CHILD ABUSE AND NEGLECT
Overview
For a majority of states (46 out of 50), child abuse and neglect are serious public health problems. Among states contributing to a report published in 2016, there were 6.6 million children in 3.6 million reports of child abuse and neglect nationwide; authorities validated 2.2 million or 61%, with an incidence rate of 29 per 1,000 children (U.S. Department of Health and Human Services [HHS], 2016, p. ix). Professionals who have contact with children as part of their job are mandatory reporters responsible for more than 45% of the reported cases (p. ix). Of the children evaluated, the majority had one report (83%), and some had two or more reports (16%; p. x). The children with validated experiences were neglected (75%) and physically abused (17%), but if the child experienced both, only one category counted toward maltreatment (p. x). Other types of maltreatment constitute the remaining percentage of validated reports. The mortality rate was 2.13 deaths per 100,000, or 1,546 fatalities (p. x). Boys had a higher fatality rate than girls (2.48 vs. 1.82 per 100,000), and Caucasians died more frequently (43%), followed by different minority populations of children (African American—30.3%; Hispanic—15.1%; p. x). The financial impact of abuse and neglect of children in 2008 was $124 billion (Fang, Brown, Florence, & Mercy, 2012). Perpetrators of child abuse and neglect were mostly women (54.1%), White (48.8%), mistreating two or more children (HHS, 2016, p. x).
Background
The Child Abuse Prevention and Treatment Act (CAPTA), with reauthorization, defined behaviors as acts of child abuse and neglect as:
Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm. (HHS, 2016, p. viii)
Maltreatment includes psychological maltreatment (emotional abuse), neglect (including endangerment), physical and sexual abuse (HHS, 2016, p. viii). The Justice for Victims of Trafficking Act of 2015 (JVTA) requires states to report the number of identified sex trafficked children younger than 18 years, allowing states to provide services and report identified victims up to 24 years (Civic Impulse, 2017). Of the adults aged 18 years rescued, overwhelmingly introduction to the industry began between the ages of 12 and 14 years. These 45legislative mandates at the national and state levels are helpful to the registered nurse responsible for evaluating injury in pediatric populations and reporting suspicions of abuse or neglect.
The changes in the federal reporting system, specifically how child abuse and neglect cases are reported and understanding the nuances of abuse, lowered the prevalence and incidence of child maltreatment in the past 20 years. In 2014, four to five children lost their lives every day to child abuse or neglect (HHS, 2016, p. x). The deceased children are younger than 2 years (70%), unable to escape the danger, dependent on the parent caregiver, and include another smaller group between 2 and 5 years (10%; HHS, 2016, p. x). Another group with falling victimization rates is the adolescent group ranging between 12 and 20 years. In the 1990s, violent crime was at an all-time high, where adolescents experienced violent victimizations including physical assaults, robberies, and sexual crimes (Child Trends, 2015). Although falling, there are persistent patterns, including increasing age, which exposes teens to increasing vulnerability (independence) and therefore, violent crimes, such as physical and sexual assaults (52 per 1,000, compared with 35 per 1,000 among adolescents ages 15 to 17 years, and 34 per 1,000 among adolescents ages 18 to 20 years; Child Trends, 2015, para 5). Additionally, females versus males, aged 18 to 20 years, were six times more likely to be victims of rape (6:1 per 1,000; Child Trends, 2015, para 7). White teens were more likely to be victimized than the African- or Hispanic-descent teens (Child Trends, 2015, para 8).
The children most at risk for child abuse and neglect are in chaotic or traumatized families, many experiencing social and personal environments not conducive to development or emotional health. Disparities and social determinants as risk factors diminish attainment of health outcomes. Social determinants include the environment and attitudes, exposure to crime and violence, disease and diminished access to health care, personal and support systems (HHS, Office of Disease Prevention and Health Promotion, 2017). Chronic stress in environments, whether from the individual’s disease, the family, the community or the system, increase hormonal dysregulation predisposing the child to an increased risk of violence and disease (McEwen, 1998).
Building on the stress and adaptation theories of the 1990s, emerging science focuses on the epigenetic transference of cellular environments that predispose offspring to poor health outcomes (Whitman & Kondis, 2016). In fact, physically and sexually victimized children display at least one mental health disorder by the age of 18 years (Silverman, Reinherz, & Giaconia, 1996), which, when passed to their children, are predictive of future victim experiences (Child Trends, 2017).
A tool to measure adverse childhood experiences (ACE) validated that there is a connection between ACE and health outcomes, including early death (Felitti et al., 1998). The research continues. Diseases once thought to be a result of genetics may be a result of physical changes following significant ACEs; in fact, the impact of ACEs affects all human body systems where earlier stress results in high-risk behaviors, chronic disease, and early death (Anda et al., 2009; Brown et al., 2009).
46Pregnant women and their developing fetus(es), newborns, infants, and children exposed to violence experience elevated stress hormones and begin a quest to escape or calm the “fear” response. The neuroendocrine system creates the brain stem irritation response (fear) to a threat and the hormonal sequelae of several hormonal pathways, including the hypothalamic–pituitary–adrenal axis (HPA axis; Nestler, Hyman, & Malenka, 2009). The resulting “fight-or-flight” response causes an elevation in stress hormones cascading and triggering other hormones in the stressed environment of the body. The hormones in the stress response originate from the primitive emotional midbrain, stimulated by the brain stem in response to fear, resulting in a constellation of symptoms, called “general adaptation syndrome” (GAS; Selye, 1974). The victim is responding normally to abnormal stresses. However, the stress hormones change end-organ function. Today, research documents change in response to chronic stress, for example, digestion, immune system, mood, anxiety, energy storage (fat), and other deleterious alterations, specifically in a child’s brain architecture, affecting learning, behavior, and long-term health (Child Welfare, 2015). The child is handicapped socially and developmentally by the exposure, usually without sensitive identification and intervention to mitigate the normal response to serious stresses in the family. The negative health outcomes include behavioral aberrations, hypertension, obesity, autoimmune diseases, poor school performance, adoption of risk behaviors (with subsequent disease or injury), and others. Understanding the underlying physiology of stress and trauma in childhood prepares the registered nurse to address obvious symptoms that lead to future poor health choices and outcomes for the child.
Clinical Aspects
An important fact for the practicing registered nurse is the recognition that child abuse or neglect occurs by a parent (HHS, 2016). Each state defines child abuse differently, but all states follow federal legislation (p. viii), so the practicing registered nurse must be familiar with his or her state legislation related to reporting child maltreatment. If there is a suspicion of child abuse, the registered nurse (caring for a pediatric patient) is a mandatory reporter in every state and all U.S. territories (HHS, 2016; Parrish, 2016).
In the interim, the registered nurse receives education about abuse and neglect to successfully screen and document developmental milestones at all ages and developmental stages. The first requirement is to understand elements of abuse and neglect, which include emotional abuse, such as words belittling the child to outright screaming obscenities at the child, physical abuse, such as pinching, pushing, slapping, shoving the child at any developmental age or chronologic age, and outcomes from the abuse, which include depression, self-injurious behavior, suicide, or homicide (HHS, 2016).
ASSESSMENT
Screening for stresses and developmental milestones identifies at-risk children and gives the registered nurse an opportunity to provide anticipatory guidance 47and intervention (Larkin, Shields, & Anda, 2012), which may include reporting the event(s) to the state’s child services agency. The registered nurse caring for pediatric populations needs a strong institutional policy and procedure for the management of abused and neglected pediatric patients, as well as the skills to identify, mitigate, and prevent early relational stresses between the child and the child’s primary parent or caretaker. The ACE questions, when asked at every visit, provide the opportunity to intervene on multiple levels, and is an important vital sign to monitor to prevent child abuse and neglect. The assessment domains for pediatric registered nurse providers include the areas of “language, literacy, and math,” and also “interpersonal interaction, and opportunities for self-expression” (Snow & Van Hemel, 2008, p. 22). Guidelines and validated tools for assessment at each developmental stage prepare the registered nurse provider to assist non-offending parents with a comprehensive plan for intervention to mitigate the impact of abuse and neglect (p. 7). Functional approaches for the registered nurse require special training in the assessment of all children, including those with challenges and deficits in abilities (p. 22). Parents from a variety of cultures, including minority and immigrant families (p. 22), also positively respond to the anticipatory guidance provided by the registered nurse.
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
Using the totality of nursing education, the registered nurse, as an expert in growth and development of children, incorporates Maslow’s hierarchy of needs to include trusting one’s environment at all developmental stages. When the closest caregiver (usually a parent) is unable or unwilling to provide the nurture, recognition is the first step to plan the necessary interventions to protect the safety of the child. Recommending prevention and parenting programs for at-risk families is a good first step, including home visitation, or more frequent visits, or phone calls to check on the well-being of the mother and child. This is particularly important for the teen mother, who may be surviving a chaotic upbringing, experiencing the predictable high-risk behaviors and teen pregnancy.
All child assessments should be head to toe and include all mucous membrane areas (eye, ear, nose, throat [EENT], and anogenital). The expectation with each visit is that the child evaluation includes behavior and skin injuries, asking about the manner and cause of the injury detected, and if serious or inconsistent, reasons for the delay. The registered nurse assessment for child abuse or neglect is descriptive only, documenting objective information, and monitoring activity between mother or caregiver and infant/child. If the registered nurse is the first to suspect abuse or neglect, he or she is a mandated reporter, regardless of other professionals’ opinions.
OUTCOMES
Not all injury or neglect is intentional, so the institutions designated to complete the comprehensive evaluation of the child, family, and social situation, is mandated to exercise legal authority over the child’s safety. Throughout the process, the registered nurse role is therapeutic and helpful, explaining the process of 48reporting and providing clarity to the process of the investigation. The registered nurse works with the institutional team to provide nursing care, assessment, and documentation, important for the safety of and planning for the pediatric patient. In the event of child removal, the registered nurse’s role is to comfort the nonoffending parent, provide community resources, and explain (to his or her ability) processes through anticipatory guidance.
Summary
Children depend on safe and secure environments created by their parent(s) or caregiver, specifically to provide the love and support for all developmental stages and ages. Child abuse and neglect represent an inability of the responsible adult to nurture the child. During pregnancy, the stress of the mother transfers to the fetus and can result in spontaneous abortion. After delivery, lack of maternal nurture arrests the infant’s development and changes the brain architecture, so the child is unable to navigate a learning environment. Stress creates anxiety in older children, which leads to the overproduction of stress hormones, crippling the capacity of the child to move through Maslow’s basic hierarchical steps toward adulthood and independence.
Domestic violence, poverty, trafficking of human families, war, drug use (covered in other chapters), neglect, and abuse by parent/caregiver create additional stress responses in the infant and child that doom the child to adopt risky behaviors beginning as young as 6 or 8 years of age. Registered nurses are in the position to recognize the child subjected to violence and the subsequent stress. The developmental milestones provide clues for the pediatric registered nurse to begin the inquiry into ACEs, scales measuring depression and anxiety, and other validated methods for assessing mother and child. Recognition of the health signs of hypertension, obesity, risk behavior, mental health diagnoses, neglect, and other signs of fear in an infant or child provide the opportunity for all registered nurses to intervene, report, and participate in interprofessional team collaboration to create safe and secure environments for all children.
Anda, R. F., Dong, M., Brown, D. W., Felitti, V. J., Giles, W. H., Perry, G. S., . . . Dube, S. R. (2009). The relationship of adverse childhood experiences to a history of premature death of family members. BMC Public Health, 9, 106. doi:10.1186/1471-2458-9-106
Brown, D. W., Anda, R. F., Tiemeier, H., Felitti, V. J., Edwards, V. J., Croft, J. B., & Giles, W. H. (2009). Adverse childhood experiences and the risk of premature mortality. American Journal of Preventive Medicine, 37(5), 389–396. doi:10.1016/j.amepre.2009.06.021
Child Trends. (2015). Violent crime victimization. Retrieved from http://www.childtrends.org/?indicators=violent-crime-victimization
Child Welfare Information Gateway. (2015, April). Understanding the effects of maltreatment on brain development. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from https://www.childwelfare.gov/pubPDFs/brain_development.pdf
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