Editorial
Child maltreatment in Canada, 2013 Michelle Shouldice MD FRCPC Guest Editor
C
hild maltreatment, which encompasses abuse, neglect and exposure to intimate partner violence, is an issue that demands the attention and engagement of all health care providers who encounter children and families. It has been difficult to measure the true impact of this problem. Determination of the numbers of children experiencing maltreatment has been challenging due to underidentification and issues related to definitions. The most accurate understanding, developed from community surveys based on self-report, suggests that maltreatment impacts more children than any other health care issue (1-4). A rapidly expanding research base is demonstrating the breadth and depth of long-term physical and mental health outcomes linked with adverse childhood experiences such as child maltreatment (5-7). From prevention, to early and accurate identification, to medical and mental health management, health care providers play essential roles in addressing and mitigating the potentially significant short- and long-term impact of child maltreatment. So, what are we, as paediatricians in Canada, doing to address this important child health issue? The present editorial discusses some recent developments related to child maltreatment in Canada. MacMillan’s advocacy article (pages 409-410) (8) challenges us to consider where we need to go from here. As recognition of the significance of child maltreatment has grown and the related literature has vastly expanded, a group of medical and mental health providers has developed specific interest and expertise in what has become a defined area of clinical practice. The Canadian Paediatric Society (CPS) Child and Youth Maltreatment Section (93 members in 2013!) and provincial organizations, such as the Association des Médecins en Protection de l’Enfance du Québec, provide established networks for this group to share practices, collaborate on the development of guidelines, and work together on advocacy and policy issues relevant to child maltreatment. In all academic paediatric health centres across Canada, and in many community settings, there are now paediatricians and/or nurse practitioners who have developed specific expertise in the assessment and management of child maltreatment. This cohort of practitioners are available as consultants to support primary care practitioners and others in the recognition and evaluation of child abuse and neglect, have an in-depth understanding of child welfare and legal system response in cases of suspected maltreatment, and recognize the mental health needs of children who have experienced maltreatment. In addition, these consultants provide teaching and training for a variety of learners, and some engage in research. They are frequently called on by the child welfare and legal systems to provide expert medical opinions, which may be used within the court setting. These opinions have important bearing in the lives of children and families because the burden of both under- and overidentification of child maltreatment is significant. It is an exciting and important time to be engaged in child maltreatment clinical practice in Canada! Under way are crucial steps toward the formation of a field of child maltreatment practice,
development of standards of training and certification, publication of consensus Canadian practices and establishment of coordinated multiagency response models. The Royal College of Physicians and Surgeons of Canada has approved Child Maltreatment Pediatrics as an Area of Focused Competence for diploma certification, which will recognize individuals who have established expertise in the field, and foster further development of formal training pathways such as fellowships and continuing education programs. Paediatricians working in Canada who are able to demonstrate (via a portfolio) competencies in the evaluation and management of children and youth with a range of maltreatment presentations, and collaboration with interdisciplinary teams, mental health care providers, and intersecting child welfare and legal systems, will be eligible for certification. Competencies may be achieved through fellowship training or practical experience combined with continuing medical education. It is expected that paediatricians who meet the defined competencies will be able to apply for certification, and fellowship training programs will be able to apply for accreditation as early as summer/fall 2014. It is essential that family physicians continue to participate in the assessment and management of child maltreatment, particularly given the geographical and resource challenges of health care provision across Canada. We are advocating for certification eligibility for family physicians, a route that is not currently available through the Royal College of Physicians and Surgeons of Canada, and we are interested in exploring other means of supporting training and practice for interested family physicans and other primary health care providers. Since 2010, working groups of paediatricians from the CPS Child and Youth Maltreatment Section who provide expert medical opinions in child maltreatment have been meeting annually to develop consensus practices based on the existing medical literature and expert opinion. The first of the ensuing CPS Practice Points, ‘The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective’, is published in the current themed issue of Paediatrics & Child Health (pages 433-437) (9). Stay tuned for upcoming publications regarding burns, fractures and head injuries, anticipated in the coming months. Also expected over the coming year is a renewed national joint statement on traumatic head injury and child maltreatment, as well as an updated edition of the ‘Multidisciplinary Guidelines on the Identification, Investigation and Management of Suspected Abusive Head Trauma’, initially published by the CPS in 2007. Child and Youth Advocacy Centres are established and growing as a model throughout Canada; these centres house the multidisciplinary and multiagency response to suspected child abuse under one roof, and are designed to provide improved coordination and effectiveness of services. Clearly, much work is under way in Canada to improve and support practice in child maltreatment. Although much has been accomplished in the past few years to support clinical practice in child maltreatment, there remains much we can and should do to address this important issue. A coordinated national response to this significant public health issue is surely the next step and is discussed in the accompanying advocacy article (pages 409-410) (8).
Correspondence: Dr Michelle Shouldice, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8. Telephone 416-813-6275, fax 416-813-5846, e-mail [email protected] Accepted for publication August 5, 2013
Paediatr Child Health Vol 18 No 8 October 2013
©2013 Pulsus Group Inc. All rights reserved
407
Editorial
RefeRences
1. Finkelhor D, Turner H, Ormrod R, Hamby SL. Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics 2009;124:1411-23. 2. MacMillan HL, Fleming JE, Trocme N, et al. Prevalence of child physical and sexual abuse in the community: Results from the Ontario Health Supplement. JAMA 1997;278:131-5 3. MacMillan HL, Tanaka M, Duku E, Vaillancourt T, Boyle MH. Child physical and sexual abuse in a community sample of young adults: Results from the Ontario Child Health Study. Child Abuse Negl 2013;37:14-21. 4. Turner HA, Finkelhor D, Hamby SL, Shattuck A. Family structure, victimization, and child mental health in a nationally representative sample. Soc Sci Med 2013;87:39-51. 5. Felitti VJ. Adverse childhood experiences and adult health. Acad Pediatr 2009;9:131-2.
408
6. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci 2006;256:174-86. 7. Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) Study. (Accessed September 18, 2013) 8. MacMillan HL. Protecting children from maltreatment: A Canadian call to action. Paediatr Child Health 2013;18:409-10. 9. Ward MGK, Ornstein A, Niec A, Murray CL; Canadian Paediatric Society, Child and Youth Maltreatment Section. The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective. Paediatr Child Health 2013;18:433-7.
Paediatr Child Health Vol 18 No 8 October 2013
Child maltreatment in Canada, 2013 Michelle Shouldice MD FRCPC Guest Editor
C
hild maltreatment, which encompasses abuse, neglect and exposure to intimate partner violence, is an issue that demands the attention and engagement of all health care providers who encounter children and families. It has been difficult to measure the true impact of this problem. Determination of the numbers of children experiencing maltreatment has been challenging due to underidentification and issues related to definitions. The most accurate understanding, developed from community surveys based on self-report, suggests that maltreatment impacts more children than any other health care issue (1-4). A rapidly expanding research base is demonstrating the breadth and depth of long-term physical and mental health outcomes linked with adverse childhood experiences such as child maltreatment (5-7). From prevention, to early and accurate identification, to medical and mental health management, health care providers play essential roles in addressing and mitigating the potentially significant short- and long-term impact of child maltreatment. So, what are we, as paediatricians in Canada, doing to address this important child health issue? The present editorial discusses some recent developments related to child maltreatment in Canada. MacMillan’s advocacy article (pages 409-410) (8) challenges us to consider where we need to go from here. As recognition of the significance of child maltreatment has grown and the related literature has vastly expanded, a group of medical and mental health providers has developed specific interest and expertise in what has become a defined area of clinical practice. The Canadian Paediatric Society (CPS) Child and Youth Maltreatment Section (93 members in 2013!) and provincial organizations, such as the Association des Médecins en Protection de l’Enfance du Québec, provide established networks for this group to share practices, collaborate on the development of guidelines, and work together on advocacy and policy issues relevant to child maltreatment. In all academic paediatric health centres across Canada, and in many community settings, there are now paediatricians and/or nurse practitioners who have developed specific expertise in the assessment and management of child maltreatment. This cohort of practitioners are available as consultants to support primary care practitioners and others in the recognition and evaluation of child abuse and neglect, have an in-depth understanding of child welfare and legal system response in cases of suspected maltreatment, and recognize the mental health needs of children who have experienced maltreatment. In addition, these consultants provide teaching and training for a variety of learners, and some engage in research. They are frequently called on by the child welfare and legal systems to provide expert medical opinions, which may be used within the court setting. These opinions have important bearing in the lives of children and families because the burden of both under- and overidentification of child maltreatment is significant. It is an exciting and important time to be engaged in child maltreatment clinical practice in Canada! Under way are crucial steps toward the formation of a field of child maltreatment practice,
development of standards of training and certification, publication of consensus Canadian practices and establishment of coordinated multiagency response models. The Royal College of Physicians and Surgeons of Canada has approved Child Maltreatment Pediatrics as an Area of Focused Competence for diploma certification, which will recognize individuals who have established expertise in the field, and foster further development of formal training pathways such as fellowships and continuing education programs. Paediatricians working in Canada who are able to demonstrate (via a portfolio) competencies in the evaluation and management of children and youth with a range of maltreatment presentations, and collaboration with interdisciplinary teams, mental health care providers, and intersecting child welfare and legal systems, will be eligible for certification. Competencies may be achieved through fellowship training or practical experience combined with continuing medical education. It is expected that paediatricians who meet the defined competencies will be able to apply for certification, and fellowship training programs will be able to apply for accreditation as early as summer/fall 2014. It is essential that family physicians continue to participate in the assessment and management of child maltreatment, particularly given the geographical and resource challenges of health care provision across Canada. We are advocating for certification eligibility for family physicians, a route that is not currently available through the Royal College of Physicians and Surgeons of Canada, and we are interested in exploring other means of supporting training and practice for interested family physicans and other primary health care providers. Since 2010, working groups of paediatricians from the CPS Child and Youth Maltreatment Section who provide expert medical opinions in child maltreatment have been meeting annually to develop consensus practices based on the existing medical literature and expert opinion. The first of the ensuing CPS Practice Points, ‘The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective’, is published in the current themed issue of Paediatrics & Child Health (pages 433-437) (9). Stay tuned for upcoming publications regarding burns, fractures and head injuries, anticipated in the coming months. Also expected over the coming year is a renewed national joint statement on traumatic head injury and child maltreatment, as well as an updated edition of the ‘Multidisciplinary Guidelines on the Identification, Investigation and Management of Suspected Abusive Head Trauma’, initially published by the CPS in 2007. Child and Youth Advocacy Centres are established and growing as a model throughout Canada; these centres house the multidisciplinary and multiagency response to suspected child abuse under one roof, and are designed to provide improved coordination and effectiveness of services. Clearly, much work is under way in Canada to improve and support practice in child maltreatment. Although much has been accomplished in the past few years to support clinical practice in child maltreatment, there remains much we can and should do to address this important issue. A coordinated national response to this significant public health issue is surely the next step and is discussed in the accompanying advocacy article (pages 409-410) (8).
Correspondence: Dr Michelle Shouldice, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8. Telephone 416-813-6275, fax 416-813-5846, e-mail [email protected] Accepted for publication August 5, 2013
Paediatr Child Health Vol 18 No 8 October 2013
©2013 Pulsus Group Inc. All rights reserved
407
Editorial
RefeRences
1. Finkelhor D, Turner H, Ormrod R, Hamby SL. Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics 2009;124:1411-23. 2. MacMillan HL, Fleming JE, Trocme N, et al. Prevalence of child physical and sexual abuse in the community: Results from the Ontario Health Supplement. JAMA 1997;278:131-5 3. MacMillan HL, Tanaka M, Duku E, Vaillancourt T, Boyle MH. Child physical and sexual abuse in a community sample of young adults: Results from the Ontario Child Health Study. Child Abuse Negl 2013;37:14-21. 4. Turner HA, Finkelhor D, Hamby SL, Shattuck A. Family structure, victimization, and child mental health in a nationally representative sample. Soc Sci Med 2013;87:39-51. 5. Felitti VJ. Adverse childhood experiences and adult health. Acad Pediatr 2009;9:131-2.
408
6. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci 2006;256:174-86. 7. Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) Study. (Accessed September 18, 2013) 8. MacMillan HL. Protecting children from maltreatment: A Canadian call to action. Paediatr Child Health 2013;18:409-10. 9. Ward MGK, Ornstein A, Niec A, Murray CL; Canadian Paediatric Society, Child and Youth Maltreatment Section. The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective. Paediatr Child Health 2013;18:433-7.
Paediatr Child Health Vol 18 No 8 October 2013
