Addressing psychiatric and psychosocial issues related to children and adolescents
“It is easier to build strong children than to repair broken men.”
This statement has become the battle cry of many child abuse prevention advocates. Frederick Douglass has been credited with these words about slavery; however, they ring true regarding the immediate and long-term sequelae from abuse of all origins. With the advent of trauma-focused care, many mental health care professionals have shifted focus from “what is wrong with you?” to “what has happened to you?”
Effects of Adverse Childhood Events
The Adverse Childhood Events (ACE) Study offered a better understanding of the lasting effects created by a difficult childhood. The ACE Study was conducted at Kaiser Permanente from 1995 to 1997. During annual physical examinations, more than 17,000 members were asked to complete confidential surveys on childhood experiences and their current health status and behaviors (Centers for Disease Control and Prevention [CDC], 2016). Researchers categorized ACEs into three major groups—abuse, neglect, and family/household challenges. Researchers discovered how ACEs contribute to disrupted neuro-development and psychosocial impairment, resulting in risk factors for physical and emotional health problems throughout life (CDC, 2016). The major finding from the study is that ACEs are common, and as the number of ACEs increase, so do the negative outcomes (CDC, 2016).
Child maltreatment produces a wide range of possible effects including comorbid psychiatric disorders, mood dysregulation, disruptive and aggressive behaviors, insecure and atypical attachment patterns, impaired peer relationships, academic underachievement, somatic complaints, and self-harm, including suicide (Joshi, Cullins, & Southammakosane, 2016). In 2015, suicide was the second leading cause of death in youth ages 10 to 24 years (American Association of Suicidology, 2017). Most studies on suicide do not separate children and adolescents; however, Peyre et al. (2017) found that although suicide attempts during adolescence were more strongly associated with a major depressive episode, suicide attempts during childhood were more strongly related to maltreatment. Suicide attempts during childhood are associated with increased risk for multiple suicide attempts; psychiatric disorders including mania, hypomania, and panic; and poor social functioning as an adult (Peyre et al., 2017).
History and Definition of Child Maltreatment
Kempe, Silverman, Steele, Droegemueller, and Silver (1962) wrote the landmark article, “The Battered-Child Syndrome,” which led the movement to recognize child abuse as a major pediatric, psychiatric, and social problem (Joshi et al., 2016). By 1965, Child Protective Services (CPS) was established, followed by the Child Abuse Prevention and Treatment Act (CAPTA) in 1974, which provided states with federal funding for the investigation and prevention of child abuse under the condition that states adopt mandatory reporting laws (U.S. Department of Health and Human Services [USDHHS], 2017). CAPTA also guaranteed immunity to reporters and began the appointment of a guardian ad litem to represent the child (USDHHS, 2017).
Although each state defines child abuse and neglect, CAPTA legislation defines it as:
…any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.
Most states recognize four types of maltreatment: neglect, physical abuse, psychological maltreatment, and sexual abuse; children may experience one form of maltreatment or a combination of more than one type (USDHHS, 2017).
Child Abuse Statistics
The National Child Abuse and Neglect Data System is a federally sponsored annual data collection on child abuse, which has been in existence since 1988. It is used by the USDHHS to create the annual Child Maltreatment report. The current report covers data collection from 2015 (USDHHS, 2017). The data collection includes referrals to CPS (allegations) as well as reports (i.e., referrals that are screened) resulting in an investigation or alternative response (USDHHS, 2017).
In 2015, there were 4 million referrals, which was a 9% increase from 2011; of these referrals, 2.2 million reports required a response (USDHHS, 2017). Professionals made 63.4% of reports; the top three professional reporting groups were education personnel (18.4%), law enforcement (18.2%), and social services (10.9%) (USDHHS, 2017). It is interesting to note that medical professionals were not listed as one of the most common reporters. Nonprofessionals, including parents, relatives, friends, and neighbors, made 18.2% of reports, and the remaining 18.2% were made by unknown sources (USDHHS, 2017).
The term victim refers to a child for whom the state determined at least one maltreatment incident was substantiated or indicated (USDHHS, 2017). According to the 2015 Child Maltreatment report (USDHHS, 2017), approximately 4 million referrals involving 7.2 million children were made to CPS agencies. CPS determined that 683,000 of these children were victims of abuse and neglect, which represents a 3.8% increase from 2011. Of these victims, 75% had no prior victimization history. More than one quarter of victims were younger than 3, and boys accounted for 48.6% and girls accounted for 50.9%. The majority of victims were White (43.2%), Hispanic (23.6%), and African American (21.4%), but victims of African American, American Indian or Alaska Native, and multiple racial descents had the highest rates of victimization at 14.5, 13.8, and 10.4 victims, respectively, per 1,000 (USDHHS, 2017).
In 2015, the type of maltreatment was primarily neglect (75.3%), followed by physical abuse (17.2%), sexual abuse (8.4%), and other (6.9%). Sadly, 1,670 children died in 2015 from abuse and neglect, representing a 5.7% increase from 2011; there may be more deaths related to abuse that did not come to the attention of CPS. Of those children, 75% were younger than 3, and one or both parents caused 78% of the deaths (USDHHS, 2017).
Prevention efforts for all children are vital. Knowing which families are more at risk allows for additional targeted efforts. Many risk factors for child maltreatment are identified in the literature; however, the combination of parental characteristics and child vulnerabilities may increase the risk significantly (Scribano, 2010). Common parental characteristics include young age, limited education, single parenthood, a large number of dependent children, poverty, mental health issues, and having experienced abuse in their childhoods (CDC, 2017). Substance use is another common risk factor; in 2015, 10% of victims had a caregiver who abused alcohol, and 25% of victims had a caregiver who abused drugs (USDHHS, 2017).
Common risk factors associated with the child include behavioral problems, mental health issues, medical conditions that increase caregiver burden (including physical and developmental disabilities), and the young age of the child (CDC, 2017). Families are at higher risk when they live in disadvantaged neighborhoods, are socially isolated, or have poor parent– child relationships (CDC, 2017). Children exposed to domestic violence in the home are at increased risk to be a victim; in 2015, 25% of victims were exposed to domestic violence (USDHHS, 2017).
Although psychiatric nurses must always assess for possible abuse with all children, there are red flags that should raise nurses' suspicions. When a child presents with multiple injuries or when the family's explanation is inconsistent, contradictory, or developmentally incongruent, additional assessment is warranted (Joshi et al., 2016). An additional cause for concern should arise when there is either excessive or limited level of concern, delay in seeking medical attention, or blaming the injuries on a sibling or the child (Joshi et al., 2016).
Joshi et al. (2016) recommend additional assessment when a child is fearful, docile, distrustful, and guarded with physical contact. Other behavioral manifestations of child abuse may include hypervigilance, role reversal with parents, and fear of going home (Joshi et al., 2016). Certain physical injuries are more common to abuse than accidental injuries and should be assessed by a child abuse expert when possible; bruises, lacerations, or burns that are in the shape of an object or not easy to obtain while playing are more consistent with abuse (Joshi et al., 2016). The U.S. Department of Justice (2014) provides a manual on how to recognize when abuse is the cause of a child's injury, as it is often difficult to differentiate from accidental injury or illness.
Common Mistakes by Mental Health Professionals
As mandated reporters, nurses are required by law to report suspicions of child abuse, but there are many reasons psychiatric nurses and other mental health professionals do not always make these reports. Some of the clinical reasons for not reporting may include uncertainty of the veracity of the child's disclosure, belief that the child is currently safe from the perpetrator, fear of ruining rapport with the family, or belief that the parent's intent was not to abuse (Eisbach & Driessnack, 2010; Francis et al., 2012). Sometimes it may be the logistical reasons for not reporting such as deferral to a supervisor or other reporter, the time it takes for a thorough assessment followed by the report, and previous lack of response by CPS (Eisbach & Driessnack, 2010; Francis et al., 2012). Despite any doubts on how to proceed, nurses must err on the side of caution, remembering it is not their role to prove abuse, rather it is their responsibility to be concerned and report suspicions.
Sometimes lack of knowledge or confidence regarding child maltreatment results in mistakes by psychiatric nurses or other mental health professionals. Lack of familiarity with maltreatment risk factors (Adams, 2005) or unclear signs of abuse (Eisbach & Driessnack, 2010) may be common reasons nurses do not report their suspicions. In addition, being unsure of the mandated reporting laws and procedures in one's state can lead to lack of reporting. Guidance on how to respond to and report suspected child abuse can be found at https://www.childwelfare.gov/topics/responding.
Treatment extends beyond the physical injuries. When choosing a mental health intervention, the target population and desired outcomes must be considered as well as the levels and types of evidence to support the intervention. Available resources and training requirements may limit options. The National Child Traumatic Stress Network (n.d.) provides a list summarizing empirically supported or promising mental health interventions and approaches.
Based on a systematic review of 37 studies conducted during the past 7 years, cognitive-behavioral therapy (CBT) is still considered the leading approach with the most evidence for treating children with trauma exposure (Dorsey et al., 2017). Trauma focused-CBT (TF-CBT) is designed to treat posttraumatic stress disorder (PTSD) and related emotional and behavioral problems by integrating cognitive, behavioral, interpersonal, and family therapy principles as well as trauma interventions offered by certified TF-CBT therapists (TF-CBT National Therapist Certification Program, 2017).
Originally developed for families with children ages 3 to 7 with externalizing behavior problems, parent– child interaction therapy (PCIT) is recommended as an effective intervention for families with a history of child maltreatment or those at risk for abuse (Thomas & Zimmer-Gembeck, 2011). This therapy is founded on social learning theory and attachment theory, which focuses on the elimination of harsh discipline strategies while promoting use of positive parenting behaviors (Hakman, Chaffin, Funderburk, & Silovsky, 2009). A recent meta-analysis has shown PCIT as effective in decreasing parental stress and reducing physical abuse recurrence (Kennedy, Kim, Tripodi, Brown, & Gowdy, 2016). Online training for PCIT in children who have been traumatized can be found at http://pcit.ucdavis.edu/pcit-web-course.
There may be times when a child needs medication to help manage the mental health effects of abuse. Historically, selective serotonin reuptake inhibitors (SSRIs) have been given to children experiencing trauma-related symptoms based on adult guidelines and U.S. Food and Drug Administration approval; however, there is limited evidence that SSRIs are effective beyond treating comorbid depression and anxiety symptoms in children who have experienced trauma (Cohen, 2010). Recent attention has been given to alternatives or adjuncts to SSRIs. An open-label study on extended-release guanfacine demonstrated a decrease in traumatic stress–related symptoms in children (Connor, Grasso, Slivinsky, Pearson, & Banga, 2013). Case reports using prazosin for trauma-related nightmares offer examples of successful treatment in adolescents (Oluwabusi, Sedky, & Bennett, 2012) and children (Racin, Bellonci, & Coffey, 2014) who have experienced abuse. Literature on the use of atypical antipsychotic agents in PTSD includes cases of successful use of risperidone in preschool age children with abuse-related acute stress disorder (Meighen, Hines, & Lagges, 2007).
Psychiatric Nursing Roles
Psychiatric nurses have many roles and responsibilities related to child abuse. Responsibilities may include reporting suspicions, evaluation and treatment, advocacy, referrals, education, being a legal expert or witness, or participation as a multidisciplinary team member (Peterson & Urquiza, 1993). Responsibilities may depend on the nurse's work setting and role. All psychiatric nurses must be part of prevention efforts. Prevention comprises activities that aim to reduce a specific problem, protect those from the problem, or promote alternative behaviors (USDHHS, 2003). Primary prevention activities help prevent abuse from occurring. Secondary prevention includes interventions intended to prevent abuse from occurring in at-risk families. Tertiary preventions are aimed at preventing abuse from reoccurring (USDHHS, 2003).
Psychiatric nurses commonly work with patients who have experienced abuse or are at risk for abuse. It is imperative that nurses know the definitions, statistics, risk factors, and outcomes of abuse. Nurses must recognize and report suspicions of abuse and obtain additional training experiences to provide effective clinical intervention if currently lacking. Psychiatric nurses can have a key role in the efforts to “build strong children” to decrease the need to “repair broken men.”
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- Oluwabusi, O.O., Sedky, K. & Bennett, D.S. (2012). Prazosin treatment of nightmares and sleep disturbances associated with posttraumatic stress disorder: Two adolescent cases. Journal of Child and Adolescent Psychopharmacology, 22, 399–402. doi:10.1089/cap.2012.0035 [CrossRef]
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- Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program. (2017). Certification process. Retrieved from https://tfcbt.org/tf-cbt-certification-criteria
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