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Child Maltreatment Prevention: Essentials for the Pediatric Nurse Practitioner

Published:October 06, 2021DOI:https://doi.org/10.1016/j.pedhc.2021.09.006

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      OBJECTIVES

      • 1.
        Define primary, secondary, and tertiary child maltreatment practice interventions.
      • 2.
        Discuss important considerations when screening for psychosocial risk factors of abuse.
      • 3.
        Explore anticipatory guidance related to child maltreatment prevention.
      • 4.
        Discuss evidence-based home visitation, parenting training, and early childhood education program using evidence-based practice guidelines.
      • 5.
        Explore the Pediatric Nurse Practitioner role in child abuse prevention.
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      INTRODUCTION

      Child maltreatment is a serious problem with the potential for lifelong physical and mental health consequences, even death. According to the , an estimated 656,000 American children were investigated by child protective services (CPS) and determined to be victims of child maltreatment in 2019, and for 1,840 children, maltreatment resulted in death. Approximately 61% of maltreated children suffered neglect, 10% physical abuse, 7% sexual abuse, and 6.1% emotional abuse, with more than 15% experiencing multiple forms of maltreatment (). However, based on retrospective studies of adults, we know that these numbers represent only a small proportion of true child maltreatment victims. Considering sexual abuse alone, studies suggest that as many as 1 in 5 victims never disclose (
      • Hébert M.
      • Tourigny M.
      • Cyr M.
      • McDuff P.
      • Joly J.
      Prevalence of childhood sexual abuse and timing of disclosure in a representative sample of adults from Quebec.
      ). Child maltreatment is a pediatric health care problem of epidemic proportions. Pediatric health care providers, especially pediatric nurse practitioners (PNPs), are uniquely positioned not only to identify potential victims of child maltreatment but also to prevent child maltreatment before its’ occurrence. This continuing education article will discuss practice level child maltreatment prevention interventions, both universal and targeted.

      PRACTICE INTERVENTIONS

      PNPs can play an integral role in the prevention of child maltreatment. The key to building resilience in families while preventing child maltreatment is to devise interventions that strengthen protective factors while reducing risk factors (
      • Vanderbilt-Adriance E.
      • Shaw D.S.
      Protective factors and the development of resilience in the context of neighborhood disadvantage.
      ). Practice interventions for the prevention of child maltreatment can best be understood using the public health prevention framework (
      U.S. Department of Health & Human Services
      Framework for Prevention of Child Maltreatment.
      ). The public health framework includes primary prevention programs which target all pediatric patients and their families regardless of known risk for child maltreatment, secondary prevention programs targeting families with specific child maltreatment risk factors, and tertiary prevention programs to prevent adverse outcomes from child maltreatment victimization and recurrence of abuse or neglect (
      • Ashraf I.J.
      • Pekarsky A.R.
      • Race J.E.
      • Botash A.S.
      Making the most of clinical encounters: Prevention of child abuse and maltreatment.
      ). See Box 1 for practice interventions.
      Child maltreatment prevention practice interventions
      Tabled 1
      Primary
       Anticipatory guidance for parents/positive parenting
       Screening for psychosocial risk factors
       Anticipatory guidance for children
       Early childhood education
      Secondary
       Linking families with identified risk factors to community resources
        Parental mental health concerns
        Parental substance abuse concerns
        Domestic violence
        Parental history of child abuse/neglect
        Homelessness
        Food insecurity
       Home visitation programs
       Parenting training programs
      Tertiary
       Identification of suspected child maltreatment
       Reporting to child protective services and law enforcement
       Linking with resources to prevent negative consequences from child maltreatment
        Trauma-informed care
        Multisystemic therapy for child abuse and neglect
      Note.
      • Lane W.G.
      Prevention of child maltreatment.
      ;
      • Ashraf I.J.
      • Pekarsky A.R.
      • Race J.E.
      • Botash A.S.
      Making the most of clinical encounters: Prevention of child abuse and maltreatment.
      .

      PRIMARY PREVENTION INTERVENTIONS

      Primary prevention interventions can be easily integrated into routine patient care without a substantial increase in time of care. Parents listen to and seek advice from their child's health care provider (
      • Cates J.R.
      • Diehl S.J.
      • Fuemmeler B.F.
      • North S.W.
      • Chung R.J.
      • Hill J.F.
      • Coyne-Beasley T.
      Toward optimal communication about HPV vaccination for preteens and their parents: Evaluation of an online training for pediatric and family medicine healthcare providers.
      ). PNPs often have positive, secure relationships with families—characterized by trust and respect (
      • Hornor G.
      • Quinones S.G.
      • Boudreaux D.
      • Bretl D.
      • Chapman E.
      • Chiocca E.M.
      • VanGraafeiland B.
      Building a safe and healthy America: Eliminating corporal punishment via positive parenting.
      ). Thus, they are well-positioned to provide anticipatory guidance encouraging the use of positive parenting practices. Positive parenting is defined as a continuing relationship between parent and child in which caregivers lead, teach, and communicate with children while providing for their needs consistently and unconditionally (
      • Jeon S.
      • Neppl T.K.
      Intergenerational continuity in economic hardship, parental positivity, and positive parenting: The association with child behavior.
      ;
      • Seay A.
      • Freysteinson W.M.
      • McFarlane J.
      Positive parenting.
      ). Core positive parenting practices include open communication between caregiver and child, having developmentally realistic expectations of the child, the use of assertive nonphysical methods of discipline in place of physical methods of discipline or corporal punishment (CP), and the discouragement of emotionally abusive discipline such as name-calling, belittling, and shaming; consistent use of these core practices can significantly decrease the risk of child maltreatment (
      • Lohan A.
      • Mitchell A.E.
      • Filus A.
      • Sofronoff K.
      • Morawska A.
      Positive parenting for healthy living (Triple P) for parents of children with type 1 diabetes: protocol of a randomised controlled trial.
      ).
      Discuss the importance of using discipline to teach children and the power of praising “good” behavior (
      • Hoeboer C.
      • de Roos C.
      • van Son G.E.
      • Spinhoven P.
      • Elzinga B.
      The effect of parental emotional abuse on the severity and treatment of PTSD symptoms in children and adolescents.
      ). Encourage parents to talk to their children about what their behavioral expectations are, why they have the expectations, and what the child's potential consequence will be for not meeting up to expectations. Stress the importance of sending consistent messages to the child. The PNP should explore and acknowledge parents’ current discipline practices along with their attitudes and beliefs regarding discipline (
      • Sege R.D.
      • Siegel B.S.
      Council on Child Abuse and Neglect., & Committee on Psychosocial Aspects of Child and Family Health
      Effective discipline to raise healthy children.
      ). Should the parent endorse the use of CP, the PNP should discuss in an open, nonjudgmental manner the potential negative consequences of CP as well as its long-term ineffectiveness (
      • Afifi T.O.
      • Mota N.
      • MacMillan H.L.
      • Sareen J.
      Harsh physical punishment in childhood and adult physical health.
      ;
      • Chiocca E.M.
      American parents’ attitudes and beliefs about corporal punishment: An integrative literature review.
      ;
      • Knox M.
      On hitting children: A review of corporal punishment in the United States.
      ;
      • Lee S.J.
      • Grogan-Kaylor A.
      • Berger L.M.
      Parental spanking of 1-year-old children and subsequent child protective services involvement.
      ;
      • Sege R.D.
      • Siegel B.S.
      Council on Child Abuse and Neglect., & Committee on Psychosocial Aspects of Child and Family Health
      Effective discipline to raise healthy children.
      ). The primary negative consequences being that children who experience spanking and other forms of physical discipline are at increased risk to experience physical abuse at the hands of their parents have lower/slower cognitive development and poorer long-term mental health outcomes (
      • Afifi T.O.
      • Mota N.
      • MacMillan H.L.
      • Sareen J.
      Harsh physical punishment in childhood and adult physical health.
      ;
      • Chiocca E.M.
      American parents’ attitudes and beliefs about corporal punishment: An integrative literature review.
      ;
      • Gershoff E.T.
      • Grogan-Kaylor A.
      Spanking and child outcomes: Old controversies and new meta-analyses.
      ;
      • Knox M.
      On hitting children: A review of corporal punishment in the United States.
      ). Offer other age-appropriate nonphysical methods of discipline such as time-out, loss of privileges, or grounding. Anticipatory guidance regarding positive parenting, including the encouragement of nonphysical methods of discipline, should begin in infancy and continue through adolescence.
      In addition, anticipatory guidance should address parental management of challenging developmental stages. Anticipatory guidance for parents of infants and young children should include acknowledgment of parental stress related to crying, discussion of ways to address the stress, and educating never to shake a baby or child. A brief, frank explanation is warranted to educate parents that when a baby or child is forcefully shaken, thrown, or jerked, there exists a potential danger of abusive head trauma or shaken baby syndrome (
      • Dias M.S.
      • Rottmund C.M.
      • Cappos K.M.
      • Reed M.E.
      • Wang M.
      • Stetter C.
      • Klevens J.
      Association of a postnatal parent education program for abusive head trauma with subsequent pediatric abusive head trauma hospitalization rates.
      ;
      • Lane W.G.
      Prevention of child maltreatment.
      ). Explain to them that abusive head injury is an injury to the brain that can result in serious lifetime disabilities, even death (
      • Dias M.S.
      • Rottmund C.M.
      • Cappos K.M.
      • Reed M.E.
      • Wang M.
      • Stetter C.
      • Klevens J.
      Association of a postnatal parent education program for abusive head trauma with subsequent pediatric abusive head trauma hospitalization rates.
      ). As the child ages, anticipatory guidance should address other potential developmental challenges such as toilet training, tantrums, or adolescent behavioral changes.
      Sexual abuse prevention provides an additional opportunity for the PNP to provide anticipatory guidance to all parents (see Box 2) and children. Every well-child visit should include an anogenital examination affording the PNP an opportunity to educate the child regarding the concept of private parts and to tell and who to tell if they are touched inappropriately (
      • Lane W.G.
      Prevention of child maltreatment.
      ). Encourage parents to teach their child the anatomically current names for all body parts, including private parts. Explain that doing so will facilitate an adult understanding of any potential sexual abuse disclosure. As a child ages, anticipatory guidance should also include a discussion with parents and children regarding Internet safety involving education regarding sexting, online sexual solicitation, healthy intimate relationships, and sex trafficking.
      Sexual abuse anticipatory guidance
      Tabled 1
      1. Most children who are sexually abused are not abused by a stranger.
      2. Children are most at risk of being sexually abused by someone they know, trust, and even love.
      3. Never leave your child with someone you do not know well.
      4. Never leave your child with anyone who has a history of sexually abusing a child.
      5. People who sexually abuse children are at high risk of abuse again.
      6. Pedophiles often present as normal, healthy individuals. They may be married and have children, even grandchildren.
      7. Pay attention if an adult likes to spend a lot of time alone with your child.
      8. Most children who are sexually abused have no physical sign, even on examination by a health care provider.
      9. If you have a concern about sexual abuse, do not ignore it. Share your concerns with your child's health care provider, teacher, counselor, or child protective services.
      10. If your child disclosed sexual abuse, always report to child protective services.
      11. You are your child's best protection against sexual abuse.
      Note. Adapted from
      • Hornor G.
      Child maltreatment: Screening and anticipatory guidance.
      .
      Another primary prevention practice intervention is the screening of families and children for child maltreatment risk. A variety of familial psychosocial factors and child characteristics increase the risk for child maltreatment (see Box 3). A child with individual risk characteristics living in a family with psychosocial risk factors is at heightened risk to experience child maltreatment. Characteristics placing the child at increased risk for child maltreatment are apparent when completing a thorough health history and physical examination. Familial psychosocial characteristics, by contrast, require more deliberate questioning/screening to uncover. Briefly explain to parents that screening is completed because these familial risk factors can have negative effects on their child's physical, emotional, and developmental well-being. Discuss that it is important to understand challenges faced by families to provide support and offer intervention to address identified challenges. Stress that screening results will remain confidential unless concerns for their child's safety should arise.
      Child maltreatment child and familial risk factors and protective factors
      Tabled 1
      Caregiver mental health concern
      Caregiver substance abuse concerns
      Household domestic violence
      Caregiver history of child maltreatment in childhood
       Sexual abuse
       Physical abuse
       Emotional abuse
       Neglect
       Medical child abuse
       Child protective services involvement
      Previous or current familial involvement with child protective services
      Previous or current familial involvement with law enforcement
      Financial stressors
       Food insecurity
       Homelessness
      Teen parent
      Protective factors
       Social supports
       Self-efficacy
       Sense of competency in child-rearing
      Note.
      • Hornor G.
      Child maltreatment: Screening and anticipatory guidance.
      ;
      • Lane W.G.
      Prevention of child maltreatment.
      .
      Screening for psychosocial risk factors must focus on those risk factors for which effective community resources are available. Before initiating screening, it is necessary to identify available, effective, affordable community resources to address each psychosocial risk factor. Gathering this information can be a time-consuming endeavor. Identifying and periodically communicating with key personnel at identified community agencies can be helpful in both learning more about the programs and how the needs of families are addressed (
      • Lane W.G.
      Prevention of child maltreatment.
      ). Children's hospitals, local or state health departments, local child advocacy centers, and United Way are sources to identify appropriate community agencies. Finally, screening for psychosocial risk factors should be universal within the practice center to avoid stigmatizing families, and familial strengths must also be assessed (
      • Lane W.G.
      Prevention of child maltreatment.
      ). See Box 4 for electronic examples of psychosocial screening tools. Electronic screening may be more effective than face-to-face screening. In a randomized controlled trial,
      • Beck A.F.
      • Klein M.D.
      • Kahn R.S.
      Identifying social risk via a clinical social history embedded in the electronic health record.
      found respondents were up to 40% more likely to report a social determinant of health need via computer-based assessment versus in-person assessment. Since the early 2000s, the American Academy of Pediatrics has encouraged the screening of pediatric patients for social and behavioral risk factors and has also encouraged the development and use of standardized screening tools (
      • Sokol R.
      • Austin A.
      • Chandler C.
      • Byrum E.
      • Bousquette J.
      • Lancaster C.
      • Shanahan M.
      Screening children for social determinants of health: A systematic review.
      ).
      Psychosocial screening tools
      Tabled 1
      Safe Environment for Every Kid (https://seekwellbeing.org/seek-materials/)
      • Dubowitz H.
      • Lane W.
      • Semiatin J.
      • Magder L.
      • Venepally M.
      • Jans M.
      The safe environment for every kid model: impact on pediatric primary care professionals.
      Bright Futures Pediatric Intake/Family Psychosocial Screen
      (https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf)
      Social Needs Screening Tool (https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-form-sdoh.pdf)
      ISCREEN (https://pediatrics.aappublications.org/content/suppl/2014/10/29/peds.2014-1439.DCSupplemental)
      • Gottlieb L.M.
      • Hessler D.
      • Long D.
      • Laves E.
      • Burns A.R.
      • Amaya A.
      • Adler N.E.
      Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial.
      Accountable Health Communities Screening Tool
      (https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf)
      IHELP (https://www.ncbi.nlm.nih.gov/pubmed/?term=multiple+behavior+change+intervention+colvin)
      • Colvin J.D.
      • Bettenhausen J.L.
      • Anderson-Carpenter K.D.
      • Collie-Akers V.
      • Plencner L.
      • Krager M.
      • Chung P.J.
      Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals.
      We Care (https://www.ncbi.nlm.nih.gov/pubmed/17766528)
      Psychosocial Assessment Tool (https://www.semanticscholar.org/paper/The-Psychosocial-Assessment-Tool-(PAT2.0)%3A-of-a-for-Pai-Pati%C3%B1o-Fern%C3%A1ndez/1c64e3b7053caa1168ccacab79ee2cde9f0a6269/figure/1)
      Note.
      • Pai A.
      • Patino-Gernandez A.
      • McSherry M.
      • Beele D.
      • Alderfer M.
      • Reilly A.
      • Kazak A.
      The psychosocial assessment tool (PAT2.0): Psychometric properties of a screener for psychosocial distress in families of children newly diagnosed with cancer.
      .
      All children benefit from early childhood education in terms of socialization and readiness preparation for primary school; early childhood education has also been protective against child maltreatment (
      • Bartlett J.D.
      • Smith S.
      The role of early care and education in addressing early childhood trauma.
      ). Two evidence-based publicly funded early education programs have been shown to prevent child maltreatment. Head Start is the largest publicly funded early childhood education and care program in the United States and targets low-income children and children with disabilities, both groups at increased risk for child maltreatment (
      • Zhai F.
      • Waldfogel J.
      • Brooks-Gunn J.
      Estimating the effects of head start on parenting and child maltreatment.
      ). Children attending Head Start were less likely to be spanked by a parent, neglected, physically assaulted, experience low parental warmth, and have CPS contact in the past year than children in other child care arrangements. Another early childhood education program targeting low-income children is the Child-Parent Centers program (CPC). CPC involves children attending the preschool program daily for 3 hr/day. In addition, the program requires parental involvement of at least 0.5 day/week. Parents are also encouraged to be involved in multiple aspects of the program, including classroom and field trip volunteering, vocational/educational training, and using the parent resource room (
      • Reynolds A.J.
      • Mathieson L.C.
      • Topitzes J.W.
      Do early childhood interventions prevent child maltreatment? A review of research.
      ). The CPC has been shown to prevent child maltreatment by decreasing child neglect and out-of-home placements because of child maltreatment. It is important for PNPs to be familiar with and encourage enrollment in early childhood education programs, especially publicly funded and evidence-based programs.

      SECONDARY PREVENTION INTERVENTIONS

      Secondary prevention interventions target families who have been identified at increased risk for child maltreatment. Families with psychosocial concerns identified on screening require secondary practice interventions. The key to successful screening for psychosocial risk factors is linkage to available, appropriate intervention services and monitoring to ensure linkage is completed (
      • Garg A.
      • Toy S.
      • Tripodis Y.
      • Silverstein M.
      • Freeman E.
      Addressing social determinants of health at well child care visits: A cluster RCT.
      ;
      • Gottlieb L.M.
      • Hessler D.
      • Long D.
      • Laves E.
      • Burns A.R.
      • Amaya A.
      • Adler N.E.
      Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial.
      ). It may be difficult to engage families with community resources, and there may be circumstances in which failure to link and remain engaged with offered interventions may raise concerns for parental ability to adequately care for their children. If failure to link with resources to address an identified psychosocial problem results in concern of child safety, the PNP must report identified concerns to CPS. For example, if a mother reports severe domestic violence occurring in the presence of the children and remains in the home with the perpetrator, and fails to link with recommended resources, including trauma-informed mental health therapy for herself and the children; a CPS report is indicated because of concerns for the physical and emotional safety of the children.
      Another secondary prevention intervention is home visitation. Home visitation programs have long been used to improve the health and well-being of children, focusing on socially high-risk pregnant women or families with young children (
      • Chaiyachati B.H.
      • Gaither J.R.
      • Hughes M.
      • Foley-Schain K.
      • Leventhal J.M.
      Preventing child maltreatment: Examination of an established statewide home-visiting program.
      ). Home visitation programs have also been proven to be effective in preventing child maltreatment. A home visitation program with the goal of preventing child maltreatment should consider the following factors: the promotion of evidence-based programs, target families most at risk for child maltreatment and use programs with processes in place to ensure implementation consistent with the original tested model (
      • Donelan-McCall N.
      • Eckenrode J.
      • Olds D.L.
      Home visiting for the prevention of child maltreatment: Lessons learned during the past 20 years.
      ). The general aims of home visitation programs are to improve parent–child relationships, support parents in decreasing stress, increasing self-efficacy, and improving education and employment while connecting families with their communities (
      • Chartier M.J.
      • Brownell M.D.
      • Isaac M.R.
      • Chateau D.
      • Nickel N.C.
      • Taylor C.
      Is the Families First Home Visiting Program effective in reducing child maltreatment and improving child development?.
      ). Several evidence-based home visitation models have proven efficacy in reducing substantiated child maltreatment rates (see Box 5).
      Home visitation programs
      Tabled 1
      ProgramHome VisitorTargetsChild MaltreatmentOther Positives
      Families First Home Visiting ProgramParaprofessionalRisk-based screeningYes

      Decreased CPS care from birth to 3 years old

      Decrease out-of-home placements
      Improved child development and behavior
      Nurse-Family PartnershipNursesFirst-time, low-income mothers

      Before 28-week gestation
      Yes

      Decrease child maltreatment and injury to children
      Improve maternal education

      Improve maternal employment

      Improved early childhood mental health and development
      Healthy Families AmericaParaprofessionalRisk-based screeningYes

      Decrease substantiated CPS reports
      Improved child behavior and development
      Parents as TeachersNurses

      Social workers

      Teachers

      Paraprofessionals
      All families pregnancy to 5 years oldYes

      Decreased suspected child maltreatment CPS cases
      Improved child behavior and development
      Early Head StartEducators

      Paraprofessionals
      Low-incomeImproved parenting behaviors

      Decrease spanking at 3 years old
      Improved child behavior and development

      Improved parent employment
      Note. CPS, child protective services.
      • Chartier M.J.
      • Brownell M.D.
      • Isaac M.R.
      • Chateau D.
      • Nickel N.C.
      • Taylor C.
      Is the Families First Home Visiting Program effective in reducing child maltreatment and improving child development?.
      ;
      • Flowers M.
      • Sainer S.
      • Stoneburner A.
      • Thorland W.
      Education and employment outcomes in clients of the Nurse-Family Partnership.
      ;
      • Lee E.
      • Kirkland K.
      • Miranda-Julian C.
      • Greene R.
      Reducing maltreatment recurrence through home visitation: A promising intervention for child welfare involved families.
      ;
      • Matone M.
      • Kellom K.
      • Griffis H.
      • Quarshie W.
      • Faerber J.
      • Gierlach P.
      • Cronholm P.F.
      A mixed methods evaluation of early childhood abuse prevention within evidence-based home visiting programs.
      ;
      • Tonmyr L.
      The Nurse-Family Partnership: Evidence-based public health in response to child maltreatment.
      .
      It is widely accepted that safe and positive parent–child interactions filled with warmth and nurturance promote positive child development, health, and behavior (
      • Sanders M.R.
      • Kirby J.N.
      • Tellegen C.L.
      • Day J.J.
      The Triple P-Positive Parenting Program: A systematic review and meta-analysis of a multi-level system of parenting support.
      ). Parenting training programs focus on providing parents with the tools needed to have safe and healthy relationships with their children: education on child development and effective discipline strategies with the aim of improving parent comfort and competence with parenting (
      • Spencer C.M.
      • Topham G.L.
      • King E.L.
      Do online parenting programs create change?: A meta-analysis.
      ). Parenting training programs vary by mode of delivery and can be individual or group-focused, office or home-based. Although parents can self-refer to many parenting training programs, many parent participants have been identified as needing assistance with the development of essential parenting skills. Specific parenting training programs with a proven significant effect on preventing or reducing child maltreatment include Triple P-Positive Parenting Programs (
      • Sanders M.R.
      • Kirby J.N.
      • Tellegen C.L.
      • Day J.J.
      The Triple P-Positive Parenting Program: A systematic review and meta-analysis of a multi-level system of parenting support.
      ) and adults and children together (ACT) Parent's Raising Safe Kids Program (
      • Van der Put C.E.
      • Assink M.
      • Gubbels J.
      • Boekhout van Solinge N.F.
      Identifying effective components of child maltreatment interventions: A meta-analysis.
      ).
      The Triple P-Positive Parenting Program provides multitiered services based on identified needs (
      • Spencer C.M.
      • Topham G.L.
      • King E.L.
      Do online parenting programs create change?: A meta-analysis.
      ). Tier 1 universally targets all parents, and these positive parenting messages can easily be incorporated into anticipatory guidance as a primary practice intervention. Tier 2 targets discreet behavioral or developmental concerns such as sleep or toilet training and involves intervention by phone or in-person in a few brief sessions. Tier 3 addresses more serious problems and involves active skills training. Behavioral concerns are addressed in Tier 4. Finally, Tier 5 addresses parents who have their issues in addition to their child's serious behavioral concerns. The intensity of service provision increases with each Tier.
      The ACT Parents Raising Safe Kids Program is a universal approach to child abuse prevention with educational components directed at all parents and other primary caregivers (
      • Portwood S.G.
      • Lambert R.G.
      • Abrams L.P.
      • Nelson E.B.
      An evaluation of the adults and children together (ACT) against violence parents raising safe kids program.
      ). The ACT Parents Raising Safe Kids Program was developed by the American Psychological Association and emphasized the critical role that parents and other adults play in protecting young children from violence and injury. The program is organized into eight 2-hr sessions focused on promoting positive parenting, understanding child behavior, positive discipline, dealing with anger, and resolving family conflicts in a positive way.

      TERTIARY PREVENTION INTERVENTIONS

      Tertiary practice interventions aim to prevent adverse outcomes from experiencing child maltreatment. The key to lessening the impact of child maltreatment is the prompt identification of victims, protecting them from their abuser, and linking them to appropriate therapeutic resources. Pediatric health care providers, including PNPs, are well-positioned to identify suspected victims of child maltreatment. Whenever a child presents with an injury, a detailed history should be obtained from the parent and child if developmentally appropriate. Certain clinical and historical indicators should raise concerns for possible physical abuse (see Box 6).
      Historical and clinical indicators of physical abuse
      Tabled 1
      No history given for the injury
      History inconsistent with the injury
      Conflicting histories for injury
      History inconsistent with the developmental level of the child
      Delay in seeking medical care
      Any of the following injuries without a clear history of injury:
       Bruising, other cutaneous injuries, or fractures in an infant or nonambulatory child
       Bruising or other cutaneous injuries on protected/nonexploring areas of the body
        Ears
        Abdomen
        Genitals
        Chest
        Neck
       Extensive bruising or other cutaneous injuries
       Intracranial trauma/head trauma
       Abdominal trauma
      Note.
      • Henry M.K.
      • Wood J.N.
      What's in a name? Sentinel injuries in abused infants.
      ;
      • Hornor G.
      Child maltreatment: Screening and anticipatory guidance.
      ;
      • Sheets L.K.
      • Leach M.E.
      • Koszewski I.J.
      • Lessmeier A.M.
      • Nugent M.
      • Simpson P.
      Sentinel injuries in infants evaluated for child physical abuse.
      .
      Sexual abuse is typically revealed by child disclosure to a nonhealthcare professional (
      • Jackson A.M.
      • Kissoon N.
      • Greene C.
      Aspects of abuse: Recognizing and responding to child maltreatment.
      ). However, on rare occasions, children may present with sexual abuse concerns that are revealed during the health care visit: pregnancy, sexually transmitted infection, anogenital examination findings, or child disclosure of sexual abuse (
      • Jenny C.
      • Crawford-Jakubiak J.E.
      & Committee on Child Abuse and Neglect., & American Academy of Pediatrics
      The evaluation of children in the primary care setting when sexual abuse is suspected.
      ). Emotional abuse can be difficult to identify, and most often, it is the child's behavioral or mental health difficulties that first raise concerns (
      • Hoeboer C.
      • de Roos C.
      • van Son G.E.
      • Spinhoven P.
      • Elzinga B.
      The effect of parental emotional abuse on the severity and treatment of PTSD symptoms in children and adolescents.
      ). On occasion, parent–child interactions observed in the health care visit can raise concerns for emotional abuse. See Box 7 for examples of questions for parents and children when concerns for emotional abuse arise. PNPs also care for children experiencing neglect, such as lack of adequate food, clothing, shelter, medical care, or supervision (
      • Jackson A.M.
      • Kissoon N.
      • Greene C.
      Aspects of abuse: Recognizing and responding to child maltreatment.
      ).
      Questions to screen for emotional maltreatment
      Tabled 1
      Parents
      • 1.
        What kind of child is _____________?
      • 2.
        Are they easy to care for?
      • 3.
        Tell me something good/positive about ________________.
      • 4.
        What is hard/difficult about ____________?
      Children
      • 1.
        How are things at home? At your dad's?
      • 2.
        How do you get along with mom/dad/stepdad/stepmom?
      • 3.
        Tell me something you like to do with mom/dad/stepmom/stepdad.
      • 4.
        Tell me something you like about mom/dad/stepmom/stepdad.
      • 5.
        Tell me something you do not like about mom/dad/stepmom/stepdad.
      • 6.
        Does anyone make you feel scared, sad, or dumb?
      Note.
      • Hornor G.
      Emotional maltreatment.
      .
      It is crucial to recognize and identify all forms of suspected child maltreatment, and as mandated reporters, PNPs are legally required to report concerns to CPS and law enforcement. The goal of involving governmental agencies is to prevent the recurrence and escalation of child maltreatment (
      • Green M.
      Nurses’ adherence to mandated reporting of suspected cases of child abuse.
      ). CPS and law enforcement will further investigate the suspected child maltreatment. CPS with the goal of ensuring the safety and well-being of the child and law enforcement to pursue possible legal consequences for the suspected perpetrator. Thus, mandated reporting of child maltreatment prevents the reabuse of the identified child victim, helps identify other potential victims, and prevents the maltreatment of other children by the perpetrator.
      Prompt identification of child maltreatment also allows for prompt evidence-based intervention to lessen the risk of negative sequelae. Children exposed to familial psychosocial risk factors, such as domestic violence, parental substance abuse, or parental mental health concerns, even if not victims of child maltreatment, are trauma-exposed children. Victims of child maltreatment and children exposed to psychosocial risk factors should be screened for trauma symptoms such as anxiety, sadness, difficulty concentrating, hyperactivity, anger, difficulty sleeping, or irritability (
      • Oral R.
      • Ramirez M.
      • Coohey C.
      • Nakada S.
      • Walz A.
      • Kuntz A.
      • Peek-Asa C.
      Adverse childhood experiences and trauma informed care: The future of health care.
      ). Although all trauma-exposed children should be assessed by a skilled mental health provider, it is crucial that symptomatic children receive a prompt referral for trauma-informed mental health services. PNPs must be familiar with local agencies providing trauma-informed mental health services.
      Families at high risk for child maltreatment may benefit from intensive family therapy. One such evidence-based program is Multisystemic Therapy for Child Abuse and Neglect (MST-CAN). The MST-CAN model is specifically designed for the treatment of families experiencing severe clinical difficulties, multiple risk factors, and highly complex situations (
      • Swenson C.C.
      • Schaeffer C.M.
      A multisystemic approach to the prevention and treatment of child abuse and neglect.
      ). There are four major treatment goals for the model: keeping families together safely, preventing reabuse and neglect, decreasing mental health difficulties experienced by adults and children, and increasing social supports for families (
      • Swenson C.C.
      • Schaeffer C.M.
      A multisystemic approach to the prevention and treatment of child abuse and neglect.
      ). The MST-CAN model is intensive, with families receiving services a minimum of three times a week for 6–9 months. Research indicates that MST-CAN decreases reabuse, out-of-home placements for children, and substantiated child maltreatment reports (
      • Swenson C.C.
      • Schaeffer C.M.
      A multisystemic approach to the prevention and treatment of child abuse and neglect.
      ).
      PNPs possess the knowledge and skills to be a driving force behind health care and societal changes that promote the prevention of child maltreatment. Be a role model for other pediatric health care providers by incorporating primary, secondary, and tertiary prevention interventions into your daily practice behaviors. Encourage other pediatric health care providers also to adopt these interventions. Develop practice-based policies to ensure universal psychosocial risk factor screening, intervention, and anticipatory guidance implementation. Psychosocial risk factors can predispose a child to not only experiencing child maltreatment but also the Adverse Childhood Experiences study,
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • Williamson D.F.
      • Spitz A.M.
      • Edwards V.
      • Marks J.S.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
      , solidified our knowledge that exposure to psychosocial traumas in childhood increases the risk for negative adult physical and mental health outcomes in a dose-related gradient (
      • Gilgoff R.
      • Singh L.
      • Koita K.
      • Gentile B.
      • Marques S.S.
      Adverse childhood experiences, outcomes, and interventions.
      ). Screening and intervention for psychosocial risk factors are crucial to the health and well-being of children.
      Advocate for the implementation and dissemination of evidence-based home visitation, parenting programs, and early childhood education at both the community and state levels (
      • Lane W.G.
      Prevention of child maltreatment.
      ). Become a voice at the individual practice level, community, state, and national level encouraging positive parenting while denouncing the use of CP. Experiencing spanking in childhood can result in negative consequences similar to those studied in the Adverse Childhood Experiences study;
      • Afifi T.O.
      • Ford D.
      • Gershoff E.T.
      • Merrick M.
      • Grogan-Kaylor A.
      • Ports K.A.
      • Peters Bennett R.
      Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience.
      suggest spanking should be designated an adverse childhood experience. Work to implement a no-hit zone in your institution. The no-hit zone is a program that trains health care workers in de-escalation techniques to address parental disruptive behaviors and the physical discipline of children in the health care setting (
      • Frazier E.R.
      • Liu G.C.
      • Dauk K.L.
      Creating a safe place for pediatric care: A no hit zone.
      ). Advocate at the local, state, and national levels for the abolition of CP in the school setting. PNPs recognize that many parents have challenges, such as financial, mental health, or substance abuse, that lead to a struggle to meet the needs of their children. PNPs also recognize a drastic shortage of affordable quality daycare and early childhood education in the United States. PNPs understand that these factors place children at increased risk for experiencing child maltreatment. PNPs must advocate for legislative changes at the state and national level, providing increased resources to meet the needs of families and children.

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      Biography

      Gail Hornor, Pediatric Nurse Practitioner, Center for Family Safety and Healing, Nationwide Children's Hospital, Columbus, OH.