Introduction: Special Collection of Medical and Health-Related Research

Introduction: Special Collection of Medical and Health-Related Research

The American Professional Society on the Abuse of Children (APSAC) is a nonprofit, national organization focused on supporting all professionals involved in helping address the problems of maltreated children and their families. Especially important to APSAC, Child Maltreatment disseminates scientific and state-of-the-art practice information for all professional disciplines related to child abuse and neglect. With APSAC in its 35^th year and Child Maltreatment its 27^th volume, our major strength comes from a multidisciplinary group of professionals who care for and advance our knowledge about children and families.

An important, but perhaps sometimes marginalized, part of this effort is the scientific advancements contributed by medical and physical health-related professionals. While others are given more authority in decision-making about maltreated children, physicians and health-related providers have been targeted in the popular media despite a long history of their contributions to the prevention, diagnosis, and treatment of child abuse and neglect. It is therefore important to periodically highlight scientific advancements and the sciences that underpin population health for this vulnerable group (Fiore, 2019; Palusci, 2017a; Palusci & Perfetto, 2019). While there has been sufficient research to justify the creation of a pediatric subspecialty (Block & Palusci, 2006) and a society for these professionals (Runyan, 2001), the available U.S. National Institutes of Health dollars for biologic research into the causes and evaluation of child abuse and neglect has limited the careers of physician-scientists as well as the number of trainees in the field (Krugman, 2016). This is problematic since much remains to be learned about the biology, diagnosis, treatment, epidemiology, and outcomes of child maltreatment.

It is therefore a distinct pleasure to present this special collection of articles with new research findings from the perspectives of the basic and clinical sciences and epidemiology. They come from a range of disciplines and specialties, from basic sciences such as neuroscience and pathology, through clinical sciences such as nursing and pediatrics, to public health sciences such as epidemiology and prevention. Aspects of child maltreatment permeate these disciplines, from the hormonal, genetic, and epigenetic changes after trauma, to the behavioral and developmental outcomes after maltreatment. It is therefore fitting that a special collection of articles should highlight work from these sectors of the medical and health-related response to child abuse and neglect. The articles in this collection, which underwent our stringent peer review and editing process, cover a range of topics related to child maltreatment, from epidemiology, mandated reporting and prevention, to neuroanatomy, clinical diagnosis, and care of medically complex children.

Biology, Risk Factors, and Behavior

While not thought of as a “medical issue” in child abuse and neglect, it would be remiss to not mention a monumental biologic event: the COVID-19 pandemic. We have attempted to streamline review of COVID-19 related articles and were hopeful that pandemic shutdowns would actually reduce child maltreatment in addition to reporting. Evidence is emerging that this may indeed be the case (Sege & Stephens, 2021; Swedo et al., 2020). However, this collection begins with a brief report by Sari et al. (2022) in the Netherlands who found that harsh parenting behaviors with a low prevalence before COVID-19 increased most strongly during the pandemic. In addition, Hidalgo et al. (2022) showed structural and diffusion-weighted brain morphological measures after harsh parenting were associated with smaller total gray and cerebral white matter and amygdala volumes but not changes in hippocampal or other microstructural metrics in children. With adolescents, Kobulsky et al. (2022) found neglect was associated with later mental health disorders (such internalizing and externalizing problems and suicidality) and high-risk behaviors (sexual abuse, risky sexual behavior, and delinquency). With these articles and others, one can imagine potential pathways linking outcomes across years and generations. We can only speculate whether the pandemic will amplify these changes or extend their effects for years to come.

Research on maltreatment has often focused on risk factors for serious injury and death. Hauck et al. (2022) extend our understanding of the strong association between prior CPS reports and child fatality (Batra et al., 2021) by examining postneonatal death and differences by cause of death. Using data from the Chicago Infant Mortality Study (CIMS) that linked all sudden, unexplained infant deaths in Chicago with report data from the Illinois Department of Children and Family Services (DCFS) State Central Registry, they found that families known to DCFS were almost 4 times more likely to have a child die during the postneonatal period. They propose that CPS involvement might provide an opportunity for education on safe sleep messaging to help reduce the incidence of potentially preventable infant deaths.

Beyond risk factors at the level of the individual, family or community, little research has examined how seasonal or meteorologic factors might be associated with serious injury and death. Bliss et al. (2022) studied temporal and weather factors in an effort to identify how these factors might increase risk for abusive head trauma (AHT) at the population level, but they found that there were no statistically significant associations between the incidence of AHT and the day of the week, month, or season. They did, however, find evidence that there were more AHT cases when there were more days with higher temperature, suggesting the need to consider environmental stresses in addition to other risk factors for this devastating form of maltreatment. With the pandemic and human-induced global warming, we can only imagine the heightened risk.

Medical Diagnosis

Johnson et al. (2022) conducted a retrospective secondary analysis of data from the Examining Siblings to Recognize Abuse (ExSTRA) study to examine how often child abuse pediatricians (CAPs) diagnose abuse. They concluded that CAPs were equally as likely to assess a low versus a high likelihood for abuse. While this was reassuring, they also found that the percentage of cases representing low likelihood differed based on practice location after controlling for patient age, sex, race/ethnicity, twin/triplet status, injury types, and injury severity. Martin-Champetier et al. (2022) assessed the findings of abdominal imaging (mostly routine ultrasound) in 405 children under 2 years of age with suspected physical abuse. Only four of those children were found to have traumatic abdominal injuries related to abuse, and these children all had clinical or biological features suggesting injury. They concluded that in the absence of clinical or laboratory signs, abdominal imaging was unlikely to show any findings related to abuse. We should remember, however, that CTs may better identify forensically-important findings without clinical signs.

Looking at the issue of missed opportunities to identify physical abuse during medical encounters, Shanahan et al. (2022) used a secondary analysis of Medicaid data from four states to find that, among 4817 infants with 12 months of continuous enrollment, 30.6% of those diagnosed with maltreatment were previously diagnosed with an injury and 88.4% had at least one well-child visit prior to the maltreatment diagnosis. This is remarkably similar to the 31.2% found in AHT by Jenny et al. (1998). Using a retrospective case–control design with 4576 cases in a large integrated healthcare system, Negriff et al. (2022) try to help us better identify the injuries that may precede a child maltreatment diagnosis, finding that all injury categories were significant predictors of a subsequent maltreatment diagnosis, but only for young children. Specifically, fracture and head injury had the highest risk for a subsequent maltreatment diagnosis, and all injury types were significant predictors for ‘Hispanic’ children <3 years, which was not the case for ‘non-Hispanic’ children. Further studies will be needed to help us to improve our diagnostic skills across all populations and to better understand and address the differences found based on race and ethnicity.

Injuries, Hospitalization, and Reporting

Two studies provide additional insights into injuries, hospitalizations, and reporting for maltreatment. Rebbe et al. (2022) used an administrative dataset in Washington State between 1999 and 2013 to identify which children who were hospitalized for maltreatment-related reasons were reported to or removed by CPS. It is surprising, but two-thirds of children identified as experiencing a child maltreatment-related hospitalization were not reported to CPS, and they found differences in responses by maltreatment subtype and the type of diagnostic code. Children whose hospitalizations were related to abuse and associated with a specific maltreatment code had increased odds of being both reported to CPS and being subsequently removed by CPS. Cain et al. (2022) used Texas inpatient hospitalization data over a 15-year time period to assess age-related differences among infants (<12 months of age) and toddlers (12–59 months of age) in injury trends and patterns of injury among abusive and non-abusive hospitalizations. For both age groups, hospitalizations for non-abusive injuries decreased significantly over time; however, those for abusive injuries did not. Compared to non-abusive injury hospitalizations, abusive injury hospitalizations were statistically more likely to involve more body regions and were associated with fractures, internal organ injuries, and superficial wounds, longer lengths of stay and higher illness severity scores. One has to wonder why only some of the children with abuse-related hospitalizations were not reported.

Children with Medical Complexity

Children with special medical needs and medical fragility are often involved in the child protection and child welfare systems (Palusci, 2017b). Azzopardi et al. (2022) found that nearly one-quarter (23.6%) of children with medical complexity had documented contact with the child welfare system, most commonly for neglect; of those, more than one-third (38.8%) were removed by CPS. Caregivers reported a history of mental health problems, chronic medical conditions, and interpersonal violence or trauma, but caregiver married/common-law relationship status and a higher number of medical technology supports were associated with decreased likelihood of child welfare system involvement. Lilly et al. (2022) describe their Child and Family Nurse Program, finding nurse care coordination improved family protective factors and health-related quality of life from baseline to follow-up. While more rigorous studies are needed with medically complex children, addressing parental mental health and providing additional services appear to improve the lives of children and families and can reduce their involvement with CPS.

Prenatal Substance Exposure

Austin et al. (2022) identified 30 studies in a review that examined the association of child maltreatment with prenatal exposure to cocaine, alcohol, opioids, marijuana, amphetamines, and multiple substances, finding that substance-exposed infants had an increased likelihood compared to unexposed infants for child protective services involvement, maternal self-reported risk of maltreatment behaviors, hospitalizations and clinic visits for suspected maltreatment, and adolescent retrospective self-report of maltreatment. Was this caused by “nature or nurture?” Azimi and Connolly (2022) studied the extent to which genetic and environmental factors influence the longitudinal association between child maltreatment and varying forms of substance use by analyzing a sample of twins from the National Longitudinal Study of Adolescent to Adult Health. They found that associations over time between cigarette and marijuana use and maltreatment were accounted for by both additive genetic and nonshared environmental factors.

Conclusions

This special collection illustrates the depth and breadth of research in basic and clinical sciences and related disciplines. It highlights a range of areas and gives us pathways to better understand the roles of medical and physical health-related professionals in the child protection and child welfare systems as well as biology, risk factors, and prevention in child maltreatment. There is still much to learn and much to do in medicine to improve our diagnosis and reporting of suspected child abuse and neglect. We need to address racism and implicit bias in reporting as well as improve our identification of child abuse injuries in the office and the hospital (Greiner et al., 2013; Kennedy et al., 2020; Palusci et al., 2019; Palusci & Botash, 2021). We need to better understand genetic and epigenetic changes and how to intervene in varied settings (LeBlanc et al., 2019; Canter, Rao, Palusci, et al., 2019). Our preliminary review of medical research publications showed definite, albeit sluggish, growth in the number of publications over time (Palusci & Perfetto, 2019), and it is promising that there has been a call for a research agenda for and increased funding in these areas, including studies of longterm effects (Lindberg et al., 2017; CDC, 2021; Recover, 2021). However, fewer than half of the articles in this collection listed governmental support, and more support is needed to build the pipeline to develop the robust research and researchers in the field needed to address this complex multidisciplinary problem (Krugman, 2016).