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Preventing child maltreatment fits well with the goals and scope
of pediatrics, as expressed by the American Academy of Pediatrics’ commitment
to “prevention, early detection, and management of behavioral, developmental,
and social problems as a focus in pediatric practice.”1 The
prevention of child abuse and neglect has benefits at the level
of the individual child, the family, the community, and the society
at large. Sparing a child from the physical, cognitive, behavioral,
and emotional problems associated with maltreatment2-6 is
intuitively and morally preferable to intervening after the fact.
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Beyond the individual child, the prevention of child maltreatment
has at its heart the goal of strengthening families and
enhancing childrearing. Effective interventions may achieve much
more than the narrow goal of preventing maltreatment. Additional
outcomes may include children’s cognitive, emotional, social, and
behavioral gains; improved maternal health and communication with
their children; decreased use of public assistance; and decreased involvement
in the criminal justice system.7-10 Child maltreatment
has significant costs, human and economic, that need to be weighed against
the cost of prevention. Although more research is needed, several
studies have demonstrated the cost effectiveness of specific child abuse
prevention programs.11-13
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To date, pediatric practice has focused primarily on the important
issues of identifying abuse and neglect, reporting to the public agencies,
and facilitating referrals for assessment and treatment. In order
to fulfill their responsibility to help ensure children’s
health and well-being, pediatricians should also focus on preventing
maltreatment. Pediatricians can do so by identifying and helping
to manage child and family risk and protective factors, referring
families to effective community-based services, and advocating for
the development of policies and funding of programs that effectively
promote family well-being. Because children and families generally
enjoy excellent relationships with primary care pediatricians, pediatricians
may play a role that other professionals cannot. Pediatricians are
usually perceived as supportive and caring without the stigma often
attached to social work and mental health. This rapport can facilitate
a remarkable entrée into families’ lives with
sharing of much sensitive information.
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Risk Factors
for Maltreatment
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The “ecological” framework of child maltreatment
posits that physically abusive and/or neglectful behavior
derives from the complex set of interactions between the child,
parent, community, and society.14 Specific patterns
of behavior observed within the parent-child dyad can
serve as important indicators of possible physical abuse or neglect.
Child characteristics, such as difficult temperament or chronic
physical or mental health problems, may challenge parents, heighten
parental stress, and increase the risk of maltreatment.15,16 The
relationship between parent and child in maltreating families may
involve harsh, inattentive, and inconsistent parenting.17 Maltreating
parents, particularly physically abusive ones, often report feeling “out
of control” as parents. They frequently hold an external
locus of control orientation, feeling that they have limited control
over their actions.17-19 For a more detailed discussion
of risk factors, see Chapter 35.
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