APRIL • 2019
Special Feature: Child Abuse Prevention Month
Aparna Kota, MD, MPH
Board Member, Safe & Sound
Chair, Kaiser Permanente San Francisco Child Abuse Services and Prevention Team
Dear Pediatricians,

Thank you for the extra moments you spend with families who have experienced trauma and adversity. By listening a little longer, reporting a suspicion of abuse and offering resources, you are changing the course of a child’s life.  

As pediatricians, we are preventing abuse every day when we educate, empower and strengthen families. April is Child Abuse Prevention Month, so this special issue highlights the resilience approach to abuse prevention: building relationships, identifying protective factors and linking with community partners.
KEY FINDINGS from The Economics of Child Abuse: A Study of California , a collaboration between Safe & Sound and Haas School of Business Social Sectors Solution program:
  • There are nearly 500,000 reports of child abuse in California each year — that’s about one report every minute.
  • The economic cost to California for the 71,289 verified victims in 2017 is $19.31 billion — that same amount could send more than 2 million children to preschool.
  • Given significant underreporting, the estimated cost incurred because of one year of abuse could be as high as $284.4 billion.
  • Community risk factors that make California children and families more vulnerable to abuse include socioeconomic inequality and poverty, lack of adequate and affordable housing, high unemployment rates, homelessness, community violence, substance abuse, social isolation and marginalization, and wildfires and natural disasters.

We see children whose health is compromised every day by social determinants, community risk factors, adversity and trauma. As we become more aware of the impact of adverse childhood events and the trajectory to chronic illness, it can feel overwhelming. How can we as pediatricians interrupt the cycle of abuse and adversity and change the trajectory? Research has shown that there are defined protective factors that strengthen families and reduce abuse. 
Strengthening Families was developed by the Center for the Study of Social Policy to help those who work with young children and their families take action to support families and reduce child abuse and neglect. The approach focuses on five protective factors associated in research literature with lower rates of child abuse and neglect (Taken directly from Center for the Study of Social Policy’s Strengthening ):

1. Parental Resilience (A parent’s ability to manage stress):
(a) Checking in on parents’ mental health – including post-partum depression
(b) Encouraging the use of positive coping strategies that can help to ease stress and, in extreme cases, prevent child abuse and neglect
2. Knowledge of Parenting and Child Development (Understanding the stages of child development and parenting strategies):
(a) Parents who understand child development have more realistic expectations of their children based on their developmental stage.
(b) The pediatrician plays an important role in sharing this knowledge with parents, empowering them to do a better job meeting their children’s physical and developmental needs.
(c) This also enables parents to more quickly identify when their children’s development is off track and seek support.
3. Social Connections (Positive relationships that provide a family emotional, informational and spiritual support):
(a) Parents who are engaged in positive social relationships receive emotional and operational supports that can help them deal with the daily stresses of parenting, as well as health crises and responding to their child’s health needs.
(b) At a minimum, physicians can encourage parents to develop and nurture positive social connections.
(c) More proactively, pediatricians, clinics and health systems can provide parenting groups and other opportunities for parents to form connections with others raising children of the same age.
4. Concrete supports in times of need (Access to concrete support and services that address a family’s needs such as food, healthcare and housing):
(a) Parents often need help accessing the resources they need to build a healthy environment for their kids. 
(b) Many programs are available to help parents deal with issues from lead abatement, to healthy and nutritious food, to developmental services to support a child with delays.
(c) Helping build parents’ awareness of the available resources and providing support as they navigate the service sector can keep families strong.
5. Children’s social and emotional competence (Family interactions that help a child develop the ability to communicate early, recognize and regulate their emotions and establish and maintain relationships):
(a) Social-emotional competence is critical to a child’s overall development.
(b) The pediatrician’s role can be to help parents understand the importance of attachment and social-emotional development, provide resources to help parents nurture that development and raise a red flag when there are concerns about a child’s development of these foundational skills.

To bolster these protective factors for every family and provide each child with a safety net requires collective community efforts.

At the end of January 2019, The Prevention Cabinet of the County Welfare Directors Association of California, the California Office of Child Abuse Prevention (OCAP), and Strategies 2.0 co-hosted the first Child Abuse Prevention Summit. Twenty-two counties were accepted to attend with their community based teams. I had the privilege of participating in the SF Team lead by Jenny Pearlman, Associate Director Strategic Partnerships & Policy and Katie Albright, Chief Executive Officer of Safe & Sound. 
Some of San Francisco’s community partners responded with these tips when asked the following questions. We hope these tips will help you as you reach out to community partners in your county.
"What recommendations do you have for pediatricians who are working with patients possibly experiencing abuse? Do you have suggestions for how pediatricians can better partner with your organization or organizations like yours?"
Call in a report to the CPS hotline ASAP and consult with medical and other child abuse experts with any questions as soon as possible.

- From: Julie Lenhardt, MSSW, Program Director, Early Intervention Program; San Francisco City and County - Human Service Agency; Family and Children's Services
Anything pediatricians can do to help assess for presence of Protective Factors. The Strengthening Families Protective Factors framework gives a fantastic foundation. Pediatricians can also be trained in trauma informed interviewing to have tools for how to engage families who might be experiencing abuse.  

- From: Lilli Milton, Director of Programs, Homeless Prenatal Program
Remember that a child's somatic complaint could be symptomatic of something else. Expanding the conversation with the child to how the child is doing in other areas of their life will allow a deeper understanding if there might be areas of concern including abuse. In other words ask -- and ask open ended questions to lead to greater understanding. Know the law and know the signs: victims of child sexual trafficking may manifest behaviors that are not typically thought of as "abuse." Further, remember that we do not criminalize children who are sexually exploited.  Getting releases so we can provide services at school to students is always helpful. We have had relationships with pediatricians that have helped us be clear on how to increase the student's sense of safety, enabling the student to be ready to learn.

- From: Kevin R. Gogin, MFT (& HIS TEAM), Director of Safety and Wellness; School Health Programs; Student, Family, and Community Support Department; San Francisco Unified School District
Really, the best response to child abuse is to prevent it in the first place. Asking parents about their experience parenting from Day 1 and making early referrals to family support organizations when families initially report stress, or lack of information about child rearing skills, social/family/community support, or concrete needs can result in less child abuse concerns. Pediatricians can be trained in the 5 Protective Factors as well as ACES and provide psycho-educational materials to parents about these. Family Resource Centers are happy to partner with Pediatricians. Pediatricians may connect with FRCs directly to begin such relationships or they can call First 5, and we can help make introductions based on the needs the pediatrician is seeing.

- From: Shelli Rawlings-Fein, Family Support Program Officer, First 5 San Francisco
Have on-going dialogue with law enforcement and pay attention to the following when making a report: What has happened? Is there imminent danger? Who is the point person? Where to meet the pediatrician? Where the situation occurred? When the situation occurred? If there is a weapon?

- From: Police Chief Scott and Lt Yamaguchi
If there is something that makes you concerned about abuse, don't be afraid to ask more questions, or to talk with other people who are involved in the child's life (other family members, teachers, child care workers etc.) Having more information is generally always helpful. Talk with your colleagues as well. Cases potentially involving abuse understandably bring up a lot of strong feelings from us as clinicians, and this can make it more important to seek assistance and work with others on these cases. Also, don't be afraid to call CPS (415-558-2650) and ask their advice about how to proceed with the case.

- From: Saba Shahid, PsyD (And Team), Program Director & Licensed Psychologist (PSY 29683); Foster Care Mental Health (FCMH); Children, Youth & Families System of Care (CYF SOC); San Francisco Department of Public Health
The adorable, smiling 4-month-old baby boy was referred to the Emergency Department for further evaluation of a single, unexplained bruise. The head CT was normal; however, the skeletal survey showed numerous healing fractures. I called the referring pediatrician to thank her for saving this baby’s life. There was a long pause on the phone and then a quiet, choked voice saying, “I missed one once, and I will never do that again.”

As medical providers, child abuse is one of the most emotional and difficult diagnoses we face. So thank you for all of the work you do to help support and protect children impacted by adversity and trauma. 

For Child Abuse Prevention Month, I thought I’d share something simple we could all do to prevent and heal child abuse and neglect together: ENSURING FAMILIES HAVE ACCESS TO RELATIONSHIPS. At the core of child abuse and neglect is a rupture of social bonds. Thus, the path to prevention and healing must involve fostering healthy relationships for both caregivers and children. 

Geereart and colleagues found that social or proximal factors , including poor social support , lack of sensitivity regarding the child, and negative perception of parenthood are more predictive of risk for physical abuse and neglect than distal factors such as demographics, financial situations and accommodations ( Geereart, 2004 ). Not surprisingly, lack of social integration and/or social support has also been found in a meta-analysis of adults to be a larger risk factor for mortality than smoking, alcohol consumption and physical activity ( Holt-Lunstad, 2010 ). Simply put, connection makes and keeps humans healthy. 

What if we could prevent child abuse simply by asking every family about positive, healthy relationships in their life? If this sounds too good to be true, the above studies suggest it’s not. Screening patients and caregivers for needed social connections and referring like we do for other risks to health is an easy and smart thing to do. We are taught to ask how much our patients smoke, drink and exercise, but how often do we ask our families who will bring them chicken soup when they are sick? Are the parents and the children part of a community group or faith-based organization where they feel involved and supported? Do they have friends? Who can help them get to their doctor appointments if their car breaks down or they don’t have money for the bus? Who do they talk to when they feel sad, angry or scared?

Interventions that foster safe, stable and nurturing relationships have been shown to prevent child abuse, and parenting programs such as Triple P and Nurse Family Partnership have been found to both reduce child maltreatment and decrease aggressive behaviors in the child ( Jaffe, 2013 ; World Health Organization, 2009 ). Just as adverse childhood experiences have been found to have a dose-dependent, negative impact on health, support and social integration have been found to have a dose-dependent, protective effect on health and well-being ( Felitti, 1998 ; Yang, 2016 ).

There’s clearly a lot we can already do in primary care to prevent child abuse. From simply asking parents and caregivers about their access to relationships to screening for parent-child relational health to intervening with more intensive, evidence-based, positive parenting models like Triple P , HealthySteps and Video Interaction Project . On this important month, pick one of these and commit to making your practice a child-abuse prevention practice. 

- From: Rachel Gilgoff, MD, CCTP, FAAP, Medical Director of Clinical Innovations and Research; Center for Youth Wellness
Thank you for all your work on behalf of children. Every moment of healing matters for generations to come. You are making a difference. You offer hope.

With Gratitude, 
Aparna Kota, MD, MPH
Board Member, Safe & Sound
Chair, Kaiser Permanente San Francisco Child Abuse Services and Prevention Team

December 7, 2019:   Pediatric Puzzles Interactive CME Conference, SF
April 7-9, 2019:  National AAP Legislative Conference, Washington D.C.

May 20, 2019: AAP California Legislative Leadership Day, Sacramento

October 25-29, 2019:  AAP National Conference & Exhibition, New Orleans

November 21-24, 2019: AAP California 41 st Annual Las Vegas Seminars

Our mission is to promote the optimal health and development of children and
adolescents of Northern California in partnership with their families and communities, and to support the pediatricians who care for them.

President: John Takayama • Vice President: Raelene Walker
Secretary: Janice Kim • Treasurer : Nivedita More Past President: Zoey Goore
Executive Director: Isra Uz-Zaman