AdvocAcy
Protecting children from maltreatment: A Canadian call to action Harriet L MacMillan MD MSc FRCPC Guest Editor
I
t is encouraging to witness the progress that has been made in recognizing, detecting and responding to child maltreatment as discussed by the contributors to the current issue of Paediatrics & Child Health. However, there remain significant gaps in our knowledge base regarding ways to prevent its occurrence, and to reduce associated impairment for children and adolescents, and across the lifespan. It is clear that these gaps exist on a global level. Most of the research examining ways of reducing child abuse and neglect has been conducted in high-income countries; we know even less about ways to intervene in low- and middle-income countries (1). But even in Canada, with its emphasis on public health and the social determinants of health, an important question needs to be asked: Why is child maltreatment not identified as one of the leading Canadian child health problems? It is not just about child health, although that should be enough to warrant a national response. There are new reports published weekly with increasing evidence about the link between exposure to one or more types of child abuse and neglect and a broad range of physical, mental, cognitive and social problems that extend into adulthood, including depression, anxiety, substance abuse, antisocial behaviour, risk for subsequent victimization and committing violence in future relationships, among others. To quote the conclusions of a recent systematic review focusing on the long-term health consequences of child abuse and neglect (2): All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. What is happening to make the major public health problem of child maltreatment a priority in Canada? In short – not enough. At the provincial level, the problem of child maltreatment falls between the jurisdiction of health and social services; even among many health care providers working with children, there is the assumption that once child abuse or neglect is identified, it becomes the responsibility of the child protection agency to follow up and provide resources. Within the health care field, some still regard the problem of child maltreatment and other types of family violence as being a ‘social’ rather than a health problem. At the federal level, the report ‘Reaching for the Top: A Report by the Advisor on Healthy Children & Youth’, published by the “authority of the Minister of Health” in 2007, identified development and implementation of a five-year national strategic plan on the topic of injury prevention as one of the key recommendations arising from the report (3). However, the focus of the national injury prevention strategy was on unintentional injury – activities such as supporting helmet use and promoting booster seats, among others. A search for the key words of ‘abuse’, ‘neglect’ and ‘maltreatment’ across the document identified use of the word ‘abuse’ most often in reference to substance
abuse, with little attention devoted to the problem of child maltreatment beyond reference to the Canadian Incidence Study of Reported Child Abuse and Neglect. The report referred to the Public Health Agency of Canada as “performing excellent surveillance and research activity” in the child maltreatment area but, as so aptly stated by Tonmyr and Hovdestad in the current issue of Paediatrics & Child Health, “[c]ollection and analysis of surveillance data are not sufficient” to determine approaches to responding to the problem of child maltreatment (4). The concept of a national injury prevention strategy has much to recommend it, but only if it also includes a major focus on child maltreatment, including the five major types: physical abuse, sexual abuse, neglect, emotional abuse and exposure to intimate partner violence. The concept of safety in injury prevention needs to be considered more broadly than reduction of physical injury; there needs to be a consideration of emotional injury and harm (5,6). Although there have been calls for strategies aimed at specific types of child maltreatment – eg, sexual abuse or abusive head trauma – the evidence indicates that all types of maltreatment are associated with impairment in health outcomes, requiring a level of commitment and investment consistent with a national strategy. The emergence of severe acute respiratory syndrome (SARS) in late 2002, which had resulted in “438 probable and suspect SARS cases in Canada, including 44 deaths” as of August 2003, galvanized creation of the National Advisory Committee on SARS and Public Health, which led to the report ‘Learning from SARS: Renewal of Public Health in Canada’ and a massive overhaul of Canada’s public health system (7). Although there are no accurate data regarding the incidence of deaths resulting from child maltreatment, there were a total of 85,440 substantiated investigations, corresponding to 14.19 investigations per 1000 children in 2008 for one or more types of child maltreatment (8). Furthermore, we know that official substantiated cases of child maltreatment represent the tip of the iceberg. Is it not high time for there to be a national strategy on safeguarding children (9)? We hope that this commentary and special issue serve as a Canadian call to action to develop a national strategy for the prevention of child maltreatment; surely this is a goal that can be shared by the Public Health Agency of Canada and the Canadian Paediatric Society. Acknowledgements: This work was supported by funds from the Canadian Institutes of Health Research Institute of Gender and Health and Institute of Neurosciences, Mental Health and Addictions to the PreVAiL Research Network (a Canadian Institutes of Health Research Centre for Research Development in Gender, Mental Health and Violence across the Lifespan – www.PreVAiLResearch.ca). Harriet L MacMillan holds the Chedoke Health Chair in Child Psychiatry at McMaster University in Hamilton, Ontario.
Correspondence: Dr Harriet L MacMillan, Department of Psychiatry and Behavioural Neurosciences, and Department of Pediatrics, Offord Centre for Child Studies, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1. Telephone 905-521-2100 ext 74287, e-mail [email protected] Accepted for publication August 23, 2013
Paediatr Child Health Vol 18 No 8 October 2013
©2013 Pulsus Group Inc. All rights reserved
409
Advocacy
ReFeRences
1. Mikton C, Butchart A. Child maltreatment prevention: A systematic review of reviews. Bull World Health Organ 2009;87:353-61. 2. Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: A systematic review and metaanalysis. PLoS Med 2012;9:e1001349. 3. Leitch KK. Reaching for the Top: A report by the Advisor on Healthy Children & Youth. Minister of Health. 2007. . (Accessed August 22, 2013) 4. Tonymr L, Hovdestad W. Public health approach to child maltreatment. Paediatr Child Health 2013;18:411-413. 5. MacMillan HL, Wathen CN, Varcoe CM. Intimate partner violence in the family: Considerations for children’s safety. Child Abuse Negl
410
6. 7.
8. 9.
2013 (Epub online ahead of print). Nilsen P, Hudson DS, Kullberg A, Timpka T, Ekman R, Lindqvist K. Making sense of safety. Inj Prev 2004;10:71-3. National Advisory Committee on SARS and Public Health. Learning from SARS: Renewal of public health in Canada: A report of the National Advisory Committee on SARS and Public Health. Ottawa: Health Canada, 2003. Public Health Agency of Canada. Canadian Incidence Study of Reported Child Abuse and Neglect – 2008: Major Findings. Ottawa: Public Health Agency of Canada, 2010. Aynsley-Green A, Hall D. Safeguarding children: A call to action. Lancet 2009;373:280-1.
Paediatr Child Health Vol 18 No 8 October 2013
Protecting children from maltreatment: A Canadian call to action Harriet L MacMillan MD MSc FRCPC Guest Editor
I
t is encouraging to witness the progress that has been made in recognizing, detecting and responding to child maltreatment as discussed by the contributors to the current issue of Paediatrics & Child Health. However, there remain significant gaps in our knowledge base regarding ways to prevent its occurrence, and to reduce associated impairment for children and adolescents, and across the lifespan. It is clear that these gaps exist on a global level. Most of the research examining ways of reducing child abuse and neglect has been conducted in high-income countries; we know even less about ways to intervene in low- and middle-income countries (1). But even in Canada, with its emphasis on public health and the social determinants of health, an important question needs to be asked: Why is child maltreatment not identified as one of the leading Canadian child health problems? It is not just about child health, although that should be enough to warrant a national response. There are new reports published weekly with increasing evidence about the link between exposure to one or more types of child abuse and neglect and a broad range of physical, mental, cognitive and social problems that extend into adulthood, including depression, anxiety, substance abuse, antisocial behaviour, risk for subsequent victimization and committing violence in future relationships, among others. To quote the conclusions of a recent systematic review focusing on the long-term health consequences of child abuse and neglect (2): All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. What is happening to make the major public health problem of child maltreatment a priority in Canada? In short – not enough. At the provincial level, the problem of child maltreatment falls between the jurisdiction of health and social services; even among many health care providers working with children, there is the assumption that once child abuse or neglect is identified, it becomes the responsibility of the child protection agency to follow up and provide resources. Within the health care field, some still regard the problem of child maltreatment and other types of family violence as being a ‘social’ rather than a health problem. At the federal level, the report ‘Reaching for the Top: A Report by the Advisor on Healthy Children & Youth’, published by the “authority of the Minister of Health” in 2007, identified development and implementation of a five-year national strategic plan on the topic of injury prevention as one of the key recommendations arising from the report (3). However, the focus of the national injury prevention strategy was on unintentional injury – activities such as supporting helmet use and promoting booster seats, among others. A search for the key words of ‘abuse’, ‘neglect’ and ‘maltreatment’ across the document identified use of the word ‘abuse’ most often in reference to substance
abuse, with little attention devoted to the problem of child maltreatment beyond reference to the Canadian Incidence Study of Reported Child Abuse and Neglect. The report referred to the Public Health Agency of Canada as “performing excellent surveillance and research activity” in the child maltreatment area but, as so aptly stated by Tonmyr and Hovdestad in the current issue of Paediatrics & Child Health, “[c]ollection and analysis of surveillance data are not sufficient” to determine approaches to responding to the problem of child maltreatment (4). The concept of a national injury prevention strategy has much to recommend it, but only if it also includes a major focus on child maltreatment, including the five major types: physical abuse, sexual abuse, neglect, emotional abuse and exposure to intimate partner violence. The concept of safety in injury prevention needs to be considered more broadly than reduction of physical injury; there needs to be a consideration of emotional injury and harm (5,6). Although there have been calls for strategies aimed at specific types of child maltreatment – eg, sexual abuse or abusive head trauma – the evidence indicates that all types of maltreatment are associated with impairment in health outcomes, requiring a level of commitment and investment consistent with a national strategy. The emergence of severe acute respiratory syndrome (SARS) in late 2002, which had resulted in “438 probable and suspect SARS cases in Canada, including 44 deaths” as of August 2003, galvanized creation of the National Advisory Committee on SARS and Public Health, which led to the report ‘Learning from SARS: Renewal of Public Health in Canada’ and a massive overhaul of Canada’s public health system (7). Although there are no accurate data regarding the incidence of deaths resulting from child maltreatment, there were a total of 85,440 substantiated investigations, corresponding to 14.19 investigations per 1000 children in 2008 for one or more types of child maltreatment (8). Furthermore, we know that official substantiated cases of child maltreatment represent the tip of the iceberg. Is it not high time for there to be a national strategy on safeguarding children (9)? We hope that this commentary and special issue serve as a Canadian call to action to develop a national strategy for the prevention of child maltreatment; surely this is a goal that can be shared by the Public Health Agency of Canada and the Canadian Paediatric Society. Acknowledgements: This work was supported by funds from the Canadian Institutes of Health Research Institute of Gender and Health and Institute of Neurosciences, Mental Health and Addictions to the PreVAiL Research Network (a Canadian Institutes of Health Research Centre for Research Development in Gender, Mental Health and Violence across the Lifespan – www.PreVAiLResearch.ca). Harriet L MacMillan holds the Chedoke Health Chair in Child Psychiatry at McMaster University in Hamilton, Ontario.
Correspondence: Dr Harriet L MacMillan, Department of Psychiatry and Behavioural Neurosciences, and Department of Pediatrics, Offord Centre for Child Studies, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1. Telephone 905-521-2100 ext 74287, e-mail [email protected] Accepted for publication August 23, 2013
Paediatr Child Health Vol 18 No 8 October 2013
©2013 Pulsus Group Inc. All rights reserved
409
Advocacy
ReFeRences
1. Mikton C, Butchart A. Child maltreatment prevention: A systematic review of reviews. Bull World Health Organ 2009;87:353-61. 2. Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: A systematic review and metaanalysis. PLoS Med 2012;9:e1001349. 3. Leitch KK. Reaching for the Top: A report by the Advisor on Healthy Children & Youth. Minister of Health. 2007. . (Accessed August 22, 2013) 4. Tonymr L, Hovdestad W. Public health approach to child maltreatment. Paediatr Child Health 2013;18:411-413. 5. MacMillan HL, Wathen CN, Varcoe CM. Intimate partner violence in the family: Considerations for children’s safety. Child Abuse Negl
410
6. 7.
8. 9.
2013 (Epub online ahead of print). Nilsen P, Hudson DS, Kullberg A, Timpka T, Ekman R, Lindqvist K. Making sense of safety. Inj Prev 2004;10:71-3. National Advisory Committee on SARS and Public Health. Learning from SARS: Renewal of public health in Canada: A report of the National Advisory Committee on SARS and Public Health. Ottawa: Health Canada, 2003. Public Health Agency of Canada. Canadian Incidence Study of Reported Child Abuse and Neglect – 2008: Major Findings. Ottawa: Public Health Agency of Canada, 2010. Aynsley-Green A, Hall D. Safeguarding children: A call to action. Lancet 2009;373:280-1.
Paediatr Child Health Vol 18 No 8 October 2013
