NEW YORK CITY, Nov. 6 – John M. Leventhal, MD, recipient of the 2006 Millie and Richard Brock Award in Pediatrics, opened his Academy lecture on child maltreatment by showing slides of the idealized American family: prim and attentive twin girls nestling against either side of their mother, Abraham Lincoln teaching his son to read. He then presented an array of starkly divergent images, the reality of family life for some children: a toddler’s face and backside bruised and swollen from a beating, the x-ray of a child’s fractured femur. Leventhal explained that American children remain maltreated at alarming rates, even though it’s been 44 years since “battered child syndrome” was first identified in a seminal report by C. Henry Kempe, MD, in the Journal of the American Medical Association. That report helped lead to the establishment of mandated reporting laws and Child Protective Services (CPS) agencies decades ago, yet maltreatment continues. To a packed auditorium, which included Mr. and Mrs. Brock, Leventhal asked, “Can America stop hurting its children?” To this he responded an unqualified “yes.”
Over the course of his riveting lecture, Dr. Leventhal led the audience on a journey of child maltreatment from 1962 to today. He concluded with a description and analysis of a visiting home nurse intervention program that has proven enormously successful in improving the lives of at-risk children and their mothers. It is Dr. Leventhal’s belief that this program could provide a model for universal, preventive services in the United States.
National Trends in Reported and Substantiated Cases of Child Maltreatment
Although reported cases of child maltreatment have increased in recent years, according to Leventhal, substantiated cases have declined and no one is entirely certain as to why. Changes in the criteria for substantiation of abuse, changes in classification of sexual abuse, economic improvements, the increased presence of what he called “agents of social change,” and the increased use of psychiatric medications could all be responsible for reduced rates of substantiated abuse. Leventhal noted that the national trend corroborates with data he has gathered at Yale-New Haven Children’s Hospital, where he has for many years served as Medical Director of the Child Abuse Committee and of the Yale Child Sexual Abuse Clinic and the Child Abuse Prevention Programs. From 1979 to 1983, 22.5 percent of the fractures seen in children between the ages of 0-35 months were attributed to abuse, as opposed to 10.8 percent between 1999 and 2002.
Nonetheless, Leventhal emphasized that child maltreatment remains a significant problem in our culture. In 2004, there were 3.5 million maltreatment reports to CPS. Nearly 900,000 of these cases were substantiated and of them, 167,000 children were removed from their homes, and 1,500 children died. There are more new cases of child maltreatment every year than there are children diagnosed with congenital heart disease, sickle cell disease, cystic fibrosis, or PKU. These maltreated children may be neglected and/or suffer from physical, sexual, and emotional abuse. They live in all parts of the United States, though certain states have higher rates of abuse than others. California, Oregon, North Dakota, New Mexico, Oklahoma, and Louisiana, for instance, report victimization rates greater than 20.1 per 1,000 children. Pennsylvania, Virginia, Arizona, and Idaho, on the other hand, report rates between 0 and 5 per 1,000 children.
The consequences of this maltreatment are severe. “Lost lives, lost families, lost souls, lost generations, lost health, and lost money” typically follow child maltreatment, Leventhal said. Most obviously, children die tragically. Leventhal told the audience about two such deaths: a three-month-old girl who was being cared for by her unemployed father and was admitted to the Yale-New Haven Children’s Hospital with a fractured rib and anoxic brain injury; and an 18-month-old boy who died from ingesting alcohol.
Child maltreatment also leads to intergenerational violence, as was demonstrated by Cathy Spatz Widom’s 1988 research showing that childhood abuse and neglect increased the odds of future delinquency and adult criminality by 29 percent. Only recently, Leventhal said, have we begun to understand that child maltreatment is also a major cause of adult mortality in the United States. The Adverse Childhood Experiences Study, an ongoing research project jointly sponsored by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente’s Department of Preventive Medicine in San Diego, California, has revealed a connection between our childhood experiences and our physical and mental health as adults. Obesity, substance abuse, chronic obstructive pulmonary disease, depression, and suicidal tendencies are much more likely to plague an adult who suffered maltreatment as a child.
The Ecology of Parenting
One model that can help elucidate the kind of pressures that cause some parents to cross over the line and harm their children, Leventhal said, is the “Ecology of Parenting.” This model illustrates the different spheres of influence that can inform a parent’s behavior toward their child. The first sphere is the context within which parent and child exist, followed by family context, social setting, and culture. He said we know that, if certain qualities are present at each sphere of influence, they can increase the likelihood of abuse. A parent who has used cocaine regularly during pregnancy, a mother who is under the age of nineteen or was abused herself, a premature or handicapped child – any of these factors can increase the risk of abuse. An atmosphere of existing domestic violence between parents also puts a child at greater risk. So do poverty and cultural violence.
Abuse also occurs when parents “minimize the value of the child,” which may manifest itself in different ways. The parent may lack empathy for the child’s needs, feel persistently negative toward them, have inappropriate expectations, believe in physical punishment, or expect the child to take on more of a parental role than the parent wishes to take on (parental role reversal).
Stopping Abuse
Leventhal explained that, in general, parents who abuse their children carry a sense of being “unimportant people.” It is not easy to change human feelings and habits, institute long-term intervention programs, or address the complex array of difficulties that often strain the resources of at-risk families (including financial problems, social isolation, and substance abuse). This reality makes child maltreatment all the more difficult to stop. Leventhal has found that programs aimed at stopping child maltreatment must engage parents at many different levels: promoting positive relationship between parents and child, modeling effective parenting skills, providing concrete services to the family, placing a watchful adult in the home, and providing long-term interventions.
The most effective way to prevent abuse, Leventhal believes, would be to institute universal home visits to families expecting their first child by nurses, social workers, paraprofessionals, and volunteers. He cited the best model for such a program as being the Elmira Study of Home Visiting Nurses, conducted between 1978 and 1980 by David Olds, PhD, and a team of researchers.
In this study, Olds enrolled 400 first time-mothers from the rural community of Elmira, New York. The women were less than thirty weeks pregnant. Eighty-nine percent were white, 61 percent poor, 62 percent unmarried, and 47 percent under the age of nineteen. Nearly half received home visits from nurses: 9 prenatally, and 23 periodically between the child’s birth and second birthday. During the visits, nurses discussed nutrition, prenatal care, developmental stages and needs of the child, and other issues that could affect maternal and child well-being. Follow-up with 324 of the mothers and their children fifteen years after the initial study showed a long-term positive impact on the intervention group. Mothers who had been provided with nurse home visitors had 46 percent fewer substantiated reports of child maltreatment as compared to those in the control group, 31 percent fewer subsequent births, gave birth to a second child two or more years after the first was born; and had relied upon 30 fewer months of Aid to Families with Dependent Children for support. The children of these mothers also benefited. They were less likely to have been arrested or exhibit criminal behaviors, run away from home, have multiple sex partners, or use cigarettes and alcohol.
In closing, Leventhal cited an epigraph at Franklin Delano Roosevelt’s monument in Washington, DC: “The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.” He pointed out that providing universal preventive, home visiting services for one year would cost $4,000 per family, or $16 billion dollars annually. Providing them as a preventive measure to high-risk, first-time parents only would cost $1.6 billion. The question is, whether or not the United States is willing to bear this cost. Leventhal pointed out that in making that decision, we should consider all the costs of maltreatment: the $4 billion spent annually providing foster care to one percent of our nation’s children, the $24 billion annually on direct costs of investigations and services, the $69 billion spent on long-term services related to the consequences of maltreatment, the $627 billion spent each year on acute medical care, and the cost of lost opportunities.
The Brock Lecture, Award, and Visiting Professorship in Pediatrics were established at The New York Academy of Medicine by Millie and Richard Brock in 1995 on the 100th anniversary of the Academy’s Section on Pediatrics. Difficult life experiences with one of their own children gave the Brocks a particular sensitivity and commitment to the needs of all children, leading them to endow this program. Nationally recognized leaders in pediatrics are invited through the program to engage in a one- to two-day visiting professorship at a New York-area pediatrics training program, to deliver the annual Brock Lecture, and to receive the Brock Award in recognition of distinguished contributions to pediatrics.
Founded in 1847, The New York Academy of Medicine is an independent, non-partisan, non-profit institution whose mission is to enhance the health of the public. The Academy is a leading center for urban health policy and action working to enhance the health of people living in cities worldwide through research, education, advocacy, and prevention.
Posted on 11/06/2006
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Malini Doddamani
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