Commentary
Public health approach to child maltreatment Lil Tonmyr MSW PhD, Wendy E Hovdestad PhD
C
hild maltreatment (neglect, exposure to intimate partner violence, emotional, physical and sexual abuse) is an important Canadian and global health challenge. The Public Health Agency of Canada (PHAC) recognizes the need to use the best evidence to inform policy and practice to remediate short- and long-term negative health outcomes associated with child maltreatment (1). Work within PHAC pertinent to child maltreatment depends on collaboration with provinces, territories, other federal departments, academia and civic communities. The work described in the present commentary spans four areas pertaining to child maltreatment: national surveillance; exploration of associations with negative health outcomes; prevention efforts; and delineation of best practice implications for family physicians, paediatricians and other health professionals. We hope the present commentary will encourage further cross-sectoral partnerships.
NatioNal child maltreatmeNt surveillaNce
Surveillance includes acquiring, analyzing and interpreting data and information from multiple sources across different systems (2). The PHAC’s child maltreatment surveillance group is involved with data collection from multiple sources including information from child protection agencies and the general population. The Canadian Incidence Study of Reported Child Abuse and Neglect (CIS) is the most comprehensive and oldest of the PHAC’s child maltreatment surveillance sources. Every five years, starting in 1998, the CIS has collected data on a sample of maltreatment investigations conducted by child protection workers across Canada. Figure 1 shows primary types of substantiated maltreatment as reported in the CIS. The CIS also provides information on family circumstances, child health and behaviour issues, and responsive actions taken (3). As with all surveillance mechanisms, there is room for improvement and, thus, ways to enhance data collection procedures are actively being explored. The CIS is well used in developing child maltreatment policy, programs and practice; however, stakeholders would like more frequent data collection to enable more timely evaluation of these innovations (4). Also, there are concerns about the representativeness of the three-month period of the CIS data collection. In response to partners’ feedback, PHAC initiated discussions with provincial and territorial authorities to investigate whether their administrative data systems could be pooled to provide timely incidence data. Also, an administrative data system could follow cases over time, link to other data and provide up-to-date information, but would not meet all surveillance needs. There are some concerns with regard to variations in case definitions across the country and representativeness of reported maltreatment.
Data reported to child protection agencies in the CIS and in a potential future national administrative data system cannot reflect unreported maltreatment. While surveys directed at children would be the ideal way to collect data, ethical and methodological challenges exist (5). Some of these challenges relate to the accuracy of parental and young children’s reports and professionals’ duty to report to child protection agencies any suspicion of child maltreatment. Ways to include maltreatment questions on surveys of Canadian children are being actively explored. To complement available data regarding children involved with child protection, PHAC has supported the collection of retrospective data about Canadians’ childhood maltreatment. In the 2012 Canadian Community Health Survey – Mental Health, respondents older than 17 years of age answered questions regarding their childhood exposure to physical and sexual abuse, intimate partner violence and childhood involvement with child protection services. The data will be available in the fall of 2013 (6) (www23.statcan.gc.ca/imdb-bmdi/pub/indexC-eng.htm). In addition, the General Social Survey of Canadians 15 years of age and older will pilot child maltreatment questions in 2013, with a planned field date of 2014. Although retrospective reports cannot tell us what Canadian children are experiencing today, recent research adds to a body of evidence in support of the validity and utility of retrospective child maltreatment data (7).
child maltreatmeNt aNd Negative health outcomes
In addition to data collection, PHAC conducts analyses to explore the relationship between child maltreatment and immediate and long-term negative health consequences. For instance, PHAC analyzed CIS data to explore maltreatment-related and other risk factors for psychological distress in adolescents investigated by child protection following an allegation of maltreatment (8). Three types of maltreatment (substantiated emotional abuse, sexual abuse and neglect) were related to adolescent psychological distress, after statistically controlling for adolescent age and parental mental health problems. Exposure to domestic violence and physical abuse did not show a statistically significant association in the analysis. In another project, PHAC has been involved with retrospective cohort research to determine predictors of first and repeat presentations to emergency departments (ED) for suiciderelated behaviours (SRB) in children and adolescents permanently removed from their parental home due to child maltreatment (Crown wards). In the first study (9), we found that compared with their peers, Crown wards were five times more likely to have a first presentation to the ED for SRB. In the second study (10), the subset of the larger cohort with a first presentation to the ED for SRB was studied. In this subset, the risk of repetition was two
Injury and Child Maltreatment Section, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario Correspondence: Lil Tonmyr, Injury and Child Maltreatment Section, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada. 785 Carling Avenue, AL 6807B, Ottawa, Ontario K1A 0K9. Telephone 613-954-8670, e-mail [email protected] Accepted for publication May 26, 2013
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Commentary
imPlicatioNs for health ProfessioNals
figure 1) Primary types of substantiated child maltreatment in Canada
in 2008 (n=6163) times more likely in Crown wards than in their peers. These studies imply that while the overall risk of an ED SRB presentation is higher in Crown wards than peers (likely due to their exposure to maltreatment), the difference is strongest at the first such presentation. Further study is needed to better understand this pattern, but some possibilities are that Crown wards may benefit from added supports/services arranged for them, in contrast to their peers (9). Child maltreatment data may be collected from both adult and child participants in a Canada-wide physical measures health study in 2016–2019. For a discussion of the burgeoning knowledge regarding child maltreatment and biomarkers, see Gonzalez (11).
PreveNtioN
Collection and analysis of surveillance data are not sufficient to determine how public money should best be spent to remediate the problem of child maltreatment. High-quality intervention research is needed, ideally using randomized controlled trials (RCTs). The Nurse-Family Partnership (NFP) is a home visitation program that has demonstrated (in three American RCTs) longlasting health benefits for both children and their mothers including prevention of child maltreatment (12). Benefits have been noted both in terms of health indicators (eg, fewer child ED presentations) and determinants of health (eg, maternal employment). With provincial funding, an RCT investigating the effects of the NFP in Canada, known as the British Columbia Healthy Connections Project, is now under way (13) with some adjustments to accommodate the Canadian context (14). Simultaneously, PHAC plans to commission a process evaluation to understand the implementation of the British Columbia Healthy Connections Project. The expected results are a detailed understanding of how the program could best be implemented and evaluated in other Canadian sites and internationally. The project will enhance understanding of issues around delivery of NFP to families in rural and remote locations and the adaption of the NFP to meet the needs of special populations (eg, mothers who are very young, homeless or living with learning disabilities). The impact of the NFP program on professional nurses’ practice will also be addressed. Process evaluation findings will be shared through newsletters, peer-reviewed publications and a regularly updated website (http://nfp.mcmaster.ca/).
412
Health professionals, including paediatricians and family physicians, have an essential role to play in identifying child maltreatment, and recognizing and treating related symptoms. For instance, further work that built on the aforementioned studies regarding SRB pointed to the importance of making victimization-sensitive mental health resources available in EDs (15). Other PHACsupported studies on child maltreatment and the role of health professionals include work on exposure to intimate partner violence (16), work on emotional abuse and neglect (17), and the development of guidelines regarding abusive head trauma (18). Analyses of reporting sources from the CIS (1998 and 2003) showed that health care professionals’ referrals to child protection have increased more than other professional groups (eg, teachers, police and social workers). Compared with other professional groups, health care professionals more frequently reported younger children, children exposed to neglect and emotional maltreatment, and those with noticeable harm and child functioning issues (19). However under-reporting may still be an issue (19), perhaps due, in part, to lack of training of health professionals. In programs such as the NFP, health care professionals have an important role. Physicians contribute in three ways: identifying and referring young, first-time mothers early in pregnancy (before 27 weeks’ gestation) to the NFP program as an augmentation to the prenatal care they would receive in the primary care system; collaborating with public health nurses to provide primary health care services and preventive health care services for both the mother enrolled in the NFP program and her infant; and participating in case/service coordination meetings as required with other health care professionals and families to develop a plan of care for the infant (Dr Susan Jack [McMaster University, Hamilton, Ontario], personal communication). More recently, the American Academy of Pediatrics challenged health professionals to integrate science-based child maltreatment prevention into their ongoing medical care to improve health across the lifespan (20). Maximizing the health of children requires investment in areas that may appear to fall outside the core health care domain.
coNclusioN
In addition to the work described in the present commentary, other efforts related to child maltreatment are ongoing within the PHAC. For instance, some of the work that the PHAC is undertaking includes health surveillance of youth living on the street and their experiences of child maltreatment, participation in research networks (such as Preventing Violence Across the Lifespan (PreVAiL) research network and the Violence Prevention Alliance of the World Health Organization) and the coordination of the Government of Canada’s Family Violence Initiative. Child maltreatment is a complex public health issue best addressed through many organizations’ collective efforts. Paediatricians, family physicians and other members of the Canadian Paediatric Society are important partners in the prevention of maltreatment and its recurrence. refereNces
1. Public Health Agency of Canada (PHAC). The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2009: Growing Up Well – Priorities for a Healthy Future. Ottawa: Public Health Agency of Canada, 2009. 2. Rolka H, Walker DW, English R, Katzoff MJ, Neuhuas E. Analytical challenges for public health surveillance. MMWR 2012;61:35-9. 3. Public Health Agency of Canada. Canadian Incidence Study of Reported Child Abuse and Neglect – 2008: Major findings. Ottawa: Public Health Agency of Canada, 2010. 4. Tonmyr L, Jack, SM, Brooks S, Williams G, Campeau A, Dudding P. Utilization of the Canadian Incidence Study of
Paediatr Child Health Vol 18 No 8 October 2013
Commentary
5. 6. 7. 8. 9. 10. 11. 12. 13.
Reported Child Abuse and Neglect by child welfare agencies in Ontario. Chronic Dis Inj Can 2012;33:29-37. Tonmyr L, Hovdestad W, Draca J. Commentary on Canadian child maltreatment data. J Interpers Violence 2014 (In press). Hovdestad W, Tonmyr L. Child maltreatment data in Canada. Can J Public Health 2012;103:160. Scott KM, Smith DR, Ellis PM. Prospectively ascertained child maltreatment and its association with DSM-IV mental disorders in young adults. Arch Gen Psychiatry 2010;67:712-9. Tonmyr L, Williams G, Hovdestad W, Draca J. Anxiety and/or depression in 10-15 year olds investigated by child welfare in Canada. J Adolesc Health 2011;48:493-8. Rhodes AE, Boyle MH, Bethell J, et al. Child maltreatment and onset of emergency department presentations for suicide-related behaviors. Child Abuse Negl 2012;36:542-51. Rhodes AE, Boyle MH, Bethell JM, et al. Child maltreatment and repeat presentations to the emergency department for suiciderelated behaviors. Child Abuse Negl 2013;37:139-49. Gonzalez A. The impact of childhood maltreatment on biological systems. Paediatr Child Health 2013;18:415-8. Olds DL, Eckenrode J, Henderson CR, et al. Nurse home visits reduced child abuse and neglect over a 15 year period. JAMA 1997;278:637-43. MacMillan HL, Waddell C. Home visitation in the prevention of child maltreatment: An evidence-based overview. In: Dubowitz H, ed. World Perspectives on Child Abuse, 10th edn.
Paediatr Child Health Vol 18 No 8 October 2013
14. 15.
16. 17. 18. 19.
20.
Turkey: International Society for Prevention of Child Abuse and Neglect (ISPCAN); 2012:103-6. Jack SM, Busser D, Sheehan D, Gonzales A, Zwygers EJ, MacMillan HL. Adaption and implementation of the Nurse-Family Partnership in Canada. Can J Public Health 2012;103:542-8. Rhodes AE, Bethell J, Newton AS, et al. Indicators for the management of pediatric suicide-related behaviors: Results from a survey of emergency department clinicians. Pediatr Emerg Care 2012;28:1124-8. Wathen N, MacMillan HL. Child and youth exposure to intimate partner violence: Impacts and interventions. Paediatr Child Health 2013;18:419-22. Hibbard R, Barlow J, MacMillan H; the Committee on Child Abuse and Neglect, American Academy of Child and Adolescent Psychiatry. Psychological maltreatment. Pediatrics 2012;130:372-8. Canadian Paediatric Society. Multidisciplinary Guidelines on the Identification, Investigation and Management of Suspected Abusive Head Trauma. Ottawa: Canadian Paediatric Society, 2007. Tonmyr L, Li A, Williams G, Scott D, Jack S. Patterns of reporting to child protection services in Canada by health care and non-health care professionals. Paediatr Child Health 2010;15:e25-e32. Shonkoff JP, Garner AS, et al; American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012;129:e232-e246.
413
Public health approach to child maltreatment Lil Tonmyr MSW PhD, Wendy E Hovdestad PhD
C
hild maltreatment (neglect, exposure to intimate partner violence, emotional, physical and sexual abuse) is an important Canadian and global health challenge. The Public Health Agency of Canada (PHAC) recognizes the need to use the best evidence to inform policy and practice to remediate short- and long-term negative health outcomes associated with child maltreatment (1). Work within PHAC pertinent to child maltreatment depends on collaboration with provinces, territories, other federal departments, academia and civic communities. The work described in the present commentary spans four areas pertaining to child maltreatment: national surveillance; exploration of associations with negative health outcomes; prevention efforts; and delineation of best practice implications for family physicians, paediatricians and other health professionals. We hope the present commentary will encourage further cross-sectoral partnerships.
NatioNal child maltreatmeNt surveillaNce
Surveillance includes acquiring, analyzing and interpreting data and information from multiple sources across different systems (2). The PHAC’s child maltreatment surveillance group is involved with data collection from multiple sources including information from child protection agencies and the general population. The Canadian Incidence Study of Reported Child Abuse and Neglect (CIS) is the most comprehensive and oldest of the PHAC’s child maltreatment surveillance sources. Every five years, starting in 1998, the CIS has collected data on a sample of maltreatment investigations conducted by child protection workers across Canada. Figure 1 shows primary types of substantiated maltreatment as reported in the CIS. The CIS also provides information on family circumstances, child health and behaviour issues, and responsive actions taken (3). As with all surveillance mechanisms, there is room for improvement and, thus, ways to enhance data collection procedures are actively being explored. The CIS is well used in developing child maltreatment policy, programs and practice; however, stakeholders would like more frequent data collection to enable more timely evaluation of these innovations (4). Also, there are concerns about the representativeness of the three-month period of the CIS data collection. In response to partners’ feedback, PHAC initiated discussions with provincial and territorial authorities to investigate whether their administrative data systems could be pooled to provide timely incidence data. Also, an administrative data system could follow cases over time, link to other data and provide up-to-date information, but would not meet all surveillance needs. There are some concerns with regard to variations in case definitions across the country and representativeness of reported maltreatment.
Data reported to child protection agencies in the CIS and in a potential future national administrative data system cannot reflect unreported maltreatment. While surveys directed at children would be the ideal way to collect data, ethical and methodological challenges exist (5). Some of these challenges relate to the accuracy of parental and young children’s reports and professionals’ duty to report to child protection agencies any suspicion of child maltreatment. Ways to include maltreatment questions on surveys of Canadian children are being actively explored. To complement available data regarding children involved with child protection, PHAC has supported the collection of retrospective data about Canadians’ childhood maltreatment. In the 2012 Canadian Community Health Survey – Mental Health, respondents older than 17 years of age answered questions regarding their childhood exposure to physical and sexual abuse, intimate partner violence and childhood involvement with child protection services. The data will be available in the fall of 2013 (6) (www23.statcan.gc.ca/imdb-bmdi/pub/indexC-eng.htm). In addition, the General Social Survey of Canadians 15 years of age and older will pilot child maltreatment questions in 2013, with a planned field date of 2014. Although retrospective reports cannot tell us what Canadian children are experiencing today, recent research adds to a body of evidence in support of the validity and utility of retrospective child maltreatment data (7).
child maltreatmeNt aNd Negative health outcomes
In addition to data collection, PHAC conducts analyses to explore the relationship between child maltreatment and immediate and long-term negative health consequences. For instance, PHAC analyzed CIS data to explore maltreatment-related and other risk factors for psychological distress in adolescents investigated by child protection following an allegation of maltreatment (8). Three types of maltreatment (substantiated emotional abuse, sexual abuse and neglect) were related to adolescent psychological distress, after statistically controlling for adolescent age and parental mental health problems. Exposure to domestic violence and physical abuse did not show a statistically significant association in the analysis. In another project, PHAC has been involved with retrospective cohort research to determine predictors of first and repeat presentations to emergency departments (ED) for suiciderelated behaviours (SRB) in children and adolescents permanently removed from their parental home due to child maltreatment (Crown wards). In the first study (9), we found that compared with their peers, Crown wards were five times more likely to have a first presentation to the ED for SRB. In the second study (10), the subset of the larger cohort with a first presentation to the ED for SRB was studied. In this subset, the risk of repetition was two
Injury and Child Maltreatment Section, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario Correspondence: Lil Tonmyr, Injury and Child Maltreatment Section, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada. 785 Carling Avenue, AL 6807B, Ottawa, Ontario K1A 0K9. Telephone 613-954-8670, e-mail [email protected] Accepted for publication May 26, 2013
Paediatr Child Health Vol 18 No 8 October 2013
411
Commentary
imPlicatioNs for health ProfessioNals
figure 1) Primary types of substantiated child maltreatment in Canada
in 2008 (n=6163) times more likely in Crown wards than in their peers. These studies imply that while the overall risk of an ED SRB presentation is higher in Crown wards than peers (likely due to their exposure to maltreatment), the difference is strongest at the first such presentation. Further study is needed to better understand this pattern, but some possibilities are that Crown wards may benefit from added supports/services arranged for them, in contrast to their peers (9). Child maltreatment data may be collected from both adult and child participants in a Canada-wide physical measures health study in 2016–2019. For a discussion of the burgeoning knowledge regarding child maltreatment and biomarkers, see Gonzalez (11).
PreveNtioN
Collection and analysis of surveillance data are not sufficient to determine how public money should best be spent to remediate the problem of child maltreatment. High-quality intervention research is needed, ideally using randomized controlled trials (RCTs). The Nurse-Family Partnership (NFP) is a home visitation program that has demonstrated (in three American RCTs) longlasting health benefits for both children and their mothers including prevention of child maltreatment (12). Benefits have been noted both in terms of health indicators (eg, fewer child ED presentations) and determinants of health (eg, maternal employment). With provincial funding, an RCT investigating the effects of the NFP in Canada, known as the British Columbia Healthy Connections Project, is now under way (13) with some adjustments to accommodate the Canadian context (14). Simultaneously, PHAC plans to commission a process evaluation to understand the implementation of the British Columbia Healthy Connections Project. The expected results are a detailed understanding of how the program could best be implemented and evaluated in other Canadian sites and internationally. The project will enhance understanding of issues around delivery of NFP to families in rural and remote locations and the adaption of the NFP to meet the needs of special populations (eg, mothers who are very young, homeless or living with learning disabilities). The impact of the NFP program on professional nurses’ practice will also be addressed. Process evaluation findings will be shared through newsletters, peer-reviewed publications and a regularly updated website (http://nfp.mcmaster.ca/).
412
Health professionals, including paediatricians and family physicians, have an essential role to play in identifying child maltreatment, and recognizing and treating related symptoms. For instance, further work that built on the aforementioned studies regarding SRB pointed to the importance of making victimization-sensitive mental health resources available in EDs (15). Other PHACsupported studies on child maltreatment and the role of health professionals include work on exposure to intimate partner violence (16), work on emotional abuse and neglect (17), and the development of guidelines regarding abusive head trauma (18). Analyses of reporting sources from the CIS (1998 and 2003) showed that health care professionals’ referrals to child protection have increased more than other professional groups (eg, teachers, police and social workers). Compared with other professional groups, health care professionals more frequently reported younger children, children exposed to neglect and emotional maltreatment, and those with noticeable harm and child functioning issues (19). However under-reporting may still be an issue (19), perhaps due, in part, to lack of training of health professionals. In programs such as the NFP, health care professionals have an important role. Physicians contribute in three ways: identifying and referring young, first-time mothers early in pregnancy (before 27 weeks’ gestation) to the NFP program as an augmentation to the prenatal care they would receive in the primary care system; collaborating with public health nurses to provide primary health care services and preventive health care services for both the mother enrolled in the NFP program and her infant; and participating in case/service coordination meetings as required with other health care professionals and families to develop a plan of care for the infant (Dr Susan Jack [McMaster University, Hamilton, Ontario], personal communication). More recently, the American Academy of Pediatrics challenged health professionals to integrate science-based child maltreatment prevention into their ongoing medical care to improve health across the lifespan (20). Maximizing the health of children requires investment in areas that may appear to fall outside the core health care domain.
coNclusioN
In addition to the work described in the present commentary, other efforts related to child maltreatment are ongoing within the PHAC. For instance, some of the work that the PHAC is undertaking includes health surveillance of youth living on the street and their experiences of child maltreatment, participation in research networks (such as Preventing Violence Across the Lifespan (PreVAiL) research network and the Violence Prevention Alliance of the World Health Organization) and the coordination of the Government of Canada’s Family Violence Initiative. Child maltreatment is a complex public health issue best addressed through many organizations’ collective efforts. Paediatricians, family physicians and other members of the Canadian Paediatric Society are important partners in the prevention of maltreatment and its recurrence. refereNces
1. Public Health Agency of Canada (PHAC). The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2009: Growing Up Well – Priorities for a Healthy Future. Ottawa: Public Health Agency of Canada, 2009. 2. Rolka H, Walker DW, English R, Katzoff MJ, Neuhuas E. Analytical challenges for public health surveillance. MMWR 2012;61:35-9. 3. Public Health Agency of Canada. Canadian Incidence Study of Reported Child Abuse and Neglect – 2008: Major findings. Ottawa: Public Health Agency of Canada, 2010. 4. Tonmyr L, Jack, SM, Brooks S, Williams G, Campeau A, Dudding P. Utilization of the Canadian Incidence Study of
Paediatr Child Health Vol 18 No 8 October 2013
Commentary
5. 6. 7. 8. 9. 10. 11. 12. 13.
Reported Child Abuse and Neglect by child welfare agencies in Ontario. Chronic Dis Inj Can 2012;33:29-37. Tonmyr L, Hovdestad W, Draca J. Commentary on Canadian child maltreatment data. J Interpers Violence 2014 (In press). Hovdestad W, Tonmyr L. Child maltreatment data in Canada. Can J Public Health 2012;103:160. Scott KM, Smith DR, Ellis PM. Prospectively ascertained child maltreatment and its association with DSM-IV mental disorders in young adults. Arch Gen Psychiatry 2010;67:712-9. Tonmyr L, Williams G, Hovdestad W, Draca J. Anxiety and/or depression in 10-15 year olds investigated by child welfare in Canada. J Adolesc Health 2011;48:493-8. Rhodes AE, Boyle MH, Bethell J, et al. Child maltreatment and onset of emergency department presentations for suicide-related behaviors. Child Abuse Negl 2012;36:542-51. Rhodes AE, Boyle MH, Bethell JM, et al. Child maltreatment and repeat presentations to the emergency department for suiciderelated behaviors. Child Abuse Negl 2013;37:139-49. Gonzalez A. The impact of childhood maltreatment on biological systems. Paediatr Child Health 2013;18:415-8. Olds DL, Eckenrode J, Henderson CR, et al. Nurse home visits reduced child abuse and neglect over a 15 year period. JAMA 1997;278:637-43. MacMillan HL, Waddell C. Home visitation in the prevention of child maltreatment: An evidence-based overview. In: Dubowitz H, ed. World Perspectives on Child Abuse, 10th edn.
Paediatr Child Health Vol 18 No 8 October 2013
14. 15.
16. 17. 18. 19.
20.
Turkey: International Society for Prevention of Child Abuse and Neglect (ISPCAN); 2012:103-6. Jack SM, Busser D, Sheehan D, Gonzales A, Zwygers EJ, MacMillan HL. Adaption and implementation of the Nurse-Family Partnership in Canada. Can J Public Health 2012;103:542-8. Rhodes AE, Bethell J, Newton AS, et al. Indicators for the management of pediatric suicide-related behaviors: Results from a survey of emergency department clinicians. Pediatr Emerg Care 2012;28:1124-8. Wathen N, MacMillan HL. Child and youth exposure to intimate partner violence: Impacts and interventions. Paediatr Child Health 2013;18:419-22. Hibbard R, Barlow J, MacMillan H; the Committee on Child Abuse and Neglect, American Academy of Child and Adolescent Psychiatry. Psychological maltreatment. Pediatrics 2012;130:372-8. Canadian Paediatric Society. Multidisciplinary Guidelines on the Identification, Investigation and Management of Suspected Abusive Head Trauma. Ottawa: Canadian Paediatric Society, 2007. Tonmyr L, Li A, Williams G, Scott D, Jack S. Patterns of reporting to child protection services in Canada by health care and non-health care professionals. Paediatr Child Health 2010;15:e25-e32. Shonkoff JP, Garner AS, et al; American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012;129:e232-e246.
413
