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NAPNAP Position Statement on Child Maltreatment

        A goal of the National Association of Pediatric Nurse Practitioners (NAPNAP) is to enhance the quality of health care for infants, children, and adolescents. To achieve this purpose, NAPNAP promotes the provision of a safe, caring, and healthy environment that contributes to optimal growth and development of children from infancy to adulthood.
        Child maltreatment is a broad term encompassing neglect, physical abuse, sexual abuse, emotional abuse, and medical child abuse. Child maltreatment, a major public health concern in the United States, has negative consequences on emotional and physical development, often with effects lasting a lifetime and into future generations. The U.S. Department of Health and Human Services (USDHHS) estimated that 702,000 children were victims of child maltreatment during 2014, at a rate of 9.4 per 1,000. More than 1,000 (1,546) children died in 2014 as a result of child maltreatment, and 78% of children who died as a result of child maltreatment were younger than 4 years. During 2014, 75% of victims suffered from neglect, 17% were physically abused, 8.3% were sexually abused, and 6% were psychologically maltreated. Nearly 82% of victims were abused by a parent (
        Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services
        Child maltreatment 2014.
        ). Despite legal mandates to report child maltreatment, lack of early identification and reporting along with limited patient disclosure of abuse make the numbers of cases of child abuse difficult to accurately estimate.
        Child maltreatment is associated with a broad array of physical and mental health problems, including eating and sleeping disorders, regression, developmental delays, psychosomatic disorders, attachment disorders, substance abuse, depression, anxiety, suicidal ideation, future victimization, violent behavior, and chronic physical illnesses. Some of these long-term consequences result from specific injuries, but other damaging effects can result from the absence of positive interactions between the caregiver and child. Research has suggested that child maltreatment is a major risk factor for the leading causes of illness, death, and poor quality of life in the United States (
        • Currie J.
        • Widom C.S.
        Long-term consequences of child abuse and neglect on adult economic well-being.
        ,
        • Slopen N.
        • McLaughlin K.
        • Shonkoff J.
        Interventions to improve cortisol regulation in children: A systematic review.
        ).
        Research has led to insight into the factors that place children at risk for maltreatment and the factors that place a caregiver at risk for becoming abusive (
        • Rodriguez C.M.
        Personal contextual characteristics and cognitions: Predicting child abuse potential and disciplinary style.
        ). These factors include increased violence in the media and society, poverty and financial strain, prematurity, children with disabilities, unrealistic developmental expectations of parents, single-parent families, substance abuse, parental stress, isolation, domestic violence, lack of social support, and cultural factors (
        • Hornor G.
        Child maltreatment: Screening and anticipatory guidance.
        ). Children and adolescents are also at risk for exposure to predators related to unsupervised use of the Internet (
        • Quayle E.
        • Jones T.
        Sexualized images of children on the internet.
        ).
        Domestic violence is closely linked with child abuse. Studies estimate that up to 10 million children are exposed to domestic violence annually (
        Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services
        Child maltreatment 2014.
        ). Child maltreatment may occur in association with domestic violence in up to 60% of cases (
        • Hamby S.
        • Finkelhor D.
        • Turner H.
        • Ormrod R.
        The overlap of witnessing partner violence with child maltreatment and other victimizations in a nationally representative survey of youth.
        ). Pediatric health care providers have been prevented from adequately addressing the problem of child maltreatment because of lack of training, psychological barriers, racial and socioeconomic factors, past negative experiences with child protective services, inadequate knowledge of reporting mandates, lack of time, and anticipated court testimony (
        • Hornor G.
        Child maltreatment: Screening and anticipatory guidance.
        ). In addition, a lack of effective and accessible treatment programs leads to continued maltreatment situations. Without intervention, child maltreatment will continue to be a national emergency with substantial costs to society.
        Theoretical frameworks for child maltreatment intervention with both the child and the perpetrator have been developed (
        • Kalmakis K.
        • Chandler G.
        Adverse childhood experiences: Towards a clear conceptual meeting.
        ). These strategies include using activities to facilitate positive parent-child interaction, reducing stress, providing support, educating parents and caregivers regarding child development and management techniques, and facilitating children's psychosocial development (
        • Leenarts L.
        • Diehle J.
        • Doreleijers T.
        • Jansma E.
        • Lindauer R.
        Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: A systematic review.
        ). Effective community intervention involves an interprofessional approach with the formation of a child protection team that includes professionals from health care, criminal justice, law enforcement, social work, and education.
        NAPNAP is an organization committed to improving the health care of children. NAPNAP believes that a concerted effort must be made to prevent child maltreatment, identify maltreatment, and intervene as soon as possible to cause the least amount of trauma to the child. Pediatric-focused advanced practice registered nurses (APRNs) are in a strategic position to assess for the presence of risk and protective factors and provide primary prevention interventions (
        • Flaherty E.G.
        • Sege R.
        • Hurley T.P.
        • Baker A.
        Strategies for saving and improving children's lives.
        ;
        • Hornor G.
        Childhood trauma exposure and toxic stress: What the PNP needs to know.
        ). Additionally, pediatric-focused APRNs can screen for maltreatment, provide anticipatory guidance on this issue, and assist children/families already engaged in maltreatment by referring to a local child protection team (
        • Hornor G.
        Child maltreatment: Screening and anticipatory guidance.
        ). A coordinated effort must be established to offer diagnostic, therapeutic, and remedial services to abused children and their families.
        Therefore, NAPNAP affirms to:
        • 1.
          Support efforts for primary prevention of child maltreatment, including assessing for risk and protective factors, educating parents and caregivers, providing assistance to families in crisis, and recognizing that child maltreatment crosses all socioeconomic, racial, and religious boundaries.
        • 2.
          Support educational programs for children that empower them to become aware of how to protect themselves from maltreatment and teach them to disclose to trusted adults.
        • 3.
          Support the development and implementation of protocols for screening, evaluation, treatment, and referral of child maltreatment.
        • 4.
          Encourage all pediatric nurse practitioner and other medical training programs to include comprehensive education in the area of child maltreatment.
        • 5.
          Serve as an educational resource to parents/caregivers, children, health care providers, child protective workers, criminal and judicial personnel, day care providers, and the community at large regarding prevention, identification, and management of child maltreatment.
        • 6.
          Recognize pediatric-focused APRNs who have acquired specialized training in the evaluation of child maltreatment as an integral member of the child protection team.
        • 7.
          Support efforts to decrease violence in the media, the Internet, the family, and society.
        • 8.
          Support increased funding for further child maltreatment research studies, including prevention efforts, intervention research, and theory testing.
        • 9.
          Encourage health care providers to refer to or provide mental health services to child maltreatment victims and to family members of abused children, including the parent(s), and in some cases the perpetrators (e.g., adolescent siblings).
        • 10.
          Support efforts to prevent victimization of children in the courtroom and to develop and implement age-appropriate environments for children involved in the judicial system.
        NAPNAP, an organization whose mission is to empower pediatric-focused APRNs and their interprofessional partners to enhance child and family health through leadership, advocacy, professional practice, education, and research, actively supports and encourages prevention, identification, and early intervention in all cases of child maltreatment.
        The National Association of Pediatric Nurse Practitioners would like to acknowledge the contribution of the Child Maltreatment and Neglect (CMN) Special Interest Group (SIG) and the following members for their contribution to this statement: Gail Horner, DNP, CPNP (CMN SIG Chair); Amy Terreros, DNP, CPNP (CMN SIG Co-Chair); Pamela Herendeen, DNP, PPCNP-BC (CMN SIG Secretary); Katie Doughty, MS, RNc, CPNP-PC (CMN SIG Treasurer); Debbie Bretl, MSN, PPCNP-BC; Evelyn Chapman, CPNP; Carrie Donnell, MSN, CPNP; Linda Frye, PhD, RN, CPNP; Nancy Mitchell, MSN, PPCNP-BC; Barbie Mulvaney, CPNP; Hannah Pressler, DNP, PPCNP-BC, AFN-BC; Saribel Quinones, DNP, PPCNP-BC; Stephanie Schaller, MSN, RN, APRN-BC; and Brigit Van Graafeiland, DNP, MS, RN, CPNP.

        References

          • Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services
          Child maltreatment 2014.
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          Long-term consequences of child abuse and neglect on adult economic well-being.
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          • Baker A.
          Strategies for saving and improving children's lives.
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          • Hamby S.
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          • Turner H.
          • Ormrod R.
          The overlap of witnessing partner violence with child maltreatment and other victimizations in a nationally representative survey of youth.
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          Child maltreatment: Screening and anticipatory guidance.
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