Child abuse and neglect in the COVID-19 era: A primer for front-line physicians in British Columbia

Issue: BCMJ, vol. 62 , No. 7 , September 2020 , Pages 238-240 Clinical Articles COVID-19

ABSTRACT: Children are widely recognized as a vulnerable population during disasters and emergencies. In BC there are growing concerns that children may be at higher risk of abuse and neglect as a consequence of the current COVID-19 pandemic and the public health measures to limit its spread. Increased family and financial stress, disrupted routines, and lack of access to community supports can all contribute to child maltreatment. At the same time, physical distancing has restricted contact between children and the protective adults, such as teachers, who most commonly report cases of suspected child maltreatment. Despite the pandemic, physicians continue to interact with children and families and are uniquely situated to identify cases of suspected child maltreatment. All physicians have a role to play in ensuring the safety and protection of children. Specific approaches to clinical practice in the pandemic era and resources adapted for the pandemic can help physicians assess risk of child maltreatment, support children and families, and recognize and respond to child abuse and neglect.


Because physicians continue to interact with patients during the COVID-19 pandemic, they are uniquely positioned to identify vulnerable children, provide support to children and their caregivers, and report suspected cases of maltreatment.


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.


References

1.    Trust for America’s Health, American Academy of Pediatrics. Pandemic influenza: Warning, children at-risk. 2007. Accessed 4 June 2020. www.tfah.org/report-details/pandemic-influenza-warning-children-at-risk.

2.    Institute of Medicine. Emergency care for children: Growing pains. Washington, DC: National Academies Press; 2007.

3.    Stevenson E, Barrios L, Cordell R, et al. Pandemic influenza planning: Addressing the needs of children. Am J Public Health 2009;99(suppl 2):255-260.

4.    Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-1242.

5.    Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics 2020. doi: 10.1542/peds.2020-0702.

6.    Bialek S, Gierke R, Hughes M, et al. Coronavirus disease 2019 in children—United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69:422-426.

7.    Peterman A, Potts A, O’Donnell M, et al. Pandemics and violence against women and children. CGD Working Paper 528. Washington, DC: Center for Global Development; 2020. Accessed 5 June 2020. www.cgdev.org/sites/default/files/pandemics-and-vawg-april2.pdf.

8.    Centers for Disease Control and Prevention. Ten leading causes of injury deaths by age group highlighting unintentional injury deaths, United States–2011. Accessed 30 April 2020. www.cdc.gov/injury/wisqars/pdf/leading_causes_of_injury_deaths_highlighting_unintentional_injury_2011-a.pdf.

9.    Child Welfare Information Gateway. Long-term consequences of child abuse and neglect. Washington, DC: US Department of Health and Human Services, Administration for Children and Families, Children’s Bureau; 2019. Accessed 5 June 2020. www.childwelfare.gov/pubs/factsheets/long-term-consequences.

10.    Burczycka M, Conroy S. Family violence in Canada: A statistical profile, 2015. Juristat 2017.

11.    Schnitzer P, Gulino S, Yuan Y-YT. Advancing public health surveillance to estimate child maltreatment fatalities: Review and recommendations. Child Welfare 2013;92:77-98.

12.    Tonmyr L, Li YA, Williams G, et al. Patterns of reporting by health care and nonhealthcare professionals to child protection services in Canada. Paediatr Child Health 2010;15:25-32.

13.    The Alliance for Child Protection in Humanitarian Action. Technical note: Protection of children during the coronavirus pandemic, Version 1. The Alliance for Child Protection in Humanitarian Action; 2020.

14.    Sistovaris M, Fallon B, Miller S, et al. Child welfare and pandemics: Literature scan. Toronto, Ontario: Policy Bench, Fraser Mustard Institute of Human Development, University of Toronto; 2020. Accessed 5 June 2020. https://cwrp.ca/sites/default/files/publications/Child%20Welfare%20and%20Pandemics%20Literature%20Scan_2020_0.pdf.

15.    Stith SM, Liu T, Davies LC, et al. Risk factors in child maltreatment: A meta-analytic review of the literature. Aggress Violent Behav 2009;14:13-29.

16.    Brown J, Cohen P, Johnson JG, Salzinger S. A longitudinal analysis of risk factors for child maltreatment: Findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse Negl 1998;22:1065-1078.

17.    World Health Organization. Coronavirus disease (COVID 2019): Situation report – 168. 2020. Accessed 6 July 2020. www.who.int/docs/default-source/coronaviruse/situation-reports/20200706-covid-19-sitrep-168.pdf?sfvrsn=7fed5c0b_2.

18.    Mihashi M, Otsubo Y, Yinjuan X, et al. Predictive factors of psychological disorder development during recovery following SARS outbreak. Health Psychol 2009;28:91-100.

19.    Reynolds DL, Garay JR, Deamond SL, et al. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol Infect 2008;136:997-1007.

20.    Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Med Public Health Prep 2013;7:105-110.

21.    Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influencing psychological distress during a disease epidemic: Data from Australia’s first outbreak of equine influenza. BMC Public Health 2008;8:1-13.

22.    Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-920.

23.    Henry B. COVID-19: Important update from the Provincial Health Officer, 23 March 2020. Province of British Columbia; 2020. Accessed 23 June 2020. www.cpsbc.ca/files/pdf/2020-03-23-Important-Update-from-the-Provincial-Health-Officer.pdf.

24.    US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2017. US Department of Health & Human Services; 2019. Accessed 5 June 2020. www.acf.hhs.gov/sites/default/files/cb/cm2017.pdf.

25.    Humphreys KL, Myint MT, Zeanah CH. Increased risk for family violence during the COVID-19 pandemic. Pediatrics 2020. doi: 10.1542/peds.2020-0982.

26.    Province of British Columbia. The BC handbook for action on child abuse and neglect: For service providers. Victoria, BC: Province of British Columbia; 2017. Accessed 5 June 2020. www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/public-safety/protecting-children/childabusepreventionhandbook_serviceprovider.pdf.


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.

Kristopher T. Kang, MD, Nita Jain, MD, FRCPC. Child abuse and neglect in the COVID-19 era: A primer for front-line physicians in British Columbia. BCMJ, Vol. 62, No. 7, September, 2020, Page(s) 238-240 - Clinical Articles, COVID-19.



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Dr Shelley Ross says: reply

Thank you to the authors, Drs Kang and Jain, for the article on child abuse and neglect. Although their article focuses on possible increased risk during the time of the Covid-19 pandemic, the risk of child abuse and neglect has always been present, having long antedated Covid-19. There is also widespread concern that intimate partner violence (IPV) is a silent but persistent pandemic accompanying the Covid-19 pandemic.

We are two physicians from BC who had the privilege of serving on the National Guidance and Implementation Committee (NGIC) for the Violence, Evidence, Guidance, Action (VEGA) Project, which developed online
educational resources to assist healthcare and social service providers in recognizing and responding to family violence.

The NGIC included representatives from 22 national organizations, including the Canadian Medical Association and the College of Family Physicians of Canada; funding was provided by the Public Health Agency of Canada. The process for developing VEGA was multidisciplinary in nature, included perspectives from the many professions, agencies and civil society that are called upon—not only to address the current crisis but to look upstream at the educational, policy, practice and cultural changes need to address prevention, not just response. VEGA focused on child maltreatment and intimate partner violence, and produced evidence-based, pan-Canadian guidance and learning modules (e.g. care
pathways, scripts, how-to videos), interactional educational scenarios and a Handbook for those of us who must jointly address this pervasive and long-standing issue. (Visit https://vegaproject.mcmaster.ca/).

Family violence has haunted us from the legends of antiquity, through Grimm’s fairy tales down to the present day. The VEGA project has engaged professional organizations, educational institutions, legal and social systems to say
“enough is enough.” But words are only words until Action follows.

In many realms, from smoking cessation to effective responses to tuberculosis and cancer, we see that action happens when there is hope and a mechanism to apply effective positive change. Finger wagging and finger pointing are both
useless and counterproductive. Individuals and organizations will only embrace action when it is simultaneously seen as both desirable and doable. The available resources VEGA has produced together with the strategic alliances
in education and policy development offer the prospect of “doability” from the individual, through family and community to provincial and national scales. They include practical information based on systematic reviews and extensive stakeholder feedback whose context is to enable recognition and the ability to respond safely to family violence.

Since the VEGA educational resources (currently undergoing deployment and evaluation) were not referenced in the article, we wanted to bring it to the attention of the readership.

An example of successful engagement in the BC context is the Shared Care Committee that has funded the ongoing work on ACEs (Adverse Childhood Experiences) as part of the legacy of BC's Child and Youth Mental Health and Substance Use Collaborative. Child abuse and neglect are a significant contributor to the ACE score.

The well-articulated, evidence- informed and positive intentions expressed by Kang, Jain, Bradley and other authors can, and must, be translated into effective impact if we are to “bend the curve of history” in this generation. The response to Covid-19 has shown that we can accomplish great things when we act together—the VEGA resources and initiative can provide a step forward in our response to both child maltreatment and IPV.
- Shelley Ross, MD, CCFP, FCFP, ICD.D
- Robert F. Woollard, MD, CCFP, FCFP, LM

References:

Health care providers must be alert for violence against children during the pandemic
Kristopher T. Kang and Nita Jain
CMAJ July 13, 2020 192 (28) E814; DOI: https://doi.org/10.1503/cmaj.75780

Bradley NL, DiPasquale AM, Dillabough K, et al. Health care practitioners’ responsibility to address intimate partner violence related to the COVID-19 pandemic. CMAJ 2020 May 1. [Epub ahead of print]. pii: cmaj.200634. doi: 10.1503/cmaj.200634

endang mei says: reply

this article very useful

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