Small Changes Can Have Large Impacts: Health Care Overhaul Should Include Child Maltreatment Prevention in Primary Care

Abstract

When we think of patient safety, we usually do not immediately think of child maltreatment prevention. Yet the incidence and prevalence of child maltreatment is a significant public health issue in the United States. As we begin to overhaul our health care system, it is a good time to think about child maltreatment prevention. Including child maltreatment prevention as a core component of pediatric care may be less complicated than understanding what child maltreatment is and how it affects children. Anonymous telephone surveys suggest that as many as 10% to 15% of children experience physical and emotional abuse. The abuse is most often long term, acting more like a chronic malady than an acute trauma. Children younger than 3 years of age experience the greatest risks for morbidity and mortality resulting from child abuse and neglect. Although we know that physical abuse is underrecognized and underreported, emotional abuse is even more difficult to identify. Research, such as the Adverse Childhood Experiences study, has shown that there is a direct association between the abuse and neglect suffered during childhood and use of drugs and alcohol, involvement in violence, depression and anxiety, and physical health in adulthood. This study of Kaiser adult enrollees shows dramatic increases in adult mental health and physical illness that are directly related to the number of adverse childhood experiences these enrollees suffered. These data are not new and yet there has been little momentum in health care to focus on prevention of childhood maltreatment. The actual prevention techniques are progressing through clinical trials and are still too early to be definitive, but a number of early studies show promise. Pediatricians see the majority of children younger than 3 years of age numerous times each year. Physicians have recognized that issues related to the child’s psychosocial health are a primary parental concern. This makes sense given that children’s physical health has improved beyond acute issues such as infectious diseases. The “new morbidities” of mental health and developmental issues have become of paramount importance to the pediatric visit. Although parents want pediatricians to help them with these topics, pediatricians often do not feel well equipped to answer questions related to psychosocial health, nor do they know what to do when they recognize family dysfunction. Several psychosocial topics related to maternal health, infancy, and toddlerhood are currently under study by researchers: maternal depression, infant crying, discipline, and toilet training (eg, Practicing Safety). Pediatric identification of and response to these issues can enhance parenting skills and behaviors and ultimately help raise a happy, healthier child and, thus, a healthier adult. Additionally, through its Bright Futures initiative, the American Academy of Pediatrics has assessment instruments and tools for pediatricians to use to identify other psychosocial issues related to the infant, child, and family. Lastly, it is essential that primary care provider sites provide medical homes for infants at risk for maltreatment or developmental delays. Interventions such as Practicing Safety, and perhaps Bright Futures, offer building blocks to primary care pediatrics to use in the development of medical homes for their infant and child patient populations. Incorporating such features into primary care requires a culture of change—a change in long-standing practice patterns. Quality improvement strategies, such as office-based coaching, learning collaboratives, and use of data to track changes, are critical to acceptance and sustainability. Rigorous studies to test child maltreatment prevention interventions are under way. The integration of risk identification, linkages and referral to community resources, and monitoring and follow-up to enhance parenting skills and behavior must undergo rigorous research to determine the treatment effect produced by such focused, proactive office-based approaches. Universal developmental screening has been suggested by the Commonwealth Fund and the American Academy of