Child Abuse in Times of Crises: Lessons Learned

Abstract

The COVID-19 pandemic has created conditions which heighten risk for child abuse. As key players in times of crisis, pediatric emergency medicine providers must be equipped with the tools to recognize, respond to, and mitigate risk of child abuse. An exploration of the scientific literature, stakeholder organization reports and lay press was undertaken to understand the impact of large-scale U.S. crises, including infectious disease, financial downturn, natural disaster, and violence, on child abuse risk and inform prevention strategies. Review of the literature suggests a relationship between crises and child abuse risk, though gaps in the research remain. We outline the role of pediatric emergency medicine providers in partnering with communities in organizing and advocating for systems that better protect children and strengthen families.

The COVID-19 pandemic has intensified numerous socio-economic stressors and inequities which have placed children at heightened risk for abuse.1, 2, 3 At times of crises, children are among the most vulnerable, both because of their lack of agency and the need for a safe and stable environment conducive to achieving critical developmental milestones.⁴

Soon after widespread implementation of social distancing measures to mitigate the spread of COVID-19, child health professionals raised concerns about the secondary effect of unreported child abuse.5, 6, 7, 8 Heightened family stressors, loss of the watchful eyes of school officials due to school closures, limited access to health providers, and decreased support from family and friends created cumulative risk for vulnerable children.^{9 , 10} Education personnel are the largest source of reports to child protective services (CPS; 20.5%), followed by law enforcement personnel, social services, medical personnel, relatives, parents, and others.¹¹ While cross-sector efforts mobilized to address basic child health needs such as delayed immunizations¹² and food insecurity,¹³ systematic efforts to address child abuse have been lacking in the COVID-19 response, despite known risks. Crisis management and pediatric disaster preparedness plans have not prioritized child abuse intervention or prevention.¹⁴

Child abuse needs to be a forethought rather than an afterthought for health providers during times of crisis. To better equip emergency medicine (EM) providers with the requisite tools, the objectives of this article are to:

• 1.Draw on lessons learned from past crises in understanding the risk of child abuse associated with the current pandemic and future crises.
• 2.Delineate the role of EM providers in child abuse prevention, using a pediatric disaster preparedness framework.
• 3.Emphasize the need for health providers to advocate for policies and practices which strengthen children's safety net.

Crises and child abuse

An exploration of the literature and lay press was undertaken to better understand the association between major crises in the US and child physical and sexual abuse. Types of crises which have been analyzed in association with child abuse are infectious disease, financial, natural disasters, and mass violence, all of which have overlapping features with the COVID-19 pandemic. Key features of the outlined crises, relevant to child abuse as a public health issue, are: (a) conditions of vulnerability, (b) insufficient capacity to cope with negative effects on physical, mental, and social well-being, and (c) socio-economic disruption.¹⁵

There is a focus on studies examining the associations between crises and factors that place children at greater risk for abuse.¹⁶ Risk factors for child abuse extend beyond the immediate household of a child and can be conceptualized using a public health bidirectional nesting forces model wherein a child is nested in a family, which is nested in a neighborhood, in a community, and in a wider culture and society.¹⁷

The following is a summary of findings, beginning with infectious disease crises and the COVID-19 pandemic. The terms crisis and disaster have been used interchangeably to describe COVID-19.

Infectious Disease Crises

The global fear and uncertainty associated with pandemics create an environment that may exacerbate or trigger violence against children.¹⁸ Literature examining an association between child abuse and prior infectious disease crises in the US, including the H1N1 “swine flu” pandemic, H5N1 “bird flu” pandemic threat and the Ebola outbreak, is limited. A study by Brooks et al found that parents and children quarantined during H1N1 had more post-traumatic symptoms compared to those not quarantined, supporting concern of crisis related social isolation as a potential stressor.¹⁹ The 1918 influenza pandemic predates establishment of child abuse mandated reporting laws in the United States.

COVID-19

While the full impact of the COVID-19 crisis on children is unknown, findings extrapolated from the scientific literature and lay press support health providers’ concerns of heightened risk for child abuse, primarily physical abuse in young children, and unreported sexual abuse. Pertinent findings are described as follows:

Evidence of heightened risk for child physical abuse during COVID-19

A surge in severe child physical abuse, particularly in young children, presenting to hospitals was reported by pediatricians in some states early in the pandemic.^{7 , 20 , 21} A report by the Centers for Disease Control of US Emergency Department (ED) visits from January 2019 to September 2020, found that ED visits for child abuse and neglect decreased by 53% during the pandemic, with the largest decline in children 5 to 11 years old. However, the proportion of child abuse and neglect related ED visits resulting in hospitalization significantly increased during the pandemic.²² While the report did not stratify by maltreatment type, physical abuse in young children is the most common type of maltreatment resulting in hospitalization.²³ These findings are further supported by Kovler et al, who reported an increase in the proportion of young children with physical abuse related injuries evaluated at a Level 1 trauma center early in the pandemic.²⁴

Immediate financial strain in vulnerable families and communities may be a key contributor to increased risk for physical abuse during COVID-19. New hotspots for child physical abuse and neglect emerged in at-risk neighborhoods in Los Angeles, using spatio-temporally analyzed law enforcement data from the first several months of the pandemic. Neighborhood risk factors included severe housing insecurity and school absenteeism.²⁵ An online survey of parents of school aged children (4-10 years old) found that those who experienced job loss during the pandemic exhibited increased physically abusive behavior towards their children. Physically abusive behaviors ranged from corporal punishment (ie, spanking) to severe assault (ie, hitting as hard as possible). Parental depression and prior physically abusive behavior were significant predictors.²⁶

Evidence for heightened risk for child sexual abuse during COVID-19

While reports to CPS decreased percipitously, these statistics may not accurately reflect child abuse rates during the pandemic. The National Hotline Consortium reported increased outreach by children for concerns of abuse during the pandemic.²⁷ RAINN (Rape, Abuse, and Incest National Network), a national sexual assault hotline, reported an increase in calls from minors early in the pandemic. Many (79%) disclosed residing with the abuser during quarantine.^{28 , 29} Childhelp, a confidential support hotline for adults and children, reported a 40% increase in the total number of contacts in May 2020 compared to May 2019. Approximately half of the web and chat contacts were initiated by adolescents 13 to 17 years old for abuse concerns, consisting of emotional (38%), physical (32%), and sexual (12%) abuse.³⁰ Most youth reported they may not have contacted the hotline if the digital option was not available.³¹ The National Center for Missing and Exploited Children (NCMEC) reported increases in reports of online sexual exploitation of children.³² “Online enticement reports” and CyberTipline reports increased by 98% and 63% respectively, from January to October 2020, compared to 2019.³² This surge raised concern amongst health professionals of an associated increase in child sex trafficking during the pandemic.

Evidence of heightened risk factors for child abuse during COVID-19

Individual child risk factors

Young children and those with special needs (ie, disabilities and mental health problems) are vulnerable to child abuse as they may increase caregiver burden.¹⁶ During the COVID-19 pandemic, children with mental health problems lost access to peer support, school counselors, and community mental health services.^{17 , 33} According to the Centers for Disease Control, the proportion of mental health ED visits increased by 24% for children (5-11 years old) and by 31% for adolescents (12-17 years old) from April to October 2020 among all pediatric ED visits.³³ A national survey found that 1 in 7 parents reported worsening of their child's behavioral health since March 2020.³⁴ Children with disabilities lost access to special education services, increasing parental stress and risk for physical abuse.³⁵ Children with disabilities are also more vulnerable to sexual abuse.³⁶ Child protection professionals expressed concern that perpetrators of sexual abuse may have increased access to children due to school closures and single working mothers in need of childcare.^{5 , 37} An increase in accidental injuries and ingestions have also been reported in young children, indicating inadequate supervision during the pandemic.³⁸

Parent and family risk factors

Parental risk factors for child abuse include substance abuse, mental health issues, singledom, and low income. Family risk factors include social isolation, intimate partner violence (IPV), and family stress.¹⁶ Parental access to mental health and substance abuse treatment was reduced during the COVID-19 pandemic.³⁹ Nearly 50% of parents with children less than 18 years old reported negative impacts to their mental health due to coronavirus related stress.⁴⁰ A study by Borg et al found that 1 in 10 parents reported worsening of their own mental health alongside worsening of their child's behavioral health. Parents of younger children (less than 5 years old) and those who lost childcare were most at risk.³⁴ Several states reported an increase in IPV-related arrests and reports.⁴¹

Community risk factors

Community violence, concentrated neighborhood disadvantage (ie, high poverty and unemployment rates) and poor social connections are risk factors for child abuse.¹⁶ Mothers of school-aged children have been disproportionately affected by high unemployment rates during the pandemic, with Black women most affected.² Neighborhoods in urban counties with the greatest proportion of poor, racial and ethnic minorities were most affected by COVID-19.⁴² Increases in gun violence were seen in urban communities^{43 , 44}, alongside record high gun sales.⁴⁵

Societal risk factors

The COVID-19 pandemic exposed gaps in child protection systems, as they primarily rely on in-person contact to identify child abuse concerns.⁴⁶ Reports to CPS dropped significantly across the US and, with that, the ability to monitor the incidence of child abuse⁴⁷ and provide prevention services.⁴⁸ Studies of child abuse reporting during the early pandemic in New York City and Florida found decreases in reporting by 50% and 27% respectively during April 2020. While schools are likely the primary source of decreased reports, a concerning decline in reports by nonmandated reporters (family and friends) was also found.^{47 , 48}

Financial crises

The Great Recession of 2007-2009 has been the largest economic downturn in the history of the United States since the Great Depression. Economic strain is associated with family risk factors for abuse, including binge drinking,⁴⁹ IPV,⁵⁰ and adverse mental health effects.^{51 , 52} The most studied type of child abuse in relation to the Great Recession has been abusive head trauma (AHT), with mixed findings likely due to varied methods for data collection and analysis. Multiple studies analyzing hospital admission data have found evidence for increased rates of AHT during the recession,^{53 , 54} with elevated incidence lingering for a period after the recession.⁵⁵ On the contrary, a study looking at national trends of AHT found no significant changes during the recession.⁵⁶

According to a study of the Great Recession using National Child Abuse and Neglect Data System (NCANDS) data, an increase in reports for child physical abuse following state job losses was found, peaking 4 to 6 months subsequent to onset of unemployment. No change in reports for child sexual abuse was found, indicating possible lack of association between child sexual abuse and financial strain.⁵⁷ An inconsistent relationship was found in a study of child maltreatment reports and multiple economic stressors in 7 states.⁵⁸ The hypothesis that physical abuse would show stronger associations with economic stressors than sexual abuse was not supported by this study.⁵⁸

A longitudinal cohort study found that mothers reported increased high frequency spanking⁵⁹ and physical aggression toward their children during the Great Recession.⁶⁰ The presence of a social father (nonbiological father figure) was associated with elevated risk, compared to households with no father or a biological father. The authors theorized that an unrelated partner may create added stress for the mother due to lack of assistance with childcare.⁶⁰

Natural disasters

Several natural disasters have been studied for association with child abuse, with mixed results. An increase in hospital admissions for both inflicted and noninflicted traumatic brain injury in children less than 2 years old was found during the 6 month period following Hurricane Floyd (North Carolina, 1999).⁶¹ Curtis et al found increased reports of child physical and sexual abuse up to 11 months following Hurricane Hugo in South Carolina and the Loma Prieta Earthquake in California, which both occurred in 1989. Conversely, these researchers found that reports of child physical and sexual abuse decreased following Hurricane Andrew in Louisiana in 1992.⁶²

Hurricane Katrina in 2005 has been the most recognized large-scale natural disaster in the United States. Only anecdotal reports of child physical and sexual abuse^{63 , 64} could be found in association with this disaster. However, there are studies documenting an increase in IPV following Hurricane Katrina.⁶⁵

Community and mass violence

Exposure to community violence is associated with child abuse and other forms of violence in children.^{66 , 67} The 9-11 terrorist attack in New York City has been the most well recognized large-scale violent event in the United States. While no studies could be found directly examining child abuse rates in association with 9-11, adults with a history of child maltreatment and exposed to 9-11 were found to be at increased risk for substance abuse and mental health problems.⁶⁸ These findings add to the notion of cumulative risk as a contributor to adverse long-term health. Studies have found an increase in firearm sales following mass shootings, 9-11, and other times of social unrest and violence in the United States, which has the potential to cause injury to children.^{45 , 69}

Child abuse prevention in disaster preparedness

Emergency care providers are uniquely positioned to mitigate risk of child abuse in times of crisis. The role of the EM provider must expand beyond reporting to facilitating ongoing care, support, and monitoring of vulnerable children. Child abuse prevention in the ED can be conceptualized using a 4 phased pediatric disaster preparedness framework.⁷⁰

Phase 1 - Preparedness: During this phase, the goal of the provider should not be limited to ensuring children are injury-free but should include optimizing child and family well-being andreducing vulnerability to abuse. EM providers can do the following:

• •Ensure access to preventive and mental health care, including telehealth,⁷¹ and communicate concerns to relevant providers.
• •Partner with communities to integrate child abuse recognition and prevention into disaster preparedness plans, create centralized location for access to support resources, and provide education on trauma informed first response systems.⁷²
• •Advocate for newborn home visitation, housing stability, food security, universal broadband access, affordable childcare, equitable health systems, safe green spaces, and poverty reduction measures.⁷³

Phase 2 - Response: Response is a time for heightened recognition of child abuse and children at risk for abuse. EM providers can do the following:

• •Ask children and families how they are coping, screen for family stressors and abuse, refer to accessible support services, and encourage utilization of informal and formal supports].⁷⁴
• •Work with communities to implement coordinated response strategies focused on child abuse prevention and recognition.^{72 , 74} Maintaining communication with vulnerable children is critical to helping them stay connected and access support.¹⁸ Digital crisis support platforms can be scaled, such as mental health chat hotlines for adolescents and video home visitation calls for parents of young children.⁷⁵
• •Ensure that crisis management processes consider safety from abuse in home quarantine and other public health measures.¹⁸

Phase 3 - Mitigation: Mitigation is an opportunity to decrease the impact of the crisis and its secondary effects on vulnerable children. EM providers can do the following:

• •Continue to ask children and families how they are coping, screen for abuse and family stressors, and refer to accessible support services
• •Foster a community of supportive adults to monitor high-risk children and promote protective factors.
• •Collaborate with community organizations, schools, local governmental agencies, parent groups, faith-based leaders, medical societies, and other stakeholders to ensure coordinated and effective child abuse recognition and prevention strategies.

Phase 4 - Recovery: The recovery phase can be classified into short-term and long-term. The goal of the short-term phase is to return to “normal.” During the long-term phase, EM providers can work with communities to assess how existing crisis management protocols impacted children and make changes in preparation for future crises.

Summary

The COVID-19 pandemic and subsequent measures to mitigate community spread have heightened the risk for child abuse, exposed serious gaps in child protection systems, and underscored the critical need for systematized prevention practices. A substantial body of cross-sector work points towards a relationship between large scale crises and increased risk for child abuse, primarily physical abuse. There are few studies analyzing child sexual abuse in relationship to crises in the United States. Varied research methodologies, lack of population level data, and reliance on child protection services reporting data limit the ability to more thoroughly define risk.

Given that EDs are hubs for crisis management, EM providers can play an integral role in child abuse prevention. A pediatric disaster preparedness approach can be employed, with an emphasis on the preparedness phase to bolster children's safety net. EM providers can advocate for vulnerable children on clinical, community, and legislative policy levels. On a clinical level, providers can screen for stressors and connect children and families to support. On a community level, providers can partner with stakeholders to ensure support services are trauma informed and accessible. On a legislative level, providers can advocate for policies that promote child and family well-being.

Front line providers have the opportunity to nurture the environment in which children grow, so that when the inevitable storm comes to pass, the child will not only survive, but thrive within a stronger family, community, and society.

Declaration of Competing Interest

None.