Child abuse: a community problem

Harriet L. MacMillan, MD

CMAJ 1998;158:1301-2

Reprint requests to: Dr. Harriet L. MacMillan, Chedoke Site, Hamilton Health Sciences Corp., 1200 Main St. W, PO Box 2000, Stn LCD 1, Hamilton ON L8N 3Z5; fax 905 574-6665; macmilnh@fhs.csu.mcmaster.ca

© 1998 Canadian Medical Association

• Letter: National incidence study of child abuse and neglect

In 1997, findings from the Ontario Health Supplement regarding the prevalence of child physical and sexual abuse were published.² This general population survey involving close to 10 000 participants was carried out in 1990­1991 as an adjunct to the Ontario Health Survey to gather in-depth information about the epidemiology of mental disorders, including correlates. Respondents were 15 years of age and older. Within the study, a self-administered questionnaire (the Child Maltreatment History Self-Report) asked participants about their experiences of having been physically or sexually abused by an adult while they "were growing up." The definition of physical abuse applied to 6 categories ranging from being pushed, grabbed or shoved (often or sometimes) to being physically attacked (often, sometimes or rarely). Although questions were asked about being slapped or spanked, these acts were not included in the definition of abuse, even if they were reported as having happened often. Being kicked, bitten, punched or hit with something was considered severe abuse if it happened often. Being choked, burned, scalded or physically attacked in some other way was considered severe abuse whether it occurred often, sometimes or rarely. The definition of sexual abuse applied to 4 categories of unwanted events, ranging from being the victim of repeated indecent exposure by an adult to being sexually attacked. The definition of severe sexual abuse excluded the category of repeated exposure.

Although they are based on retrospective, self-reported data, the following prevalence rates provide important information about the extent of 2 types of child maltreatment: physical and sexual abuse. A history of physical abuse during childhood was reported by 31.2% of males and 21.1% of females. Sexual abuse during childhood was reported by 4.3% of males and 12.8% of females. Similar proportions of males (10.7%) and females (9.2%) reported a history of severe physical abuse, while severe sexual abuse was reported by 3.9% of males and 11.1% of females. Overall, 33% of males and 27% of females reported that they had experienced physical or sexual abuse or both during childhood. The message is clear: a history of maltreatment during childhood is common among Ontario residents.

These findings only begin to tell us about the scope and burden of this problem. The data provide few insights into factors that influence risk or protection. Moreover, no questions were asked about emotional abuse and neglect. What the field needs, and Canadian children deserve, is a longitudinal study of youth in which data about child maltreatment and its correlates are collected prospectively. This could address crucial questions such as What puts children and young people at risk for maltreatment? and Why do some abused or neglected children go on to develop emotional disorders while others do not?

The fact that few data are available about the extent of this serious problem is a matter of concern. The need should be obvious: such data are essential to the development of interventions and policy. Estimates of the extent of child maltreatment have been derived from official reports to child protection agencies and hence represent only the tip of the iceberg. Collecting information about child maltreatment is fraught with ethical and legal dilemmas. Even so, the burden of suffering associated with child abuse should induce us to make it a priority to address such dilemmas.

Given the paucity of research on child maltreatment, is there any good news for practitioners? Fortunately, knowledge about families at risk for maternal and child health problems has led to the development of an intervention aimed at preventing physical abuse and neglect. In 1986, David Olds and colleagues published results of a randomized controlled trial conducted in New York State showing that intensive home visits by nurses to pregnant women and continuing through the infancy of the child could reduce rates of child abuse and neglect among disadvantaged families.³ Eighty-five per cent of the participants had at least one of the following risk factors: low socioeconomic status, single parenthood or teenage parenthood. Now, results of a follow-up study of the original trial⁴ show that women who received home visits were identified as perpetrators of child abuse and neglect less often than those in the comparison group during the 15 years after the birth of their first child. Among a subgroup of unmarried women with low socioeconomic status, additional benefits were found. These included a reduction in subsequent pregnancies, criminal justice encounters, substance abuse problems and reliance on welfare payments.

Although there is now evidence of the long-term effectiveness of home visits by nurses in preventing child abuse and neglect in disadvantaged families, a few cautions are necessary. The program evaluated by Olds and colleagues was intensive, extended until the child's second birthday and focused on families at greatest risk.⁵ Their findings cannot be extrapolated to interventions or populations that differ significantly from this model.⁴ For example, research by the same investigators demonstrated that a less intensive program did not have the same effect.³ The more intensive intervention was shown to be effective for disadvantaged families, but there is no evidence that its universal application would be equally effective.

In addition, we do not know how to target families most likely to benefit from home visits,⁵ and there is no evidence that screening individuals for risk of committing abuse is effective.^6,7 Some authors suggest that the use of a screening instrument can be stigmatizing and may have negative effects.⁷ However, this problem can be overcome by providing home visits in communities with high rates of poverty and of single and adolescent parenthood.⁵

Family physicians, pediatricians and allied health professionals can recommend home visits by nurses for disadvantaged families, beginning prenatally and extending through infancy. Referrals can be made through public health services. Because there is no evidence to support the use of screening for such services, home visits can be offered to all families with one or more of the sociodemographic risk factors discussed earlier. This also avoids the potential stigma of screening. If intensive home-visit programs are not available in communities, clinicians can emphasize the need for such services through referral and advocacy.⁸ A program of prenatal and early childhood home visits is the only intervention with proven long-term effectiveness in preventing child abuse and neglect. Until clinicians and communities ask for such programs, they are unlikely to be provided, particularly in view of their cost. However, it is worth noting that an economic evaluation of the program implemented by Olds and colleagues showed that the service cost for families with low socioeconomic status was recovered before the children involved reached 4 years of age.⁴

As well as contributing to the prevention of abuse, clinicians also have a role in recognizing and identifying children who are maltreated. All provinces have legislation that requires those who work with children to report suspected abuse to child-protection agencies. Health professionals need to work closely with these agencies in ensuring that children are protected from all types of abuse and neglect. They can also assist in determining the health and developmental needs of children who have experienced maltreatment.

Studies to date, including the Ontario Health Supplement, show that maltreatment continues to be one of the most important public health problems facing children and youth. We need a range of interventions to reduce child abuse and neglect, but they must be rigorously evaluated. All clinicians who work with children and families have an essential role to play in advocating this research.

Dr. MacMillan's work is supported by a Faculty Scholar Award from the W.T. Grant Foundation (New York, NY).

References

1. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA 1962;181:17-24.
2. MacMillan HL, Fleming JE, Trocmé N, Boyle MH, Wong M, Racine YA, et al. Prevalence of child physical and sexual abuse in the community: results from the Ontario Health Supplement. JAMA 1997;278:131-5.
3. Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics 1986;78:65-78.
4. Olds DL, Eckenrode J, Henderson CR Jr, Kitzman H, Powers J, Cole R, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect: fifteen-year follow-up of a randomized trial. JAMA 1997;278:637-43.
5. Olds DL, Kitzman H. Can home visitation improve the health of women and children at environmental risk? Pediatrics 1990;86:108-16.
6. MacMillan HL, Niec AC, Offord DR. Child physical abuse: risk indicators and prevention. In: David TJ, editor. Recent advances in paediatrics. New York: Churchill Livingstone; 1995. p. 53-67.
7. Caldwell RA, Bogat GA, Davidson WS II. The assessment of child abuse potential and the prevention of child abuse and neglect: a policy analysis. Am J Community Psychol 1988;16:609-24.
8. American Academy of Pediatrics Council on Child and Adolescent Health. The role of home-visitation programs in improving health outcomes for children and families. Pediatrics 1998;101:486-10.

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