certain states require a referral to child protective services whenever a child is identified as living in a violent home. It is crucial to know and understand your state reporting laws regarding children exposed to domestic violence. Unfortunately, violence can also be a component of teen dating relationships. Rivera-Rivera, Allen-Leigh, Rodriguez-Ortega, Chavez-Ayala, and Lazcano-Ponce (2007) state that 10% to 38% of teens report having been the recipient of physical dating violence and 15% to 40% of teens report perpetrating physical violence against a dating partner. It is interesting to note that a higher percentage of females report perpetrating physical dating violence than do males (Fosbee et al., 1996; O’Leary, Slep, Avery-Leaf, & Cascardi, 2008). However, teen girls are three times more likely to suffer severe physical violence or even death in a dating relationship than are teen boys. Teen girls are three times more likely than teen boys to report forced sexual contact in a dating relationship (Coker et al., 2000). It is important to ask teens questions regarding dating violence (see Box 3) at all initial patient appointments, all well visits, and any ill visit that raises the concern for physical, sexual, or emotional trauma. PNPs should have appropriate trauma-based mental health referrals available such as cognitive behavioral therapy with the goal of preventing violent relationships from becoming a lifelong pattern. Additional important information for the PNP to obtain is the ages of teen sexual partners, because the age difference between the two partners may necessitate a referral to child protective services (e.g., a 13year-old sexually involved with a 28-year-old). If the history of violence disclosed constitutes a crime (e.g., rape or physical assault) even if participants are age mates, a referral to child protective services or law enforcement may be warranted. Be honest and open with the teen and explain that if they disclose information that makes you concerned about their safety, you www.jpedhc.org
may need to inform their parents and child protective services/law enforcement. Urge teens to be open with their parents and discuss concerns related to violence. PHYSICAL ABUSE Child physical abuse occurs in all age groups. However, infants and very young children are at increased risk of experiencing physical abuse. It is estimated that in 2010, 1,560 American children died as a result of child maltreatment (Child Welfare Information Gateway, 2012). Nearly 80% of those children were younger than 4 years of age, and nearly 65% of deaths were attributed to physical abuse and/or physical abuse combined with other maltreatment types. Anticipatory guidance and screening for physical abuse involves assessing and discussing discipline practices (see Box 2), as well as parental stress/frustration and support systems. Physical abuse screening should occur at all initial patient appointments, wellchild visits, and all injury visits, especially those concerning for physical abuse. A thorough cutaneous inspection should always be a part of the physical examination, and all bruises, abrasions, burns, scars, and lesions should be documented. Consider the developmental level of the child. If an infant who is not yet cruising has bruises or other injuries to the body, the caregiver should be able to give a detailed history of how the bruise/injury occurred. Patterned bruising or injury and bruising to nonexploring body surfaces (e.g., genitals, behind the ear, and the abdomen) increase concern for abusive injury. Always obtain a detailed history of injury from the caregiver whenever a child presents with any injury and, if developmentally appropriate, from the child as well (see Box 4 for historical indicators of physical abuse). Additional laboratory and or/radiologic testing may be needed to eliminate nonabusive medical explanations for injuries (such as a child with multiple bruises having an underlying bleeding disorder) or to document further injury. A July/August 2013
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BOX 4. Historical indicators of physical abuse 1. 2. 3. 4.
No history given for the injury History inconsistent with the injury Conflicting histories given History inconsistent with the developmental level of the child 5. Delay in seeking health care
referral to a child advocacy center or an emergency department may be indicated to obtain the additional testing. A referral to child protective services is necessary whenever physical abuse is suspected. The referral should be made before discharging the child to ensure safety. The emotional needs of physical abuse victims are too often forgotten. Children of preschool age and older who are victims of physical abuse should be referred to a counselor with trauma experience to determine the need for ongoing therapy. SEXUAL ABUSE Most child sexual abuse is not reported or investigated in childhood. Many persons who experience sexual abuse never disclose their victimization or do so when they are adults. It is a reality that PNPs are caring for child sexual abuse victims who have not yet disclosed or have made a disclosure that has not been reported to authorities, making sexual abuse screening and anticipatory guidance crucial. Sexual abuse should be discussed with parents and children at all initial patient appointments, all well visits, and when presenting with a genitourinary or behavioral/emotional concern that raises a suspicion of possible sexual abuse. See Box 5 for appropriate screening questions for parents and children and Box 6 for anticipatory guidance. An
BOX 5. Sexual abuse screening questions Parent 1. Do you have any concerns of sexual abuse? 2. Were you or your partner sexually abused as a child? 3. Is there a history of sexual abuse in your family or your partner’s family? 4. Is your child ever in contact with anyone who has been accused of sexually abusing a child or adolescent?
Child 1. Have the child identify his or her body parts. 2. Have the child identify his or her private parts. 3. Using the child’s words for his or her private parts, ask if anyone has ever touched, tickled, hurt, or put anything in their private parts. Reprinted from Hornor (2011).
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BOX 6. Sexual abuse anticipatory guidance 1. Most children who are sexually abused are not abused by a stranger. 2. Children are at much higher risk from someone they know, trust, and love. 3. Never leave your child with someone you do not know well. 4. Never leave your child with someone who has a history of sexually abusing a child. 5. People who sexually abuse children are at high risk to do so again. 6. Pedophiles often present as normal, healthy individuals. 7. Pay attention if an adult likes to spend a lot of alone time with your child. 8. Most children who are sexually abused have no physical sign even on examination by a doctor or nurse. 9. If you have a concern of sexual abuse, explore it. Share your concerns with your child’s doctor/ nurse, teacher, counselor, or child protective services. 10. If your child discloses sexual abuse, always report to child protective services. 11. YOU are your child’s best protection against sexual abuse.
external ano-genital examination should be completed at all well-child visits, which provides an opportunity to educate the child regarding the concepts of private parts and inappropriate touching or other acts. Children should be instructed to tell an adult if anyone touches their private parts, and they should verbalize adults whom they could tell. Encourage parents to teach their child the correct anatomic names for their genitalia, explaining that this will facilitate adult understanding of a disclosure if one is made. Note any acute or chronic ano-genital injury. Educate parents that a normal anogenital exam does not negate the possibility of sexual abuse and that they should always listen closely to any disclosure made by their child and report concerns to child protective services. If screening questions result in a disclosure of sexual abuse from the child or if anogenital examination reveals a finding concerning for sexual abuse, the PNP must make a referral of suspected sexual abuse to child protective services. Again, referral should be made before discharge to ensure the safety of the child. Testing for sexually transmitted infections may be indicated as a result of child disclosure of abuse and/or physical symptoms (e.g., dysuria, discharge, and pain), and evidence collection may be necessary in acute cases of sexual abuse. Referral to an emergency department or child advocacy center may be necessary to facilitate comprehensive care. Child sexual abuse victims should be assessed by a therapist Journal of Pediatric Health Care
with expertise in trauma treatment, such as traumafocused cognitive behavioral therapy, to determine the need for ongoing treatment. Incorporation of screening practices and anticipatory guidance related to child maltreatment and psychosocial risk factors is a vital element of providing comprehensive care to children and their families. This step allows the PNP to more easily identify children experiencing not only child Incorporation of maltreatment but also exposure to other psyscreening chosocial risk factors. practices and Prompt identification anticipatory of child maltreatment coupled with approguidance related to priate intervention can child maltreatment lead to better outand psychosocial comes for victims. Screening for psychorisk factors is a vital social risk factors can element of identify children who providing are at risk for potential child maltreatment comprehensive and provide the PNP care to children and with the opportunity their families. to offer appropriate anticipatory guidance and intervention that can prevent child maltreatment from actually occurring and help to strengthen families by enhancing parenting abilities. REFERENCES American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. (2002). Guidelines for health supervision III, revised (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. American College of Obstetricians and Gynecologists. (1995). ACOG issues technical bulletin on domestic violence. American Family Physician, 52, 2391. American Medical Association Council on Scientific Affairs. (1992). Violence against women: Relevance for medical practitioners. Journal of the American Medical Association, 267, 3184-3189. Child Welfare Information Gateway. (2012). Child maltreatment 2010: Summary of key findings. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Coker, A. L., McKeown, R. E., Sanderson, M. D., Davis, K. E., Calois, R. F., & Huebner, E. S. (2000). Severe dating violence and quality of life among South Carolina high school students. American Journal of Preventive Medicine, 19, 220-227. Currie, J., & Widom, C. S. (2010). Long-term consequences of child abuse and neglect on adult economic well-being. Child Maltreatment, 15, 111-120. Dubowitz, H., Feigelman, S., Lane, W., & Kin, J. (2009). Pediatric primary care to help prevent child maltreatment: The safe environment for every kid (SEEK) model. Pediatrics, 123, 858-864. Farason, C., Chernoff, R., & Socolar, R. (1996). Attitudes of academic pediatricians with a specific interest in child abuse toward the spanking of children. Archives of Pediatric & Adolescent Medicine, 150, 1049-1053. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7-26.
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Fosbee, V. A., Linder, G. F., Bauman, K. E., Langwick, S. A., Arriaga, X. B., Heath, J. K., . Bangdiwala, S. (1996). The Safe Dates project: Theoretical basis, evaluation design, and selected baseline findings. American Journal of Preventive Medicine, 12, 39-47. Gershoff, E. (2002). Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin, 128, 539-579. Greenfield, E. A. (2010). Child abuse as a life-course social determinant of adult health. Maturitas, 66, 51-55. Hornor, G. (2005). Physical abuse: Recognition and reporting. Journal of Pediatric Health Care, 19, 4-11. Hornor, G. (2010). Child sexual abuse: Consequences and implications. Journal of Pediatric Health Care, 24, 358-364. Hornor, G. (2011). Medical evaluation for child sexual abuse. Journal of Pediatric Health Care, 25, 250-256. Hurley, T. P., Kellogg, N. D., O’Connor, K. G., & Baker, A. E. (2008). Pediatrician’s counseling behaviors of sexual violence prevention topics: A national survey (presented at the 2008 Pediatric Academic Societies Annual Meeting). Retrieved from http:// www.aap.org/en-us/professional-resources/Research/Pages/ Pediatricians-Counseling-Behaviors-on-Sexual-Violence-PreventionTopics-A-National-Survey.aspx?nfstatus=401&nftoken=00000 000-0000-0000-0000-000000000000&nfstatusdescription= ERROR%3a+No+local+token Knox, M. (2010). On hitting children: A review of corporal punishment in the United States. Journal of Pediatric Health Care, 24, 103107. Leder, M. R., Emans, S. J., Hafler, J. P., & Rappaport, L. A. (1999). Addressing sexual abuse in the primary care setting. Pediatrics, 104, 270-275. MacKenzie, M., Nicklas, E., Waldfogel, J., & Brooks-Gunn, J. (2012). Corporal punishment and child behavioral and cognitive outcomes through 5 years of age: Evidence from a contemporary urban birth cohort study. Infant and Child Development, 21, 3-33. MacMillan, H. L., Wathen, C. N., Jamieson, E., Boyle, M. H., Shannon, S. H., Ford-Gilboe, M., . McNutt, L. A. (2009). Screening for intimate partner violence in health care settings: a randomized trial. Journal of the American Medical Association, 302, 493-500. McCormick, K. (1992). Attitudes of primary care physicians towards corporal punishment. Journal of the American Medical Association, 267, 3161-3165. National Association of Pediatric Nurse Practitioners. (2011). NAPNAP position statement on child maltreatment. Journal of Pediatric Health Care, 25, e17-e19. National Association of Pediatric Nurse Practitioners. (2011). NAPNAP position statement on corporal punishment. Journal of Pediatric Health Care, 25, e31-e32. National Center on Shaken Baby Syndrome. (2011). Shaken baby syndrome statistics. Retrieved from http://www.dontshake.org O’Leary, K. D., Slep, A. M., Avery-Lear, S., & Cascardi, M. (2008). Gender differences in dating aggression among multiethnic high school students. Journal of Adolescent Health, 42, 473479. Regalado, M., Sareen, H., Inkelas, M., Wissow, L., & Halfon, N. (2004). Parents’ discipline of young children: Results from the national survey of early childhood health. Pediatrics, 113, 1952-1958. Rivera-Rivera, L., Allen-Leigh, B., Rodriguez-Ortega, G., ChavezAyala, R., & Lazcano-Ponce, E. (2007). Prevalence and correlates of adolescent dating violence: Baseline study of a cohort of 7960 male and female Mexican public school students. Preventive Medicine, 44, 477-484. Sanapo, M., & Nakamura, Y. (2011). Gender and physical punishment: The Filipino children’s experience. Child Abuse Review, 20, 39-56.
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Sege, R. D., Hatmaker-Falnigan, E., DeVos, E., Levin-Goodman, R., & Spivak, H. (2006). Anticipatory guidance and violence prevention: Results from family and pediatrician focus groups. Pediatrics, 117, 455-463. Sidebotham, P., & Heron, J. (2006). ASPAC Study Team. Child Abuse & Neglect, 30, 497-522. Snider, C., Webster, D., O’Sullivan, C. S., & Campbell, J. (2009). Intimate partner violence: Development of a brief risk assessment for the emergency department. Society for Academic Emergency Medicine, 16, 1208-1216. Springer, K. W., Sheridan, J., Kuo, D., & Carnes, M. (2007). Long-term physical and mental health consequences of childhood physical abuse: Results from a large population-based sample of men and women. Child Abuse & Neglect, 31, 517-530. Taylor, C., Hamvas, L., Rice, R., Newman, D., & DeJong, W. (2011). Perceived social norms, expectations, and attitudes toward corporal punishment among an urban community sample of
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parents. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 88, 254-269. Thackeray, J. D., Hibbard, R., & Dowd, M. D. (2010). Intimate partner violence: The role of the pediatrician. Pediatrics, 125, 1094-1100. Turner, H. A., Finkelhor, D., & Ormrod, R. (2010). Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine, 38, 323-330. U.S. Department of Health & Human Services. (2012). Child maltreatment 2010. Retrieved from http://www.childwelfare.gov/carn/ prevalance U.S. Preventive Services Task Force. (2004). Screening for family and intimate partner violence: Recommendation statement. Annuals of Family Medicine, 2, 156-160. Zolotor, A. J., Theodore, A. D., Chang, J. J., Berkoff, M. C., & Runyon, D. K. (2008). Speak softly and forget the stick. Corporal punishment and child physical abuse. American Journal of Preventive Medicine, 35, 364-369.
Journal of Pediatric Health Care
Continuing Education
Child Maltreatment: Screening and Anticipatory Guidance Gail Hornor, DNP, CPNP
ABSTRACT Child maltreatment is a problem of epidemic proportions in the United States. Given the numbers of children affected by child maltreatment and the dire consequences that can develop, prompt identification of child maltreatment is crucial. Despite support of the implementation and development of protocols for child maltreatment screening by professional organizations such as the National Association of Pediatric Nurse Practitioners and American Academy of Pediatrics, little is available in the literature regarding the screening practices of pediatric nurse practitioners and other pediatric health care providers. This Continuing Education article will help pediatric nurse practitioners incorporate this vital screening intervention into their practice. Practical examples of when and how to incorporate screening questions and anticipatory guidance for discipline practices, crying, intimate partner violence (domestic violence), physical abuse, and sexual abuse will be discussed. J Pediatr Health Care. (2013) 27, 242-250.
KEY WORDS Child maltreatment, screening, guidance
Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children’s Hospital, Center for Family Safety and Healing, Columbus, OH. Conflicts of interest: None to report. Correspondence: Gail Hornor, DNP, CPNP, Nationwide Children’s Hospital, Center for Family Safety and Healing, 655 East Livingston Ave, Columbus, OH 43205; e-mail: Gail.hornor@ nationwidechildrens.org. 0891-5245/$36.00 Copyright Q 2013 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2013.02.001
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OBJECTIVES Based on the content of the article, you will be able to: 1. Identify negative consequences to children resulting from child maltreatment. 2. Describe when and how to provide screening and anticipatory guidance related to discipline, infant crying, intimate partner violence, sexual abuse, and physical abuse. 3. Recognize the impact on children of witnessing intimate partner violence. 4. State when to report a concern of suspected child maltreatment to child protective services. 5. Recognize the link between corporal punishment use and physical abuse. 6. Identify historical indicators of physical abuse.
Child maltreatment is a problem of epidemic proportions in the United States. During 2010, approximately 754,000 children were victims of child maltreatment (U.S. Department of Health & Human Services, 2012). An estimated 1,560 children die nationally each year because of child abuse or neglect, a rate of 2.07 deaths per 100,000 children. Reports indicate that in 2010, 78.3% of victims suffered neglect, 17.6% were physically abused, 9.2% experienced sexual abuse, and 8.1% were psychologically maltreated. Additionally, 3.3 to 10 million children witness domestic violence each year. In nationally representative samples of 2,030 children and 4,053 children, Finklehor, Ormrod, and Turner (2007) and Turner, Finkelhor, and Ormrod (2010) found that 69% and 66% of the children, respectively, had experienced more than one form of child maltreatment. Given the numbers of children affected by child maltreatment and the dire consequences that can develop, Journal of Pediatric Health Care
prompt identification of child maltreatment is crucial. Health care personnel were responsible for only 8.2% of the estimated 3.3 million referrals to child protective service agencies in 2010 (U.S. Department of Health & Human Services, 2012). The importance of early identification of child maltreatment led the National Association of Pediatric Nurse Practitioners (NAPNAP) to issue a position statement that supports the implementation and development of protocols for child maltreatment screening (NAPNAP, 2011). When developGiven the numbers ing protocols for child of children affected maltreatment screening, it is important to by child realize that any one maltreatment and form of child maltreatthe dire ment rarely occurs in isolation. If only one consequences that form of child maltreatcan develop, ment is assessed, proprompt viders may fail to recognize the full buridentification of den of victimization child maltreatment and leave children is crucial. unprotected and inadequately treated. Despite the recognition of the need to identify and intervene in cases of child maltreatment as soon as possible to decrease trauma to children, little is available in the literature regarding the screening practices of pediatric nurse practitioners (PNPs) and other pediatric health care providers, screening for child maltreatment, and psychosocial risk factors for maltreatment, including intimate partner violence. This article will help PNPs incorporate this vital screening intervention into their practice.
REVIEW OF LITERATURE Consequences Consequences of child maltreatment can be physical and/or psychological, and short-term and/or longterm. Immediate consequences of physical abuse can range from minor cutaneous injuries such as abrasions or bruises to more severe injuries such as fractures, abdominal trauma, inflicted head injury, or death. Longterm consequences of physical abuse include residual mental and/or physical disabilities resulting from the initial injuries and psychological problems related to experiencing trauma such as posttraumatic stress disorder, anger, and aggression. Springer, Sheridan, Kuo, and Carnes (2007) and Greenfield (2010) found child physical abuse to be associated with negative health outcomes in adulthood, including an increased likelihood of reporting more diagnosed illnesses such as heart disease, stomach ulcers, and hypertension. Adults who experienced physical abuse were also found to rewww.jpedhc.org
port more physical symptoms, along with anxiety, anger, depression, and drug/alcohol abuse. Sexual abuse has been linked with a variety of behavioral concerns, including sexualized behaviors in young children, symptoms similar to attention deficit disorder, and violent behaviors (Hornor, 2010). Child sexual abuse can also result in the development of posttraumatic stress disorder, depression, suicide, substance abuse, and adult revictimization. Furthermore, exposure to domestic violence can have negative physical, developmental, and psychological effects on children (Hornor, 2005). Children who witness domestic violence are at risk for the development of behavioral and mental health consequences such as posttraumatic stress disorder, anxiety, depression, withdrawal, attention problems, and aggression (Thackeray, Hibbard, & Dowd, 2010). Experiencing corporal punishment (CP) has been linked to a number of negative consequences for children. The use of CP has been linked to increased risk of physical abuse (Sanapo & Nakamura, 2011). Physical abuse often begins as an act of discipline that morphs into abuse at the hands of a frustrated caregiver who loses control of himself or herself. Higher rates of externalizing behavioral problems are seen in children who are spanked (Mackenzie, Nicklas, Waldfogel, & Brooks-Gunn, 2012). Decades of research have implicated CP in the etiology of criminal and antisocial behavior in children and adults (Gershoff, 2002). Children who are spanked demonstrate slower development of receptive verbal capacity (Mackenzie et al., 2012). Experiencing any form of child maltreatment can have negative affects on future parenting ability (Currie & Widom, 2010; Hornor, 2010). Experiencing childhood physical abuse and/or exposure to domestic violence has been linked with perpetrating physical abuse as an adult. A parent who has experienced child sexual abuse is at increased risk to have a child who is sexually abused, not by sexually abusing the child themselves, but by placing the child in high-risk situations and exposing him or her to persons who are likely to abuse. Risk Factors for Child Maltreatment Child maltreatment crosses all economic, ethnic, racial, and religious boundaries. However, certain psychosocial factors place a parent at increased risk of perpetrating child maltreatment and place a child at increased risk for victimization. Parental risk factors include poverty, a childhood history of abuse/neglect, social isolation, being an adolescent or young parent, having unrealistic developmental expectations, having poor impulse control, substance abuse, domestic violence, mental illness/depression/mental retardation, and previous involvement with child protective services or law enforcement (Hornor, 2005; Sidebotham & Heron, 2006). Factors placing children at increased risk include young age (for physical abuse), developmental delay, July/August 2013
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prematurity, congenital anomalies/medical condition, behavior problems, and female gender (for sexual abuse). Corporal punishment and child physical abuse are often linked (Knox, 2010; Zolotor, Theodore, Chang, Berkoff, & Runyon, 2008). Child Maltreatment Screening Practices The role of pediatric health care providers in child maltreatment has primarily focused on the issues of identifying abuse and neglect, reporting it to the appropriate agencies, and facilitating referrals for assessment and treatment (Dubowitz, Feigelman, Lane, & Kim, 2009). However, Dubowitz and colleagues (2009) also discuss the role of the pediatric health care provider in the prevention of child abuse and neglect. Universal or primary prevention efforts can target all children receiving primary care with the intent of screening children and families for known risk factors for child maltreatment (Sidebotham & Heron, 2006), as well as exposure to sexual abuse and/or physical abuse. Leder, Emans, Hafter, and Rappaport (1999) used a qualitative research design to describe barriers to inquiry about sexual abuse by pediatric health care practitioners. Six Maternal and Child Health Bureau– sponsored collaborative office rounds (COR) groups participated in a focus group interview. These COR groups, consisting of pediatric primary care providers (6 to 17) and at least one child psychiatrist or psychologist, were formed in 1989 to promote positive psychosocial development in patients and families. Some COR participants reported giving anticipatory guidance to their patients regarding sexual abuse; however, many reported inconsistencies in their practice. Barriers to inquiry included lack of time, loss of rapport with family, lack of training in sexual abuse, discomfort with discussing sexuality, uncertainty about what to do if sexual abuse is disclosed, lack of appropriate referral services, and belief that child protective services are inadequate. A survey of 542 pediatricians regarding counseling behaviors about inappropriate sexual touching, internet safety, media issues, sexual harassment, and domestic violence was conducted by Hurley, Kellogg, O’Connor, and Baker (2008). Few pediatricians reported routine discussions of inappropriate touching (40%), sexual harassment (14%), and domestic violence (13%) during well-child visits. The opinions of parents and pediatricians in relation to effective anticipatory guidance regarding corporal punishment were elicited by Sege, HatmakerFlanigan, DeVos, Levin-Goodman, and Spivak (2006). Forty-nine parents and 26 pediatricians participated in the facilitated focus groups. Very few parents stated that they used corporal punishment as their primary means of discipline; however, they would use corporal punishment if other means of discipline failed. Many 244
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parents recognized a connection between physical abuse and corporal punishment. Pediatricians reported time constraints as a barrier to providing anticipatory guidance related to corporal punishment. Regalado, Sareen, Inkelas, Wissow, and Halfon (2004) examined the use and predictors of discipline practices by parents of children from the ages of 4 to 35 months. A telephone survey of 2,068 parents was conducted by the National Center for Health Statistics. The survey included questions regarding the use of the following discipline practices: yelling, spanking, time out, toy removal, and explanations. Spanking as a form of discipline increased with age. Parents of children aged 4 to 9 months reported the use of spanking often (0%); sometimes (2%); rarely (4%); and never (94%). However, parents of children aged 19 to 35 months reported the use of spanking often (2%); sometimes (24%); rarely (38%); and never (35%). More adolescent and black parents reported spanking their children. More than half of the parents surveyed denied discussing discipline with their physician at a health visit in the past year. The effectiveness of domestic violence or interpersonal violence (IPV) screening in health care settings in reducing subsequent violence and improving quality of life was examined by MacMillan and colleagues (2009). More than 6,000 women (6,743) were recruited from 12 primary care sites, 11 emergency departments, and three obstetric/gynecology clinics in Ontario, Canada. All participants were adult women seeking medical care for themselves. Participants were randomly assigned to a screening for IPV group and a nonscreening group. Women in both groups were followed up for 18 months. Both groups completed IPV screening tools, the difference being that for the women who screened positive in the screening group, their medical provider was informed; in the nonscreening group, their medical provider was not informed. Women in both the screened and nonscreened groups exhibited reductions over time in IPV, posttraumatic stress disorder symptoms, and alcohol problems, and also reported improvements in quality of life, depression, and mental health. There was no indication that screening for IPV resulted in harm to the women. A serious limitation to the study was that nearly half (42%) of participants were lost to follow-up. MacMillan and colleagues (2009) concluded that there was not sufficient evidence to support IPV screening in health care settings. Little research has been conducted on the effectiveness of screening and intervention in the primary care setting in preventing child maltreatment and IPV. The U.S. Preventive Services Task Force (USPSTF, 2004) found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children or women for IPV. However, the USPSTF states that all clinicians Journal of Pediatric Health Care
BOX 1. Psychosocial assessment 1. Previous or current familial involvement with child protective services 2. Previous or current parental involvement with law enforcement 3. Parental employment/financial stressors 4. Parental drug/alcohol use 5. Interpersonal violence/domestic violence 6. Parental mental health concerns a. Mental retardation/low functioning b. Anxiety c. Depression d. Other diagnosis e. Mental health/psychiatric medications 7. Maternal/paternal a. Sexual abuse as a child b. Physical abuse as a child c. Child protective service involvement as a child 8. Support systems
examining children should be alert to physical and behavioral signs and symptoms associated with child maltreatment or neglect. The USPSTF found fair to good evidence that once child abuse or neglect has been assessed, interventions reduce harm to children. The American Academy of Pediatrics (AAP, 2002) supports the promotion of healthy sexuality in children by encouraging the education of children regarding private parts and that no one should touch their bodies inappropriately. Children should be encouraged to tell a trusted adult if anyone touches them inappropriately, and parents should be encouraged to be supportive of children if they do disclose (AAP, 2002). The American College of Obstetricians and Gynecologists (1995) and the American Medical Association (1992) recommends that physicians routinely ask women direct and specific questions about abuse. The AAP Committee on Child Abuse and Neglect supports assessment for IPV in either a universal or case-finding manner (Thackeray et al., 2010). IMPLICATIONS FOR PRACTICE Early identification of child maltreatment coupled with appropriate intervention leads to better outcomes for victims of child maltreatment. A thorough psychosocial assessment provides invaluable information when screening for child maltreatment, as well as when providing pediatric care for any concern. At the initial health care visit, a complete psychosocial assessment should be completed and updated annually. At interval health care visits, parents/caretakers should be asked if there are any changes in the home or family since the last visit, especially those that could be affecting the child. www.jpedhc.org
A thorough psychosocial assessment allows the provider to better understand the family’s challenges and strengths. Begin by drawing a family tree that provides a visualization of the persons present in the child’s life. The names and ages of the mother and father, as well as children they have together and with other partners, should be included in the family tree. Include in the family tree all individuals living with the child; a circle can be drawn around the persons living together. When pertinent, include the child’s visitation schedule with a noncustodial parent or the names of other relatives and individuals living in the home of a noncustodial parent. Next, complete a brief psychosocial screening. Explain to the parent/caregiver that you ask all of your families these questions to provide care that addresses all of their child’s needs. See Box 1 for a list of psychosocial characteristics to assess. DISCIPLINE The negative effects of CP have been well documented, yet many American parents continue this practice (NAPNAP, 2011). All well-child visits beginning in infancy should include a discussion of discipline practices with encouragement of the use of nonphysical methods. Provide education to parents regarding the potential negative consequences to children All well-child visits experiencing CP. Chilbeginning in dren as young as 3 or infancy should 4 years of age should be asked, ‘‘What hapinclude pens when you get in a discussion of trouble?’’ See Box 2 discipline practices for questions to ask both children and parwith ents regarding disciencouragement of pline. Assessment of the use of discipline practices is especially important nonphysical when a child presents methods. with an injury of concern for inflicted injury/physical abuse, such as a patterned bruise consistent with being struck with an object. Parents do listen to pediatric health care providers when considering discipline practices, as demonstrated by a study that involved a telephone survey of 500 parents in an urban southern American city (Taylor et al., 2011). Interestingly, these investigators found that the strongest predictor of parents’ positive attitudes towards CP was their perception that the professional they were most likely to turn to for advice about child discipline approved of CP. The professionals the parents stated that they were most likely to turn to for advice were pediatricians (48%), religious leaders (21%), and mental health professionals (18%). Be cognizant of your July/August 2013
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BOX 2. Discipline/corporal punishment screening questions Parents 1. How do you discipline your child? 2. Do you or anyone else ever spank your child with your hand? a. Where on their body? b. How often? c. Has it ever left a mark? 3. Do you or anyone else ever hit your child with an object? a. What object? b. Where on their body? c. How often? d. Has it ever left a mark? 4. Do you ever use other physical means of discipline? a. Pinching/kicking/pulling hair 5. Do you ever use nonphysical means of discipline? a. Time out b. Stand in corner c. Take away privileges d. Grounding/send to room
Child 1. 2. 3. 4.
What happens when you get in trouble? What does Mommy do when you get in trouble? What does Daddy do when you get in trouble? Does anyone ever hit/whoop/or spank you? a. What do they hit you with? b. Where on your body do they hit? c. Who hits you? d. How often do you get hit? e. Does it ever leave a mark on your body?
personal attitude and beliefs related to CP. A study of primary care physicians in Ohio found that 59% of pediatricians and 70% of family practice physicians supported the use of CP (McCormick, 1992). Another study found that 39% of academic pediatricians specializing in child abuse thought that CP was sometimes appropriate and only 29% taught residents how to address parents regarding the use of CP (Farason, Chernof, & Socolar, 1996). Although both studies are more than a decade old and most likely physician attitudes regarding CP have changed, it raises concern regarding the message that pediatric health care providers are sending to parents regarding discipline. CRYING Infant crying is a primary risk factor for abusive head trauma and other forms of physical abuse. Anticipatory guidance beginning at the newborn visit must address infant crying and assess parental stress and coping mechanisms. Inform parents that crying typically peaks between 2 and 4 months and excessive crying is a normal phase of infant development (National Center on Shaken Baby Syndrome, 2011). Reinforce that crying 246
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does not mean they are a bad parent or that their baby does not like them. Discuss measures to comfort a crying infant, such as checking for signs of illness, changing the diaper, and feeding. Parents need to be informed that sometimes the baby will continue to cry despite exhausting all efforts to calm the baby, and that it will not hurt the baby to cry. Crying can be very frustrating; parents should be told that this frustration is normal but that it is important to recognize when they are frustrated and to take a break. Educate the parent to place the infant somewhere safe, like in a crib on his or her back, and walk away, checking on him or her every 5 to 10 minutes. Reinforce that infants should never be shook and that shaking can result in serious permanent injury and even death. INTIMATE PARTNER VIOLENCE IPV or domestic violence negatively affects many American children. IPV screening and anticipatory guidance should occur at the initial health care visit, subsequent well-child visits, whenever a child presents with an injury of concern for nonaccidental trauma (recognizing the strong association between IPV and child physical abuse), and when a child presents with an emotional/psychological concern (recognizing the association between living in a violent home and the development of emotional/psychological problems). Caution should be practiced when screening for IPV. If both parents or caregivers are present, they should be separated to ask questions regarding violence, because disclosure is unlikely in the presence of the perpetrator or could result in placing the victim at increased risk. Children should also be questioned regarding the witnessing of violence in their home. See Box 3 for questions to ask both parents and children. Parents disclosing IPV should be educated regarding potential negative consequences to children exposed to the violence. Inform parents that children are typically much more aware of the violence going on in their homes than the parent may think. Provide the parent victim with local domestic violence counseling and shelter information. Recognize that disclosing IPV is only the first step in the process of removing oneself or addressing the situation. The IPV victim must decide his or her own path. Snider, Webster, O’Sullivan, and Campbell (2009) recommend asking five additional questions when IPV is disclosed to determine risk: Has the physical violence increased in frequency or severity during the past 6 months? Has a weapon been used or threatened? Do you believe he or she is capable of killing you? Have you ever been beaten when you were pregnant? Is he or she violently and constantly jealous of you? The PNP, as a health care provider for children, must assess the safety of his or her patient and any other children in the home. A referral to child protective services may be necessary to Journal of Pediatric Health Care
BOX 3. Interpersonal violence screening questions Parents/Dating Teens 1. Have you ever been hit, kicked, punched, or hurt by a partner/spouse/boyfriend or girlfriend, or have they ever threatened to hurt you? 2. Do you feel safe in your current relationship? 3. Do you have a past relationship where you did not feel safe or were afraid? 4. Is there a partner/spouse/boyfriend or girlfriend from a past or current relationship who is making you feel afraid or unsafe? 5. Has a partner/spouse/boyfriend or girlfriend ever made you feel ashamed, embarrassed, or hurt emotionally? 6. Have you ever been forced to have sex? 7. Have weapons ever been used against you?
Child/Teens 1. What happens when Mommy and Daddy fight? 2. Have you ever seen anyone hit/push/hurt Mommy? 3. Have you ever seen anyone hit/push/hurt Daddy?
protect the children. Certain states require a referral to child protective services whenever a child is identified as living in a violent home. It is crucial to know and understand your state reporting laws regarding children exposed to domestic violence. Unfortunately, violence can also be a component of teen dating relationships. Rivera-Rivera, Allen-Leigh, Rodriguez-Ortega, Chavez-Ayala, and Lazcano-Ponce (2007) state that 10% to 38% of teens report having been the recipient of physical dating violence and 15% to 40% of teens report perpetrating physical violence against a dating partner. It is interesting to note that a higher percentage of females report perpetrating physical dating violence than do males (Fosbee et al., 1996; O’Leary, Slep, Avery-Leaf, & Cascardi, 2008). However, teen girls are three times more likely to suffer severe physical violence or even death in a dating relationship than are teen boys. Teen girls are three times more likely than teen boys to report forced sexual contact in a dating relationship (Coker et al., 2000). It is important to ask teens questions regarding dating violence (see Box 3) at all initial patient appointments, all well visits, and any ill visit that raises the concern for physical, sexual, or emotional trauma. PNPs should have appropriate trauma-based mental health referrals available such as cognitive behavioral therapy with the goal of preventing violent relationships from becoming a lifelong pattern. Additional important information for the PNP to obtain is the ages of teen sexual partners, because the age difference between the two partners may necessitate a referral to child protective services (e.g., a 13year-old sexually involved with a 28-year-old). If the history of violence disclosed constitutes a crime (e.g., rape or physical assault) even if participants are age mates, a referral to child protective services or law enforcement may be warranted. Be honest and open with the teen and explain that if they disclose information that makes you concerned about their safety, you www.jpedhc.org
may need to inform their parents and child protective services/law enforcement. Urge teens to be open with their parents and discuss concerns related to violence. PHYSICAL ABUSE Child physical abuse occurs in all age groups. However, infants and very young children are at increased risk of experiencing physical abuse. It is estimated that in 2010, 1,560 American children died as a result of child maltreatment (Child Welfare Information Gateway, 2012). Nearly 80% of those children were younger than 4 years of age, and nearly 65% of deaths were attributed to physical abuse and/or physical abuse combined with other maltreatment types. Anticipatory guidance and screening for physical abuse involves assessing and discussing discipline practices (see Box 2), as well as parental stress/frustration and support systems. Physical abuse screening should occur at all initial patient appointments, wellchild visits, and all injury visits, especially those concerning for physical abuse. A thorough cutaneous inspection should always be a part of the physical examination, and all bruises, abrasions, burns, scars, and lesions should be documented. Consider the developmental level of the child. If an infant who is not yet cruising has bruises or other injuries to the body, the caregiver should be able to give a detailed history of how the bruise/injury occurred. Patterned bruising or injury and bruising to nonexploring body surfaces (e.g., genitals, behind the ear, and the abdomen) increase concern for abusive injury. Always obtain a detailed history of injury from the caregiver whenever a child presents with any injury and, if developmentally appropriate, from the child as well (see Box 4 for historical indicators of physical abuse). Additional laboratory and or/radiologic testing may be needed to eliminate nonabusive medical explanations for injuries (such as a child with multiple bruises having an underlying bleeding disorder) or to document further injury. A July/August 2013
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BOX 4. Historical indicators of physical abuse 1. 2. 3. 4.
No history given for the injury History inconsistent with the injury Conflicting histories given History inconsistent with the developmental level of the child 5. Delay in seeking health care
referral to a child advocacy center or an emergency department may be indicated to obtain the additional testing. A referral to child protective services is necessary whenever physical abuse is suspected. The referral should be made before discharging the child to ensure safety. The emotional needs of physical abuse victims are too often forgotten. Children of preschool age and older who are victims of physical abuse should be referred to a counselor with trauma experience to determine the need for ongoing therapy. SEXUAL ABUSE Most child sexual abuse is not reported or investigated in childhood. Many persons who experience sexual abuse never disclose their victimization or do so when they are adults. It is a reality that PNPs are caring for child sexual abuse victims who have not yet disclosed or have made a disclosure that has not been reported to authorities, making sexual abuse screening and anticipatory guidance crucial. Sexual abuse should be discussed with parents and children at all initial patient appointments, all well visits, and when presenting with a genitourinary or behavioral/emotional concern that raises a suspicion of possible sexual abuse. See Box 5 for appropriate screening questions for parents and children and Box 6 for anticipatory guidance. An
BOX 5. Sexual abuse screening questions Parent 1. Do you have any concerns of sexual abuse? 2. Were you or your partner sexually abused as a child? 3. Is there a history of sexual abuse in your family or your partner’s family? 4. Is your child ever in contact with anyone who has been accused of sexually abusing a child or adolescent?
Child 1. Have the child identify his or her body parts. 2. Have the child identify his or her private parts. 3. Using the child’s words for his or her private parts, ask if anyone has ever touched, tickled, hurt, or put anything in their private parts. Reprinted from Hornor (2011).
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BOX 6. Sexual abuse anticipatory guidance 1. Most children who are sexually abused are not abused by a stranger. 2. Children are at much higher risk from someone they know, trust, and love. 3. Never leave your child with someone you do not know well. 4. Never leave your child with someone who has a history of sexually abusing a child. 5. People who sexually abuse children are at high risk to do so again. 6. Pedophiles often present as normal, healthy individuals. 7. Pay attention if an adult likes to spend a lot of alone time with your child. 8. Most children who are sexually abused have no physical sign even on examination by a doctor or nurse. 9. If you have a concern of sexual abuse, explore it. Share your concerns with your child’s doctor/ nurse, teacher, counselor, or child protective services. 10. If your child discloses sexual abuse, always report to child protective services. 11. YOU are your child’s best protection against sexual abuse.
external ano-genital examination should be completed at all well-child visits, which provides an opportunity to educate the child regarding the concepts of private parts and inappropriate touching or other acts. Children should be instructed to tell an adult if anyone touches their private parts, and they should verbalize adults whom they could tell. Encourage parents to teach their child the correct anatomic names for their genitalia, explaining that this will facilitate adult understanding of a disclosure if one is made. Note any acute or chronic ano-genital injury. Educate parents that a normal anogenital exam does not negate the possibility of sexual abuse and that they should always listen closely to any disclosure made by their child and report concerns to child protective services. If screening questions result in a disclosure of sexual abuse from the child or if anogenital examination reveals a finding concerning for sexual abuse, the PNP must make a referral of suspected sexual abuse to child protective services. Again, referral should be made before discharge to ensure the safety of the child. Testing for sexually transmitted infections may be indicated as a result of child disclosure of abuse and/or physical symptoms (e.g., dysuria, discharge, and pain), and evidence collection may be necessary in acute cases of sexual abuse. Referral to an emergency department or child advocacy center may be necessary to facilitate comprehensive care. Child sexual abuse victims should be assessed by a therapist Journal of Pediatric Health Care
with expertise in trauma treatment, such as traumafocused cognitive behavioral therapy, to determine the need for ongoing treatment. Incorporation of screening practices and anticipatory guidance related to child maltreatment and psychosocial risk factors is a vital element of providing comprehensive care to children and their families. This step allows the PNP to more easily identify children experiencing not only child Incorporation of maltreatment but also exposure to other psyscreening chosocial risk factors. practices and Prompt identification anticipatory of child maltreatment coupled with approguidance related to priate intervention can child maltreatment lead to better outand psychosocial comes for victims. Screening for psychorisk factors is a vital social risk factors can element of identify children who providing are at risk for potential child maltreatment comprehensive and provide the PNP care to children and with the opportunity their families. to offer appropriate anticipatory guidance and intervention that can prevent child maltreatment from actually occurring and help to strengthen families by enhancing parenting abilities. REFERENCES American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. (2002). Guidelines for health supervision III, revised (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. American College of Obstetricians and Gynecologists. (1995). ACOG issues technical bulletin on domestic violence. American Family Physician, 52, 2391. American Medical Association Council on Scientific Affairs. (1992). Violence against women: Relevance for medical practitioners. Journal of the American Medical Association, 267, 3184-3189. Child Welfare Information Gateway. (2012). Child maltreatment 2010: Summary of key findings. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Coker, A. L., McKeown, R. E., Sanderson, M. D., Davis, K. E., Calois, R. F., & Huebner, E. S. (2000). Severe dating violence and quality of life among South Carolina high school students. American Journal of Preventive Medicine, 19, 220-227. Currie, J., & Widom, C. S. (2010). Long-term consequences of child abuse and neglect on adult economic well-being. Child Maltreatment, 15, 111-120. Dubowitz, H., Feigelman, S., Lane, W., & Kin, J. (2009). Pediatric primary care to help prevent child maltreatment: The safe environment for every kid (SEEK) model. Pediatrics, 123, 858-864. Farason, C., Chernoff, R., & Socolar, R. (1996). Attitudes of academic pediatricians with a specific interest in child abuse toward the spanking of children. Archives of Pediatric & Adolescent Medicine, 150, 1049-1053. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7-26.
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Fosbee, V. A., Linder, G. F., Bauman, K. E., Langwick, S. A., Arriaga, X. B., Heath, J. K., . Bangdiwala, S. (1996). The Safe Dates project: Theoretical basis, evaluation design, and selected baseline findings. American Journal of Preventive Medicine, 12, 39-47. Gershoff, E. (2002). Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin, 128, 539-579. Greenfield, E. A. (2010). Child abuse as a life-course social determinant of adult health. Maturitas, 66, 51-55. Hornor, G. (2005). Physical abuse: Recognition and reporting. Journal of Pediatric Health Care, 19, 4-11. Hornor, G. (2010). Child sexual abuse: Consequences and implications. Journal of Pediatric Health Care, 24, 358-364. Hornor, G. (2011). Medical evaluation for child sexual abuse. Journal of Pediatric Health Care, 25, 250-256. Hurley, T. P., Kellogg, N. D., O’Connor, K. G., & Baker, A. E. (2008). Pediatrician’s counseling behaviors of sexual violence prevention topics: A national survey (presented at the 2008 Pediatric Academic Societies Annual Meeting). Retrieved from http:// www.aap.org/en-us/professional-resources/Research/Pages/ Pediatricians-Counseling-Behaviors-on-Sexual-Violence-PreventionTopics-A-National-Survey.aspx?nfstatus=401&nftoken=00000 000-0000-0000-0000-000000000000&nfstatusdescription= ERROR%3a+No+local+token Knox, M. (2010). On hitting children: A review of corporal punishment in the United States. Journal of Pediatric Health Care, 24, 103107. Leder, M. R., Emans, S. J., Hafler, J. P., & Rappaport, L. A. (1999). Addressing sexual abuse in the primary care setting. Pediatrics, 104, 270-275. MacKenzie, M., Nicklas, E., Waldfogel, J., & Brooks-Gunn, J. (2012). Corporal punishment and child behavioral and cognitive outcomes through 5 years of age: Evidence from a contemporary urban birth cohort study. Infant and Child Development, 21, 3-33. MacMillan, H. L., Wathen, C. N., Jamieson, E., Boyle, M. H., Shannon, S. H., Ford-Gilboe, M., . McNutt, L. A. (2009). Screening for intimate partner violence in health care settings: a randomized trial. Journal of the American Medical Association, 302, 493-500. McCormick, K. (1992). Attitudes of primary care physicians towards corporal punishment. Journal of the American Medical Association, 267, 3161-3165. National Association of Pediatric Nurse Practitioners. (2011). NAPNAP position statement on child maltreatment. Journal of Pediatric Health Care, 25, e17-e19. National Association of Pediatric Nurse Practitioners. (2011). NAPNAP position statement on corporal punishment. Journal of Pediatric Health Care, 25, e31-e32. National Center on Shaken Baby Syndrome. (2011). Shaken baby syndrome statistics. Retrieved from http://www.dontshake.org O’Leary, K. D., Slep, A. M., Avery-Lear, S., & Cascardi, M. (2008). Gender differences in dating aggression among multiethnic high school students. Journal of Adolescent Health, 42, 473479. Regalado, M., Sareen, H., Inkelas, M., Wissow, L., & Halfon, N. (2004). Parents’ discipline of young children: Results from the national survey of early childhood health. Pediatrics, 113, 1952-1958. Rivera-Rivera, L., Allen-Leigh, B., Rodriguez-Ortega, G., ChavezAyala, R., & Lazcano-Ponce, E. (2007). Prevalence and correlates of adolescent dating violence: Baseline study of a cohort of 7960 male and female Mexican public school students. Preventive Medicine, 44, 477-484. Sanapo, M., & Nakamura, Y. (2011). Gender and physical punishment: The Filipino children’s experience. Child Abuse Review, 20, 39-56.
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parents. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 88, 254-269. Thackeray, J. D., Hibbard, R., & Dowd, M. D. (2010). Intimate partner violence: The role of the pediatrician. Pediatrics, 125, 1094-1100. Turner, H. A., Finkelhor, D., & Ormrod, R. (2010). Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine, 38, 323-330. U.S. Department of Health & Human Services. (2012). Child maltreatment 2010. Retrieved from http://www.childwelfare.gov/carn/ prevalance U.S. Preventive Services Task Force. (2004). Screening for family and intimate partner violence: Recommendation statement. Annuals of Family Medicine, 2, 156-160. Zolotor, A. J., Theodore, A. D., Chang, J. J., Berkoff, M. C., & Runyon, D. K. (2008). Speak softly and forget the stick. Corporal punishment and child physical abuse. American Journal of Preventive Medicine, 35, 364-369.
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