COVID and Child Abuse

Program announcer

Welcome to the Peds Ethics Podcast, where we talk to leaders in pediatric bioethics about a hot topic or current controversy. Here's your host, John Lantos, from the Children's Mercy Bioethics Center in Kansas City.

Dr. John Lantos

Hi, everybody. This is John Lantos. Welcome back to the Pediatric Ethics Podcast from Children's Mercy Hospital in Kansas City. We are thrilled today to have Dr. Stephanie Deutsch. She's a pediatrician at the Nemours. Hospital for Children in Wilmington, Delaware, where she's section chief of child abuse pediatrics and co-director of the CARE program, the Nemours program, to take care of children with suspected abuse or neglect. Thanks so much for joining us today, Dr. Deutsch. We're talking with people all week about tough ethical issues that come up as a result of the COVID pandemic, the coronavirus. many of the discussions have focused on acute care issues and what people are anticipating for ICU decisions and DNR orders and decisions about who gets a ventilator. But those are not the only effects that a worldwide event like this has on children. We know from past experiences with things like Hurricane Katrina that Disasters have lots of other effects on children's well-being. Dr. Deutsch, can you tell us a little bit about what the impact of this has been on the care of children with child abuse?

Dr. Stephanie Deutsch

Yes, certainly the COVID-19 pandemic has some obvious health implications for our community, but there are also serious and unintended consequences for our most vulnerable children, specifically related to abuse and neglect. Our statistics nationally from the Centers for Disease Control and Prevention indicated that last year, one in seven children experienced child abuse or neglect under what I would describe as normal circumstances. And certainly, we're not in normal circumstances nationally at this time. Instead, we're in a situation of extreme distress, future uncertainty, and social distancing. We have had unprecedented school and workplace closures that certainly lead to increased caregiver stress and instability within the family. There's been profound economic stressors due to loss of income potential and an unexpected need for child care. Compounding that, many families are now juggling... working remotely from home while also trying to manage homeschooling children, all of which can contribute to caregiver stress and frustration. Certainly, the social distancing is also a form of isolation. And all of these factors have, in the literature, been associated with child abuse and neglect perpetration and child maltreatment perpetration.

Dr. Stephanie Deutsch

Certainly children under a year of age are the most vulnerable, but this vulnerability now extends, the safety concerns now extend even to older children and teens. For teenagers, they may be spending, for example, increased time online where they may be interacting with online predators, for example. In addition to all of these risk factors for abuse and neglect, food and housing insecurity, anxiety, mental health instability, social isolation, future uncertainty, We also have children and teenagers who are now really behind closed doors. So those social distancing efforts kind of radically disrupt what has been the safety net and are limiting previously existent protective opportunities for children and teenagers, buffering both the caregiver and the child. So when we think about efforts like shelter in place, for example, that's really stifling a caregiver's opportunity for any kind of external support. There's minimal opportunities to blow off steam outside of the home, for example. And probably most importantly for children, it's really eliminating a child's contact with mandated reporters of abuse and neglect. We know from the federal statistics that... professionals or mandated reporters in the year 2018 were responsible for nearly 70% of hotline reports regarding abuse or neglect. And those professionals encompass educational personnel, social services personnel, for example, and around 21% or so of hotline reports and child maltreatment reports came from educational personnel. So now we're dealing with a situation where children are really unable to rely on support from teachers and school personnel, and they're not interfacing directly with teachers and with other school nurses, for example, who may be able to detect abuse and neglect.

Dr. John Lantos

So it really sounds like a frightening situation. More stress, likely more abuse, fewer contacts with people who could notice what is going on and report it. What is your program or hospital trying to do to address these risk factors?

Dr. Stephanie Deutsch

Well, specifically here in Delaware, we have been engaged in dialogue with our state child protective services system. Right now, the information that we're receiving from our state child welfare agency is that operations have been modified slightly. So hotline and investigation staff are still working as they always have been. They're still going out on investigation cases, both new and already existing. But for those families that have been active, for example, with treatment teams or children in foster care, our state agencies have modified their contacts and are now emphasizing the use of virtual visits, for example, to stop that in-person visitation. So certainly that's not... without obvious barriers, there may be circumstances where families have limited access to technological devices to support this type of televisitation. We've noticed in our state that the hotline volume is actually down. We do have an online portal that can be used to supplement hotline reports, and there has been some activity there. So we're anticipating that because of the widespread school closures here in the state, that that may have contributed to why hotline volume is down. However, at the hospital, we have had an uptick in children presenting with serious abuse concerns, including increased admission rates to our hospital of children with serious injuries resulting from abuse and neglect.

Dr. John Lantos

When did that start?

Dr. Stephanie Deutsch

That started probably in about the last two and a half weeks or so. We've also had an increase in volume of... children presenting to our outpatient center. So here in our hospital, we do have a dedicated children's advocacy center and medical clinic, which provides specialty care to child abuse victims. We have made a plan with our emergency department here at the hospital to try to divert less serious abuse cases from our emergency department. and instead adhere to our outpatient specialty care center in order to preserve very critical emergency department personnel and resources so that they can treat children who may be presenting with serious respiratory conditions, for example. As well, the American Academy of Pediatrics, as you probably are aware, does recommend that siblings and household contacts of suspected abuse victims have medical evaluations. And so we've been partnering with our state child welfare agency and our emergency department to schedule children on an urgent basis in our outpatient specialty care center for their abuse evaluation, again, in an effort to preserve critical emergency department resources. At the hospital level, We have also been engaging in different efforts to try to support families who may be in crisis. You had asked whether or not we're making some hospital-wide efforts, and we certainly have been partnering with our behavioral health and psychology colleagues in order to develop messaging that will target both patients and families as the audience. avail ourselves of telehealth visits, for example. So we are working with our behavioral health colleagues to increase the availability of telehealth appointments for families who may be struggling with

Dr. Stephanie Deutsch

crises in parenting with children who may be acting out as a result of having routine and consistency disruptions, and to help families deal with that emotional dysregulation, both at the caregiver and the child level, resulting from some of our social distancing and the situation at hand.

Dr. John Lantos

Have you done any of those telehealth visits yourself yet?

Dr. Stephanie Deutsch

So I have not personally done them yet. We're currently working with our psychology partners to operationalize this effort. The telehealth platform will ideally offer parenting advice, de-stressing resources, tips to parents on restoring structure and routine. And we're also going to be doing some messaging in the Delaware Valley regarding various websites and electronic sources that families can access themselves if they're not interested in the telehealth-specific appointment that offers some resources regarding parenting, anxiety, talking to children about COVID, reestablishing routine and consistency in the home.

Dr. John Lantos

So much of the discussion around COVID at many of the children's hospitals that I'm talking to people about is anticipatory. That is, many of them have not yet seen a peak in cases, and they're speculating or trying to anticipate what's coming. As you look forward over the next couple of months, What do you anticipate in this whole domain? What are you most worried about? And what do you think would help the most to avoid some of the more serious problems?

Dr. Stephanie Deutsch

when we have looked historically at what has happened in similar crisis periods, such as the economic recession in the last decade, we have seen spikes in child maltreatment rates in these critical time periods. There have been several studies, including by a number of my child abuse pediatric medicine colleagues, linking child maltreatment with periods of economic distress, unemployment, mortgage foreclosure. There have been studies linking low-level of consumer confidence with worse parenting behavior, specifically spanking, and increases in abusive head trauma diagnoses, for example, during periods of economic recession. So unfortunately, I do think that... the constellation of societal stressors may result in spikes in abuse and neglect perpetration. And so I do think that at the hospital level, we are likely to be assessing many more children in the next weeks to months. Certainly once schools reopen and those community supports become available again, I do anticipate that children who've experienced unsafe circumstances at home may be more likely to disclose, and we may see a bump in hotline reports, children being forensically interviewed, and in child protective services and law enforcement investigations. I think, however, the most concerning result will really be the long-term impact. So certainly, we anticipate that the pandemic will come to an end at some point. While it seems indefinite right now, this is likely to last weeks to months, and the risks posed by this novel coronavirus are finite. But I do think that its impact will be felt for decades, specifically around abuse and neglect. So my team here at the hospital has been talking a lot about the COVID-19 pandemic as... an ace, a new ace, a new adverse childhood experience. This has certainly been traumatic, both for caregivers and for children, even if they have not been victims of abuse or neglect. But if you compound the experience of the COVID pandemic with abuse and neglect, I think it really will result in a trauma. enduring, just like other ACEs, with really neuroendocrine, neurologic, behavioral, epigenetic changes, unfortunately, potentially negatively impacting mental and physical health outcomes, both now and in future generations to come. So looking at it from that vantage point, I think really activities that promote prevention and risk reduction are really paramount. So whatever we can do both as medical providers and within society to positively reduce these negative impacts is going to be of critical importance. And it's achievable even in this time of uncertainty, but it does require us to really very rapidly try to ensure that there are supports in place for families and children who may be struggling right now.

Dr. John Lantos

And we know the effect of adverse childhood experiences, the ACEs, are cumulative. So the more you have, the higher risk you are. This one seems like one that's going to affect an entire generation. So everybody's propensity for adverse long-term consequences will be ramped up, it seems.

Dr. Stephanie Deutsch

Yes.

Dr. John Lantos

It's a frightening thought. Anything we can do to flatten the curve of those long-term sequelae?

Dr. Stephanie Deutsch

So I think a critical role that we can play is ensuring emotional connectedness, even in this time of physical social distancing. So, for example, the president of the American Academy of Pediatrics recently offered some advice for families about importance of self-care for everyone in the household, which are very concrete. actionable, it's very concrete, actionable advice around eating healthy, exercising, getting sleep, maintaining social connections through the phone, through email. So those types of very normal behavior can help decrease anxiety that many people may be experiencing in a time that feels very abnormal. Certainly trying to restructure, trying to

Dr. Stephanie Deutsch

see in children when they're bored or they're frustrated and they're more likely to act out. So I think very concrete things that we're doing in our everyday life may actually have a fundamental impact on how we experience this and look back on this time period in the future.

Dr. John Lantos

Boy, that's some great advice to address what seems to be a very frightening set of problems that kids and and the pediatricians who take care of them will be facing. Thanks so much for talking to us about this. We're talking to Stephanie Deutsch. Dr. Stephanie Deutsch is a pediatrician at the Nemours Hospital for Children in Wilmington, Delaware, and co-director of their program to take care of abused and neglected children. Thanks for listening. I'm John Lantos with the Pediatric Ethics Podcast coming to you from Children's Mercy Hospital in Kansas City. Thank you, Dr. Deutsch.