The health care system has the potential to address child maltreatment in a number of different ways, including primary, secondary, and tertiary prevention programs and services.
Primary prevention programs and services aim to prevent maltreatment from occurring in the first place. Home visitation programs staffed by health care professionals such as nurses have been well studied, and at least one has demonstrated some effectiveness in preventing child abuse and neglect. More recently, prevention programs based in the hospital and primary care setting have been developed. Programs to prevent abusive head trauma typically teach parents not to shake babies, and offer methods other than shaking for dealing with new baby frustrations. Less structured, but similar interventions may occur in primary care settings, and may include printed handouts from organizations such as the American Academy of Pediatrics, the National Exchange Club, and others.
Secondary prevention includes interventions that target families already at high risk for maltreatment, such as those with substance abuse, intimate partner violence, depression, other mental health problems, and/or lack of social support. Parents and caregivers with these risk factors can be identified through screening during their own primary or pregnancy-related health care, or during child health care visits. Brief screening questionnaires for substance abuse, intimate partner violence, and depression have been developed and validated for a variety of populations and health care settings.
The purpose of tertiary prevention is to ameliorate the short and long-term adverse effects of maltreatment once the abuse or neglect has occurred. The health care system spends more resources on tertiary prevention than on primary or secondary prevention. Components of tertiary prevention may include diagnosis and acute treatment; long-term medical, rehabilitative, and mental health services; reporting to child protective service and law enforcement agencies; and providing court testimony.
Health care professionals play a significant role in identifying children with suspected maltreatment, and in providing further medical evaluation and treatment.
Children who have been maltreated may present to their primary health care providers, to a hospital emergency department, or to subspecialists such as orthopedic surgeons, gastroenterologists, pulmonologists, neurologists, and neurosurgeons. Therefore, all health care professionals who treat children must be aware of the possibility of maltreatment, and the need to distinguish abuse from other injuries. Specialists in the field of child maltreatment are available in many, but not all, jurisdictions to assist in the identification, evaluation, and reporting of maltreatment.
Medical care for children with suspected abuse may include treatment of presenting injuries, as well as identification and treatment of occult (masked) injuries, such as fractures, head/brain injuries, and abdominal injuries. Because caregivers of maltreated children may provide a misleading or absent history of injury, such injuries may be missed unless they are screened for using x-rays and/or laboratory tests. Identification of occult injuries may also solidify a diagnosis of abuse when a child presents with injuries that are suspicious for, but not diagnostic of, maltreatment. Medical treatment will vary according to the type and extent of injuries present. Injuries such as bruises may require no medical intervention. Minor burns and fractures may require emergency department care. Other, more severe injuries such as burns, fractures, brain injuries, and injuries to internal organs may demand hospitalization, surgery, and/or intensive care management.
All health care professionals in the United States are required by law to report children with suspected maltreatment to child protective service agencies. Doing so allows for further investigation into the circumstances surrounding the alleged abuse or neglect, and intervention, when necessary, to ensure the safety of the maltreated child. Health care professionals may also be required to report suspected physical and sexual abuse to law enforcement for investigation of possible criminal activity. Professionals in health care may be subpoenaed to testify in criminal and/or civil legal proceedings.
Abused and neglected children may have chronic medical and mental health care needs as a result of maltreatment. Children with significant brain, skin, and/or abdominal injuries may require extensive physical, occupational, speech, and other therapy to aid in functional recovery. These services may be provided to inpatients in acute care and rehabilitation hospitals. Outpatient rehabilitation services may also be needed.
Finally, health professionals play an important role in addressing the mental health care needs of children who have been abused or neglected. While some providers will refer children to mental health services, others, such as psychiatrists, psychologists, social workers, and licensed therapists, will be directly responsible for providing mental health treatment services.
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