Child Maltreatment: A Problem Both Worsened and Concealed in Crises

Our society is in the midst of several public health crises. The COVID-19 pandemic and its associated educational, social, and economic fallout are a primary concern. Additionally, our country is battling structural racism, an opioid epidemic, and ongoing health effects of natural disasters such as hurricanes and wildfires. Those we serve, including impoverished or otherwise vulnerable children, are often disproportionately impacted by these crises.¹ Consequences can include infections, disparities, intoxication, displacement, and countless other issues that may present to medical teams. Conversely, the manifestations of local or global crises may be silence. Silence in the form of fewer emergency department (ED) visits, missed well-child care appointments, delayed immunizations, and hidden traumas undetectable during a medical assessment.² Reported cases of maltreatment to child protective service agencies decreased dramatically at the start of the COVID-19 pandemic, illustrating how this particular crisis is masking an already under-detected problem.^{3 , 4} In the face of this silence, we are called to be more vigilant. Each clinical encounter can be an opportunity to acknowledge the crises we are all experiencing and recognize the hidden consequences, including child maltreatment.

This issue of Clinical Pediatric Emergency Medicine broadly covers topics related to child abuse and neglect, heightened in the context of our national crises. The potential impact of COVID-19 on child abuse and neglect is discussed. While much remains unknown, inferences can be made based on what has been learned from prior economic, infectious, and environmental crises.

Three articles feature the current state of knowledge regarding inflicted injuries that emergency care providers are likely to encounter, including abusive head trauma, fractures, and cutaneous injuries. Given the high cost to the child and their family from either under or over diagnosing abuse, it is imperative that clinicians remain abreast of current literature in order to make evidence-based, non-biased decisions. Toxicology, in the context of child maltreatment, is also covered as children frequently present to EDs after ingestions. An understanding of the child's environment and the circumstances surrounding the ingestion is key in determining whether the child can be safely discharged, or whether a report to child protective services is warranted. While neglect is often characterized as a chronic problem rather than an emergent issue, these children may not be seen by other providers, and the ED may be the only opportunity to identify and report neglect to prevent future harm. Neglect may also represent a true medical emergency.

Children with concern for sexual abuse also often present to EDs, regardless of the acuity of abuse. In a fast-paced setting, these evaluations can be time-consuming endeavors. This issue highlights a quality improvement project conducted at a high volume tertiary pediatric ED. The improvement team addressed challenges with the management and communication in sexual abuse cases to create a streamlined process that may be helpful to other centers. Two case reports are also included in this issue, which draw attention to medical conditions that can mimic sexual abuse, and highlight the importance of keeping a broad differential in order to avoid unnecessary stress to the family and unwarranted involvement of child protective services.

COVID-19 has brought about practice challenges that have led to novel approaches to patient care. While telemedicine is not a new concept, its broad application during the pandemic has opened doors to expanded use within different specialties, including child abuse pediatrics. Given the limited number of child abuse pediatricians, particularly outside of urban areas and academic centers, telemedicine has a potential role for providing expanded and improved patient care in all acute care settings.

A final focus of this issue is on the use of a psychosocial assessment in evaluating children with physical abuse. Through the use of a structured interview with caregiver(s), social workers gain valuable information about a child's environment, identifying risk factors that may increase the likelihood of maltreatment. In settings constrained by a lack of social work support, suggestions are made to facilitate this process with medical providers.

Child maltreatment is an age-old problem whose identification and intervention requires diligence on the part of the clinician. This is particularly true in the midst of a pandemic, where the usual safety nets are diminished and risks are heightened. Emergency medicine providers are in a unique position to recognize child abuse and prevent further harm. The stakes are high; it is worth the effort.