Children are widely recognized as a vulnerable population during disasters and public health emergencies such as pandemics.[1,2] Despite this, their needs are often overlooked.[3] Emerging data from the ongoing pandemic caused by SARS-CoV-2, the causal agent of the acute respiratory distress syndrome COVID-19, suggest that severe illness in children is uncommon and mortality is rare.[4-6] However, the nature and extent of secondary effects of the pandemic on children are not yet well established.

Pandemics and child maltreatment

Historically, one serious consequence of pandemics has been an increased risk of child maltreatment, including physical abuse, sexual abuse, emotional abuse, neglect, and exposure to family violence.[7] Child abuse is a leading cause of child death, and child maltreatment can have long-term effects on child health and development.[8,9] At baseline, maltreatment is a common experience among Canadian children, with up to 33% of Canadians reporting some experience of maltreatment before age 15 years.[10] It is widely recognized that these numbers likely underestimate the prevalence of maltreatment.[11]

Community mitigation measures designed to limit the rapid spread of infectious disease may lead to physical and social isolation, meaning that families may have less contact with adults outside their home environment, including teachers, physicians, and child welfare workers. These adults typically provide support and protection for vulnerable children and are often the first to recognize and report suspected child maltreatment.[12] While many of these professionals are struggling to reach children in a meaningful way, physicians are uniquely situated to respond to cases of suspected child maltreatment. They have access to telehealth technology and financial compensation and have routine cause (i.e., well-child visits) to connect with children and families. Furthermore, physicians often have relationships with families, which make them well positioned to inquire about a child’s home environment, offer support, and promote children’s overall health, development, and safety.

With the potential for increased risk of child abuse and neglect during the COVID-19 pandemic, practical strategies and resources can help physicians recognize and respond to child maltreatment.

Effect of COVID-19 on child maltreatment risk

There is growing recognition of the increased risk of child abuse and neglect as a result of the COVID-19 pandemic.[13,14] Many factors may contribute to this risk. For perpetrators, parenting stress, financial stress, mental illness, increased substance use, social isolation, and negative interactions with children—all of which may be present and potentially exacerbated during this pandemic—are associated with an increased risk of child abuse and neglect.[15,16]

With more than 11 million cases of COVID-19 reported globally,[17] many families are experiencing the trauma of severe illness or the loss of loved ones, including friends and family members. This trauma is compounded by the cancellation of rituals, such as funerals, and the reduction and suspension of religious gatherings and grief support groups.

Even when families are safe from the infection itself, the public health interventions to control the pandemic have secondary consequences. Widespread restrictions on business activities have immediate financial repercussions, and may limit access to extended health care and other benefits. School closures have forced children to stay home with adults who may struggle to care for them. Previous studies of quarantine during pandemics show an increase in symptoms of psychological distress, depression, anxiety, and posttraumatic stress disorder.[18-22]

At the same time, there has been widespread disruption of the communities and services that typically support children and families during times of stress. Physical and social distancing foster isolation and disrupt routines, and may limit access to extended family and other community support networks. Social workers, along with other health professionals, have been advised to minimize nonessential services that involve direct contact with families.[23] While exceptions are made for urgent care, and telephone and video technology allow for client contact, some families may still lack the oversight, assessment, and support they need.

These factors affect the identification and reporting of suspected child maltreatment. Nearly two-thirds of reports of child abuse and neglect are made by professionals who have work-related contact with children, including teachers, law enforcement personnel, social services workers, and health care providers.[24] Most of the remaining reports are made by friends, neighbors, and relatives. Limited access to these groups during the pandemic may result in cases of child maltreatment being missed.

Identifying and addressing child maltreatment

Front-line physicians can take steps to identify cases of child maltreatment and support caregivers and children.

Assess risk

Child maltreatment often occurs in settings where there are no known risk factors. All families—not just the most vulnerable—are at a higher risk of child maltreatment as a result of the current pandemic. Every patient encounter should include an assessment of risk. Recommendations for clinicians[25] include:

• Asking about family stress levels and how caregivers manage stress.
• Asking about the relationship between caregivers.
• Asking about the social supports available to, and used by, the family.
• Asking about alcohol and other substance use, and any recent increase in use.
• Looking for signs of stress, irritability, and depression in caregivers.
• Looking for harsh responses to child behaviors by caregivers.
• Looking for signs of fearfulness and dysregulation in children.
• Looking for evidence of controlling behaviors by one caregiver.

Identify vulnerable children

Every clinical practice includes children who are vulnerable to abuse and neglect. During the pandemic, these children may experience even greater risk of maltreatment and isolation. Physicians should be aware of the risk factors for child maltreatment and pay particular attention to children in households where those risk factors are present. In addition, children who frequently miss scheduled health interventions (e.g., appointments, immunizations) may be a group to target. Physicians can take the initiative to deliberately connect and “check in” with these children—that is, conduct a well-child visit.

Recognize signs of child maltreatment

The first step in helping children who experience maltreatment is learning to recognize the warning signs of abuse and neglect, as outlined in the BC Handbook for Action on Child Abuse and Neglect.[26]

Although many physicians are familiar with symptoms and suspected signs of maltreatment, the increased use of telehealth technology and the corresponding decline in in-person visits create new challenges for physicians in assessing children and families. History-taking can be cumbersome without a face-to-face interaction, particularly where language barriers exist. Physical examination may be limited. Physicians should pay special attention to children and caregivers who appear to be in distress, and to the relationship between children and caregivers.

Report suspected child maltreatment

With limited organized programs available for children (e.g., school, day care, sports, community groups), they may have less contact with adults who can report maltreatment, and physicians may thus have a bigger role to play. Health care providers in British Columbia have a legal duty to promptly report concerns about child maltreatment to a child welfare worker. The duty to report overrides the confidential requirements of the physician-patient relationship. Physicians should understand their duty to report maltreatment and know how to contact a child welfare worker, as outlined in the BC Handbook for Action on Child Abuse and Neglect.[26] The handbook and other resources related to reporting are available at www2.gov.bc.ca/gov/content/safety/public-safety/protecting-children/reporting-child-abuse.

If a child is in immediate danger, call police (911 or local police). If you think a child or youth under 19 years of age is being abused or neglected, call 1 800 663-9122 any time of the day or night to reach a child welfare worker.

Help caregivers manage stress

Increased stress and mental health issues among caregivers are widely recognized in the context of the pandemic. Government agencies, civil society organizations, and health care groups have allocated resources and shared advice for helping caregivers cope. Physicians should be aware of specific resources that are relevant in their jurisdictions and know how to refer to them in case of a crisis.

The HealthLink BC website (www.healthlinkbc.ca/mental-health-covid-19) provides a list of resources for children and families, including links to a comprehensive set of virtual mental health supports that are free or inexpensive.

Support child well-being

Now, perhaps more than ever, children and caregivers are facing extreme personal and family stress, social isolation, and financial insecurity, and the absence of typical supports. Everyone can play a role in maintaining the health and well-being of children, families, and communities. Physicians should encourage all patients to support each other through the pandemic. There are many ways that people can help, such as:

• Staying connected to family and friends, and checking in on neighbors and other community members (while taking the proper safety measures).
• Sharing positive news and acts of kindness with your community.
• Connecting families with virtual programming for children—many public institutions and community centres are providing free virtual experiences, including educational resources, games and activities, tours of popular museums and attractions, and physical activities.

Summary

Children are known to be at greater risk of abuse and neglect during public health emergencies such as the current COVID-19 pandemic. Physicians can help ensure the safety of children by using the resources and strategies discussed here to identify and address cases of child maltreatment.

Competing interests

None declared.

This article has been peer reviewed.

Dr Kang is a pediatrician with the Child Protection Service Unit, BC Children’s Hospital, and a clinical instructor in the Department of Pediatrics, University of British Columbia. Dr Jain is the medical director of the Child Protection Service Unit, BC Children’s Hospital, and a clinical assistant professor in the Department of Pediatrics, University of British Columbia.