Guide to comprehensive care of the child who has been maltreated
Emalee G.Flaherty, M.D., FAAP
AAP Clinical Report
It is not uncommon for pediatricians to provide primary care for children who have
Up to 25% of children have experienced some form of maltreatment. About two-thirds
of youths who are reported to child protective services will remain in their parents’
care, and about half of those placed outside their home will return within eight months,
according to the U.S. Department of Health and Human Services.
Pediatricians are in an ideal position to address the physical, emotional, cognitive
and developmental needs of maltreated children.
A new AAP clinical report focuses on how pediatricians can provide primary medical
follow-up care for children who have been identified as maltreated and who are in
the care of those who may have maltreated them.
The report Ongoing Pediatric Health Care of the Child Who Has Been Maltreated, from the AAP Council on Child Abuse and Neglect, is available at https://doi.org/10.1542/peds.2019-0284 and will be published in the April issue of Pediatrics.
Conduct thorough history, monitoring
Initially, the child will need to be seen frequently. As with all pediatric visits,
the history is important and needs to include the initial cause for intervention and
the care provided. In addition, the pediatrician should take a history of any new
medical problems, injuries, hospitalizations and emergency department visits, placements
outside the home, and services recommended.
Children with certain types of injuries, such as abusive head trauma, require specialized
medical care and long-term follow-up. This includes monitoring head circumference
until the child is 2 or 3 years old.
Pediatricians should focus on the emotional and physical growth and development of
all children who have been maltreated and monitor the academic progress of school-age
children. In addition, the family’s discipline habits should be explored and the most
effective methods discussed.
It is important to identify stressors that may affect the family’s ability to care
for the child and recommend community resources that may help ease stress and build
resiliency in the child and family.
Recurrence of abuse is not uncommon, ranging from 1%-2% in low-risk families to 65%
in high-risk families, studies have shown. The greatest risk for recurrence is in
the first six months following the initial intervention.
Pediatricians will need to watch for signs of recidivism. The same factors that place
a child at risk of maltreatment, such as poverty, parental depression, parental lack
of emotional support, domestic violence and harsh disciplinary practices, make a child
more susceptible to recurrence.
The pediatrician can encourage the parent/caregiver to follow through with services
recommended by child protective services and identify additional community resources
that may give the family the knowledge and skills necessary to provide optimal care
for their child. Pediatricians who understand the stressors and dysfunction that led
to the maltreatment can better identify the most appropriate community services. They
also can coordinate with school personnel to support at-risk children and families.
Advocate for evidence-based programs
In addition to strengthening the family, pediatricians can educate the community about
the effects of stress on families and advocate for evidence-based programs that help
children with a history of trauma.
Home visiting programs, for example, may help improve a parent’s caregiving ability.
Early childhood education has been shown to improve school readiness. Parent training
programs can improve knowledge of child development and child-rearing skills and encourage
positive child management techniques.
Pediatricians can play an important role in caring for children who have been maltreated,
fostering good parenting and advocating for programs that strengthen families and
Dr. Flaherty, lead author of the clinical report, is immediate past chair of the Council
on Child Abuse and Neglect Executive Committee.