The Issue: About Child Abuse and Neglect

A Major Public Health Problem

Child maltreatment is a major public health issue, as noted by William Foege, MD, formerly with the Center for Disease Control (CDC), in a commentary “The ACE Study, A Public Health Perspective“, (PDF) American Journal of Preventive Medicine, 1998. The commentary was  in response to the publication on the Adverse Childhood Experiences (ACE) study “Turning Gold into Lead” (PDF), JAMA 2000. This retrospective study of some 17,000 San Diego Kaiser Permanente middle aged patients concluded that child abuse and related adverse childhood experiences are more common than generally thought, that the effects persisted over a life-time and are strongly correlated with later health problems. Over half of the patients had experienced one or more of the adverse childhood experience (ACE factors) studied. One in four were exposed to two ACE factors; one in 16 were exposed to four categories. Given an exposure to one factor, there was an 80% likelihood of exposure to another category.  ACE factors were strongly correlated with obeisity, diabetes, heart and lung disease including COPD, IV drug use, smoking and other costly chronic health problems.

A compendium of studies linking early abuse and neglect to a wide range of social problems  titled “What Can Happen to Abused Children When They Grow Up” (PDF), compiled by the Maine Office on Trauma,  is discussed in research section.

Nation-wide, about  3  million reports of child abuse are received by child protective services annually.  The National Incidence Studies (NIS) have concluded that the actual number of cases may be as much as 5 times greater than the number of reports. Some highlights: between the 1986 NIS-2 study and the 1996 NIS-3 study, the number of physical abuse cases doubled, sexual abuse cases more than doubled, emotional abuse increased 2.5 times and the total number of overall known maltreatment cases quadrupled. Children whose families had incomes of less than $15,000 were 44 times more likely to experience maltreatment than those with incomes of over $30,000.  It was noted that protective services had investigated only about 25% of all children reported.

The 2005-2006 NIS-4 study, as well as state reporting data compiled  for the years  2007-2010 by the Department of Health and Human Services (HHS) in a report entitled “Child Welfare Outcomes 2008-2011: Report to Congress“  showed significant decreases in most categories of maltreatment. There has been considerable discussion about this trend, as many states have adopted diversion systems, with cases considered less serious being referred to community services, by passing investigation and the state data system. It was reported that only 32% of child abuse related reports are actually investigated In addition, 27% of informants stated that they do not make reports to child welfare. While confirmed reports show decreases in most categories of child abuse and neglect, data on the Endangerment of Harm category  for very young children increased significantly per the NIS-4.

Further, a 2012 study by John Levanthal, MD, “Children Hospitalized at Alarming Rate Due to Abuse” showed a 10.9% increase in nation-wide hospitalizations for child abuse and neglect for under one year of age. Rates changed from 52.2/100,000 to 62.3/100,000 (p<0.5) over the last 10 years.

The four national incidence studies provide a great deal of information on the prevalence of abuse and neglect, the perpetrators, the age of victims, issues related to reporting etc .

Child Abuse in Hawaii

The Hawaii  child protective services were established in 1969-1970, as a result of advocacy led by Patti Lyons, MSW and Dr. Calvin Sia, HFSI Board members. Report numbers increased dramatically in 1990s, with increases in family substance abuse and domestic violence.

In  about 2003, the Hawaii Department of Human Services (DHS) restructured its’ child protective service system in response to a federal audit. A diversion system was established, by which reports appearing to be less serious are referred directly to private agencies contracting with DHS, by-passing the investigation process. This reduces the volume of cases going through the state protective service intake/investigative process, with the intent of improving quality of service for confirmed cases. Apparently fewer cases enter the data system. DHS annual child abuse reports have shown significant reductions in abuse reports since this system was established. Regarding recent trends, reports spiked in 2003, dropped in 2004, 2005 and 2006 and spiked again in 2009. (See the Hawaii DHS Child Abuse and Neglect Reports.)

Cases confirmed for abuse, neglect and threatened harm continue to be highest among the birth to five age group; comprising almost half of cases (936 of 2,174 in 2011). The  annual DHS Child Welfare Reports also show that report numbers are highest for children age one and under.

What factors precipitate child abuse and neglect?

1. Many studies have been conducted on the causes of child maltreatment. Dr. Henry Kempe, author of “The Battered Child” (1964) (PDF) developed  the “Family Stress Checklist” from his research into the issues involved with  confirmed maltreatment cases. This Checklist, and the Parent Survey derived from the Checklist, are now used extensively by Healthy Families America in prevention programs to reach out to families in need of extra support in parenting. The risk factors include abuse and neglect in parents own childhood; previous protective service reports; substance abuse, domestic violence and mental health issues; low-self-esteem, chaotic life style, marital and financial problems; social isolation; violent temper outbursts; lack of knowledge about normal child development; an unwanted child; and lack of bonding with the infant. As previously noted, child abuse and neglect are often inter-generational.  Stress factors basically affect the ability of a parent to be attentive to the needs of their infant and overall capacity to parent effectively.  Confirmed cases of maltreatment usually involve several risk or stress factors; risk increases exponentially with the number of risk factors.
2. Increasing income disparity over the past 30 years has left more families in poverty, creating stress and despair among vulnerable families.  This phenomenon has been publicly reported by MSNBC news, with graphs  showing the effect of nearly stagnant wages upon the middle class while the more affluent income has risen dramatically. The Pew Charitable Trust issued a  paper in 2011, “The Rising Age Gap in Economic Well-being“, which describes the plight of the younger generations. Low income is highly correlated with abuse and neglect as noted by the national incidence studies.
3. Substance abuse, domestic violence and mental health issues are major factors associated with confirmed cases of child abuse; these problems have increased dramatically among families over recent years, without increases in availability of treatment resources to address these.
4. The 2008 financial crisis has created additional financial stress and pushed more families into poverty; it has also resulted in near elimination of the social safety net and resulted in set backs for recent successful efforts of the Hawaii child welfare system to institute policy and program improvements.

What are the barriers to successful, effective prevention?

1. In Hawaii, the states’ response to the 2008 financial crisis resulted in decimation of Hawaii’s major child abuse prevention service, Healthy Start.  This program, which previously made family support services available to all overburdened families in every community in the state, is now available in only two communities. Some Healthy Families America programs have also experienced loss of funding.
2. There are few resources to effectively reduce substance use, domestic violence and emotional health issues of both parents and children. As already noted, these issues are usually involved in confirmed cases of maltreatment. Treatment services for parents are critical components of effective prevention and early intervention services related to child abuse and neglect.
3. With the establishment of prevention services, innovative interventions to avert abuse and neglect within individual programs are emerging but are not yet widely disseminated.  This is due to lack of funding for credible evaluations to provide evidence of effectiveness and to inform providers of needed quality improvement. Available information on evidence based practice needs to be documented and made more available to practitioners.
4. Unfortunately, while prevention programs work, these are historically the first to be cut in economic downturns. Strategies need to be established to protect effective prevention services as investments in young children.
5. Financial resources for all aspects of child abuse prevention and treatment are very limited nationwide and as well as  in Hawaii, where  services are reaching only a fraction of those in need.  A 1986 Harris poll showed that 86% of Americans want to help children, especially children in poverty, even if it means raising taxes.  (U.S. Department of Justice, Office of Juvenile Justice; a review of “Strengthening America’s Families”, p.3 ).  Despite this strong finding,  this has not yet resulted in stable, on-going resources for child abuse prevention and other early childhood services.  Clearly this public concern needs to be translated into the  political will to commit resources for early child abuse prevention and early intervention services.

Intervening to strengthen vulnerable families of newborns is a practical, effective approach to increasing the odds for infants and toddlers to  get a safe, healthy start in life. Prevention of child abuse is critical for school readiness and success, prepares the next generation to be better parents, and can reduce overall societal violence and related future costs.