CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

The Pediatrician’s Role in Preventing

Child Maltreatment: Clinical Report
John Stirling, MD, FAAP,a Amy Gavril, MD, MSCI, FAAP,b Brian Brennan, MD, FAAP,c Robert D. Sege, MD, PhD, FAAP,d
Howard Dubowitz, MD, MS, FAAP,e American Academy of Pediatrics, COUNCIL ON CHILD ABUSE AND NEGLECT

Pediatricians have always seen the value of preventing health harms; abstract
a
this should be no less true for child maltreatment than for disease or Retired, San Diego, California; bDepartment of Pediatrics, West
Virginia University School of Medicine, Morgantown, West Virginia;
unintentional injuries. Research continues to demonstrate that c
The Armed Forces Center for Child Protection, Walter Reed National
maltreatment can be prevented, underscoring the vital roles of both the Military Medical Center, Bethesda, Maryland. The views expressed in
this presentation are those of the author and do not reflect the official
family and society in healthy childhood development and the policy or position of the Department of the Army, Department of
importance of strong, stable, nurturing relationships in preventing Defense, or the US Government; dDepartments of Medicine and
Pediatrics, Tufts University School of Medicine, Center for Community
maltreatment and building the child’s resilience to adversity. This Engaged Medicine, Institute for Clinical Research and Health Policy
clinical report elaborates the pediatrician’s multitiered role in Studies, Tufts Medical Center, Boston, Massachusetts; and eDivision of
Child Protection, Center for Families, Department of Pediatrics,
supporting relational health from infancy through adolescence, from University of Maryland School of Medicine, Baltimore, Maryland
universal interventions assessing for maltreatment risks and protective
Drs Stirling and Gavril served as lead authors and editors; and all
factors to targeted interventions addressing identified needs and authors contributed text and collaborative review.
building on strengths. When maltreatment has already occurred, This document is copyrighted and is property of the American
interventions can prevent further victimization and mitigate long-term Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy of
sequelae. Advice is provided on engaging community resources, Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
including those that provide food, shelter, or financial support for Pediatrics has neither solicited nor accepted any commercial
families in need. involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefit
from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, clinical reports from the American
Academy of Pediatrics may not reflect the views of the liaisons or
INTRODUCTION the organizations or government agencies that they represent.

Child maltreatment (physical, sexual, and emotional abuse, neglect) is a The guidance in this report does not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations,
complex, multifactorial phenomenon that presents in a bewildering va- taking into account individual circumstances, may be appropriate.
riety of guises. Presenting signs and symptoms range from minor to fa- All clinical reports from the American Academy of Pediatrics
tal, from acute to chronic. More than an estimated 7.5 million children automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
are referred to child protective services each year, out of a population
DOI: https://doi.org/10.1542/peds.2024-067608
of about 80 million. In 2021, 1820 children died of abuse or neglect.1
These statistics, tragic as they are, are conservative estimates.2 Child Address correspondence to John Stirling, MD, FAAP. Email: jstirlings@
aol.com.
maltreatment can be a source of toxic stress that creates a significant
risk of lifelong morbidity for the child, with consequences to social and
cognitive development and to both mental and physical health.3–6 To cite: Stirling J, Gavril A, Brennan B, et al; American
Most child maltreatment involves family or other trusted caregivers; Academy of Pediatrics, Council on Child Abuse and Neglect.
The Pediatrician’s Role in Preventing Child Maltreatment:
neglect is the most common manifestation.7 Maltreatment often results Clinical Report. Pediatrics. 2024;154(2):e2024067608
from situations in which adult caregivers lack the necessary resources,

PEDIATRICS Volume 154, number 2, August 2024:e2024067608 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 education, or supportive relationships to maintain a safe one in which acute or chronic stressors overcome the care-
and nurturing environment. Child maltreatment can be giver’s ability to cope.
thought of as a health risk that derives from a lack of Children grow within their families, and families in
healthy relationships and is often associated with eco- turn function in the broader context of a larger commu-
nomic or environmental stress.8 nity. Risk and protective factors for child maltreatment
Prevention of child maltreatment revolves around helping may occur at the level of the child, family, community,
families form and maintain relational health, defined as the and society. Child maltreatment often arises from the in-
safe and stable relationships that protect and nurture a teraction of multiple factors. An infant or child with an
child’s growth and development, increasing resilience.9,10 ongoing medical condition, for example, may make more
Supporting relational health offers benefits in healthy child demands on their parents than would a healthier child.
development and well-being beyond keeping children safe Their parents’ ability to provide effective care, in turn,
from maltreatment. Pediatric health care providers (pediat- might be challenged by unemployment, depression, or
ric HCPs) have a unique opportunity to monitor and sup- substance use. Some examples of child, parent, family,
port these essential relationships. and community factors associated with child maltreat-
This clinical report focuses on the prevention of child ment are shown in Fig 1.
maltreatment and makes recommendations to providers Conversely, protective factors at the individual, family, and
of pediatric care who are eager to integrate child mal- community levels support the development of resilience.11,12
treatment prevention opportunities into their practice. Maximizing support for resilience at all levels is key to child
It does not discuss targeted screening for child mal- maltreatment prevention strategies elaborated by the World
treatment or its diagnosis, reporting, evaluation, inves- Health Organization and the Centers for Disease Control and
tigation, or treatment. For the purposes of this report, Prevention (CDC).13,14 Five key preventive factors that help
the term child refers to infants, children, adolescents, families cope with stresses are succinctly identified in the
and young adults; the term pediatric health care pro- Center for the Study of Social Policy’s Strengthening Families
vider (pediatric HCP) refers to pediatricians, pediatric Protective Factors Framework (https://cssp.org/our-work/
medical subspecialists, pediatric surgical specialists, project/strengthening-families/):
other physicians, and nonphysician clinicians in both
ambulatory medicine and hospital medicine practice  Parents’ ability to manage stress and function well in
settings. the face of adversity
 Positive relationships to provide needed support
FOCUSING ON REDUCING RISKS AND IMPROVING RESILIENCE  Knowledge of parenting and child development
For the pediatric HCP, the goals of child maltreatment pre-  Concrete support in times of need, particularly hous-
vention should be twofold: to minimize risk by anticipat- ing, food, and access to vital services, such as child
ing, recognizing, and mitigating family and community care, health care, and transportation
stressors, and to increase resilience by enhancing child  Interactions that teach children to communicate, self-
and family protective factors. In considering approaches to regulate, and maintain relationships.
prevention, it is helpful to think of abuse or neglect as
symptoms of underlying dysfunction, usually related to di- Recognizing families’ sources of support and limita-
verse and interacting contributors over time. An episode of tions enhances the pediatric HCP’s ability to meet the
abuse or neglect can be conceptualized as an imbalance, specific needs of the family and deliver effective, family-

FIGURE 1
Examples of factors contributing to family risk or resilience.

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 focused care.15 Especially in early childhood, pediatric (available for download at: https://brightfutures.aap.org/
HCPs observe and advise families at frequent intervals materials-and-tools/PerfPrevServ/Pages/default.aspx) is a
and can serve as trusted advisors who can facilitate re- free companion reference that provides practical instruction
ferrals to community resources. The commitment of pe- and recommends many useful resources for the practitioner,
diatric HCPs to assess risk and protective factors to including specific tools and techniques.
promote resilience, although only a first step, can literally A variety of tools for assessing risks and resilience
be lifesaving. have been published in peer-reviewed literature and range
from broad assessments to targeted measures of specific
UNIVERSAL INTERVENTIONS: ASSESSING RISK AND conditions. Some specifically address resilience; others
PROTECTIVE FACTORS explore conditions often associated with maltreatment,
such as intimate partner violence, parental mental health,
History Taking: Including Relational Health and unhealthy substance use. A few of these are listed in
Social histories attuned to relational health should in- Table 1.
volve not only characteristics of the child but also of the The AAP Screening Technical Assistance and Resource
parents, family, and other caregivers in the child’s life, Center provides valuable and practical help in screening
extending to the wider community. History taking, obser- for developmental issues, parental depression, family
vation, and surveillance can identify characteristics par- strengths, and social determinants of health (https://www.
ticular to the children that are challenging for a parent. aap.org/en-us/advocacy-and-policy/aap-health-initiatives/
Normal variations in infant crying, feeding difficulties, Screening/Pages/Social-Determinants-of-Health.aspx). These
toilet training, and defiant behavior have all been trigger- tools may be administered during or before the medical en-
ing events for physical or emotional abuse. The extra de- counter, by the pediatric HCP, online, or by office staff.20
mands posed by a given child’s physical, intellectual, or However the questions are asked, it is imperative that all re-
medical challenges, especially when chronic, can also sults be reviewed and that responses be addressed with the
overwhelm some parents’ coping abilities, giving way to family. Disclosures of family stresses are often made at
frustration, anger, and loss of self-control.16,17 When some emotional cost, and to ignore them betrays trust, im-
chronic, stressful medical conditions are correctly identi- periling future communication.21,22 Acknowledgment should
fied, anticipatory guidance from the pediatric HCP may be nonjudgmental and validate the concern. Asking “How
help set realistic expectations, reduce caregivers’ anxiety, do you think this [identified condition] is affecting you and
and teach coping and management skills.18 Conversely, a your family?” opens the door to more information and col-
child’s good health, “easy” temperament, cognitive ability, laborative problem solving. If a problem is not in need of
and ability to adapt emotionally can all help the child current attention, or the caregivers choose not to discuss it
and family to cope with stressors.19 at that time, pediatric HCPs can maintain vigilance, offering
help if and when help is wanted.
How to Ask About Relational Health Relational health questions can trigger emotional re-
Basic assessment of risks and resilience should be inte- sponses in caregivers. Pediatric HCPs who choose to ask
gral to pediatric health care. A universal approach, as- about parental histories should be prepared to do so in a
sessing all families rather than selecting some, can help trauma-informed environment, ready to provide support
lessen family concerns about stigma. Pediatric HCPs can and referral where needed. Staff training in the consequen-
explain that assessing all families seeking medical care is ces of trauma and in avoiding personal and institutional
an established routine that arises from a shared concern biases can help make the process safe and comfortable for
for the child’s health. Pediatric HCPs can communicate all involved.
respect and earn trust by first asking about family pro- Specific factors identified by these tools may reflect
tective factors and resilience and by explaining how the the results of racism, historical trauma, or other forms of
clinic may be able to help with problems that are identi- oppression that have been years in the making. Acknowl-
fied. Social information should be updated periodically, edgment of system-level stressors by the pediatric HCP
such as at well-child visits. It can be useful to start each may be a potent tool to build rapport with families af-
visit by asking “Has anything changed with your family fected by them and can help in focusing supportive
since our last visit? How are you doing with [previously efforts.23
identified challenge]?” Caregivers’ histories of their own early adversity have
The Pediatric Intake Form in the Bright Futures health su- proven useful in predicting problems with their child-
pervision guidelines from the American Academy of Pediat- ren’s development, behavior, and health care use.24–26
rics (AAP), also known as the Family Psychosocial Screen, Implications for child maltreatment prevention, however,
provides one blueprint for assessing family functioning. are less clear. Screening for adverse childhood experi-
Performing Preventative Service: A Bright Futures Handbook ence (ACE)s, which assigns a numerical score reflecting

PEDIATRICS Volume 154, number 2, August 2024 3

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 TABLE 1 Examples of Useful Assessment Tools
Focus Factors Evaluated Tool Questions
Parent or family focused Risk Parent or teen depression PHQ-9 and -2109,110 9 and 2, respectively
Risk Parental depression SEEK PQ-Ra 20
Risk Parental unhealthy substance use
Risk Intimate partner violence or
domestic violence
Risk Food insecurity
Risk Harsh punishment
Risk Parental (postpartum) depression Edinburgh Depression 10
Scaleb
Child specific Risk Neurodevelopment Ages and Stages Varies by age
Questionnaire
Risk Adolescent substance use S2BIc 3–7 questions depending
on patient responses
Protective factors Resilience Emotional support Protective Factors Surveyd 65
Resilience Concrete support
Resilience Nurturing and attachment
Resilience Family Functioning
Resilience Knowledge of parenting and child
development
Positive experiences Resilience Perceived safety and security Benevolent Childhood 10
Resilience Positive and predictive quality of life Experiences Scalee
Resilience Relational support
Positive experiences Resilience Family support Positive Childhood 7
Resilience Safety and security Experiences Scalef
Resilience Relational support
Resilience Community support and belonging
PQ-R, SEEK Parent Questionnaire–R.
a
Dubowitz H, Lane WG, Semiatin JN, Magder LS. The SEEK model of pediatric primary care: can child maltreatment be prevented in a low-risk population? Acad Pediatr.
2012;12(4):259–268.
b
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786.
c
Levy S, Weiss R, Sherritt L, et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatr. 2014;168(9):822–828.
d
Sprague-Jones J, Counts J, Rousseau M, Firman C. The development of the protective factors survey, second edition: A self-report measure of protective factors against child
maltreatment. Child Abuse Negl. 2019;89:122–134.
e
Merrick JS, Narayan AJ, DePasquale CE, Masten AS. Benevolent Childhood Experiences (BCEs) in homeless parents: a validation and replication study. J Fam Psychol.
2019;33(4):493–498.
f
Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive childhood experiences and adult mental and relational health in a statewide sample: associations across adverse
childhood experiences levels. JAMA Pediatr. 2019;173(11):e193007.

the variety (although not the intensity) of adverse experien- predictive value of social support, which has led to
ces in a child’s or caregiver’s history, has vocal advocates.25,27 Health Outcomes from Positive Experiences,34,35 a frame-
The state of California recently enacted its ACE-Aware Ini- work that stresses monitoring development in 4 crucial
tiative, training health care providers on ACEs and their areas: relationships, safe environments, social engage-
importance and providing them payment for each patient ment, and opportunities for emotional growth. Further
screened (https://www.ACEsaware.org/). Critics have discussion about assessing for positive experiences can
raised questions about the practical use of the ACE ques- be found on the Health Outcomes from Positive Experien-
tionnaire at the individual level, cautioning that further re- ces Web site at https://positiveexperience.org/wp-content/
search and development are needed before a widespread uploads/2021/11/Four-Ways-to-Access-Positive-Childhood-
program of formal ACE screening is undertaken for pa- Experiences.pdf.
tients or caregivers.4,7,28–31 For this reason, the AAP does
not currently recommend universal ACE screening.32 Including Relational Health in Anticipatory Guidance
Even more important than knowing what is going Prevention of maltreatment can begin at the very first fam-
wrong in a family is knowing what is going strong. Tools ily contact with the pediatric HCP and continue through all
are available to help assess resilience or protective fac- subsequent visits. By anticipating the challenges inherent to
tors. Several are listed in Table 1. The Positive Childhood childrearing and guiding families through difficult times, pe-
Experiences scale33 has been useful in researching the diatric HCPs bolster family resilience before inappropriate

4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 expectations for child behavior can give rise to frequent, gives examples of opportunities for incorporating child abuse
harsh, or physically punitive disciplinary efforts. Well-child maltreatment prevention into a pediatric health supervision
visits offer valuable opportunities for pediatric HCPs to pre- visit by addressing parental support and coping skills at vari-
emptively discuss anticipated and challenging behavioral ous developmental stages. Although this list is not exhaus-
and developmental issues ranging from infant crying, toilet tive, it highlights key recommendations for anticipatory
training, and discipline to adolescent self-assertiveness and guidance. The AAP offers a conceptual framework and a va-
independence.36,37 Subsequent visits allow follow-up on pre- riety of practical resources for supporting early relational
viously identified issues. The more frequent visits recom- health at https://www.aap.org/en/patient-care/early-childhood/
mended for children and adolescents with disabilities and early-relational-health/.
other special health care needs should also include anticipa- One well-studied tool for primary prevention of child
tion of added caregiver stresses and practical guidance on maltreatment in the office setting is the evidence-informed
maintaining a healthy parent-child relationship.38 Table 2 Safe Environment for Every Kid (SEEK) model (information

TABLE 2 Opportunities to Integrate Child Maltreatment Prevention Into Health Supervision Visits111
Age Parent Coping Skills and Support System
Prenatal or first visit  Social determinants of health: Living situation or who lives in the home? History of unhealthy substance use or
intimate partner violence? Are there financial problems and/or poverty?
 Was the pregnancy planned?
 Parent and family health and well-being: History of mental health problems? What were the parents’ experience(s)
with trauma?
 How were the parents parented and disciplined?
 Who will care for the infant? What is the family’s support system?
Newborn  Social determinants of health changes;
 infant crying and calming;
 positive parent-newborn interactions and expectations;
 family support system: Identify 3 friends or family members who can help (safety line)
First months  Social determinants of health changes;
 infant crying and attachment, loving is not “spoiling”;
 normal development and expectations (sleeping and waking, feeding). Positive parent-newborn interactions;
 postpartum depression;
 family support system
Cruiser or toddler  Social determinants of health changes;
 normal development and age-appropriate expectations (behaviors or temper tantrums, eating, language);
 sleep routines and issues;
 discipline 5 teaching;
 toilet-training;
 importance of routines and play;
 family support system
Preschool  Social determinants of health changes;
 sexual development, teach child names for genitalia;
 teach child self-stimulation is appropriate in private, but not in public;
 safe touch or unsafe touch;
 normal development and age-appropriate expectations;
 discipline 5 teaching;
 model nonviolent anger management and conflict resolution;
 family support system
Middle childhood or school  Social determinants of health changes;
 normal development and age-appropriate expectations, appropriate supervision;
 discipline 5 teaching;
 model nonviolent anger management, emotion regulation or coregulation, and conflict resolution;
 respect private parts of others and others to do the same;
 personal safety; peer pressure; internet use;
 family relationships, importance of family routines or time together
Adolescence  Social determinants of health changes;
 normal development and age-appropriate expectations;
 discipline 5 teaching;
 dating violence and signs of healthy versus unhealthy relationships;
 model nonviolent anger management, emotion regulation or coregulation, and conflict resolution;
 family relationships, importance of family routines or time together

PEDIATRICS Volume 154, number 2, August 2024 5

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 at www.SEEKwellbeing.org). SEEK offers a practical approach for the child.14,47 The evidence regarding home visiting
to help pediatric HCPs address prevalent, targeted risk factors programs in preventing child maltreatment is mixed, pos-
(parental depression, major stress, unhealthy substance use, sibly reflecting variations in program implementation
domestic violence, food insecurity, and harsh punishment) in and focus and the difficulty of ascertaining child mal-
families with children 0 to 5 years of age. Core components treatment outcomes. However, certain programs have
include: (1) online training for pediatric HCPs; (2) the SEEK been associated with up to a 45% reduction of child mal-
Parent Questionnaire–R, a brief tool used at selected well- treatment, a decrease in multiple family risk factors,48–51
child visits; (3) the Reflect–Empathize–Assess–Plan approach decreased harsh parenting practices,52 and decreased in-
to efficiently assess and initially address problems; (4) princi- juries from child maltreatment.53,54 Programs with the
ples of Motivational Interviewing; (5) facilitating referrals; most significant effect have used highly qualified and
and (6) SEEK (or similar) parent handouts customized with trained staff, have research-based or quality improve-
information on local resources. Where possible, a social ment approaches to program development, and target
worker or behavioral health professional partners with pedi- families with multiple risk factors.49,50,54,55 More infor-
atric HCPs and parents. Findings from 2 large randomized mation on home visitation programs can be found in the
controlled trials found that SEEK reduced rates of child abuse
AAP policy statement “Early Childhood Home Visiting.”47
and neglect and harsh punishment.39,40 Parenting programs, when effective, may enhance fam-
Another more tightly targeted program, the Period of
ily resilience. Although services vary from one program
PURPLE Crying,41 attempted to reduce the community in-
to another, the overarching shared goal is to teach par-
cidence of abusive head trauma (AHT) by educating all
enting skills to help build a safe and supportive home en-
parents of newborn infants during their postpartum hos-
vironment for children. The best studied parenting program
pital stay via a brochure and video and obtaining a
is the Positive Parenting Program (often shortened to
signed commitment statement indicating their under-
“Triple P”), which was developed as a tiered series of in-
standing that shaking is harmful. An 8-year follow-up of
terventions offering training and support to meet differ-
province-wide implementation in British Columbia (add-
ing home visits and additional reinforcement) showed ent families’ levels of need, from brief interventions to
significant reductions in AHT.42 Other evaluations, how- family focused counseling and services addressing spe-
ever, although showing improvement in parental knowl- cific issues, such as discipline or behavioral concerns.
edge and confidence, were unable to demonstrate any Triple P is not only a prevention program but also has
significant reduction in AHT.43–45 reactive elements to address past maltreatment and re-
currence of abuse.14,56,57 Studies have shown decreases
TARGETED INTERVENTIONS in substantiated child maltreatment, foster care place-
ments, and child injury.58,59
After risk assessment there may be a need for further
Other parenting programs have also shown success in
evaluation and intervention to help build protective fac-
reducing child maltreatment and related risk factors,
tors and address risk. Targeted (also called “secondary”
such as less use of aggressive discipline, including corpo-
or “indicated”) child abuse prevention interventions fo-
ral punishment, and less parental support for harsh disci-
cus resources on families with identified risk factors. In
pline.14 The use of corporal punishment is associated
some instances, pediatric HCPs or clinic staff can provide
with child physical abuse. The AAP policy on the use of
education and guidance, such as helping a parent address
effective discipline suggests that “Parents, other care-
a child’s challenging behaviors. In other instances, such
as intimate partner violence, parental depression, or sub- givers, and adults interacting with children and adoles-
stance use disorders, Pediatric HCPs serve to facilitate cents should not use corporal punishment (including
referrals—a potentially pivotal role that may make a hitting and spanking).” The AAP also advocates banning
significant difference in only a few strategic minutes.46 the use of corporal punishment in out-of-home educa-
Home visitation programs, such as Nurse Family Part- tional settings.37
nership, Child FIRST, and Healthy Families America, are Early childhood education programs such as Head
well researched targeted child maltreatment prevention Start, Early Head Start, and Child-Parent Center have
programs. Qualifying families may include first-time pa- been shown to be effective in reducing child maltreat-
rents, single and/or young parents, low-income house- ment.60,61 These programs offer preschool enrichment
holds, or those with other heightened risks, depending while encouraging family engagement, increasing and
on the program. Although different models have varying strengthening family relationships to promote early child
content and emphasis, all programs share a similar ap- development. As with parenting training, these programs
proach in which a professional or paraprofessional en- may vary widely. Research has shown that families re-
ters the family’s home to offer support, mentorship, and ceiving early childhood education services have fewer
guidance on providing a nurturing and safe environment child welfare services encounters, fewer out-of-home

6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 placements, and decreased child maltreatment rates, par- for further history and heightened surveillance, even if the
ticularly when combined with a home visitation program. child presently appears to be doing well.69,70 Symptoms
Pediatric HCPs should become familiar with home vis- arising from previous trauma may not be immediately ap-
itation programs, parenting programs, and early child- parent; behavior may change over time in new environ-
hood education programs in their communities and ments or developmental stages. The AAP recommends that
learn how to connect their patients’ families with these any history of child maltreatment, along with consequen-
services. ces, such as out-of-home care, warrants provision of men-
tal health services, preferably from therapists familiar with
AFTER MALTREATMENT HAS OCCURRED: PREVENTING FUTURE evidence-based trauma therapies.2
HARM Understanding a child’s trauma history assists a pedia-
Children and adolescents who have suffered from child trician in accurate diagnosis and directs therapeutic in-
abuse or neglect remain at risk for future maltreatment, terventions. When the pediatric HCP is well-informed
even if removed from their homes.62,63 They are also at in- and aware of the effects of trauma, those effects are less
creased risk of toxic stress and related poor health effects. likely to be mistaken for willful defiance or an idiopathic
The goals of intervention should include preventing further condition that can only be treated with medication. Trauma-
victimization (so-called “tertiary” prevention) and inter- aware practices recognize the importance of supportive
vening to minimize the effects of previous maltreatment. relationships and work to build resilience in the family
Success largely depends on strengthening child and family and child.32,71
resilience through supportive relationships.64–66 Pediatric HCPs can monitor symptoms and the progress
Paradoxically, the path to safety for some children of- of therapeutic interventions by scheduling frequent appoint-
ten includes further traumatic transitions. Victims may ments to assess adherence to recommended treatment or
be removed from birth parents, perhaps to kinship care, care, address family concerns, and track growth, develop-
foster homes, and even adoption. Each move itself may ment, and well-being. The AAP recommends that children
be stressful, all the more for being repeated. Pediatric and adolescents who have experienced maltreatment be fol-
HCPs can watch for signs and symptoms of dysfunction lowed more frequently, recommending 3 visits in the first
while helping kinship, foster, and adoptive parents un- 3 months after maltreatment is identified and every 6 months
derstand this dynamic and respond in a sensitive fashion. thereafter.69
Pediatric HCPs will find practical guidance in supporting
children and families in foster, kinship, or adoptive care SOCIOECONOMIC SUPPORT FOR FAMILIES IN NEED
relationships in 2 AAP toolkits: Helping Foster and Adop- Low family income is statistically associated with child
tive Families Cope With Trauma (https://downloads.aap. abuse and neglect.19,72 Public policies that improve the
org/AAP/PDF/Foster%20Care/hfca_foster_trauma_guide. socioeconomic conditions of families are found to have a
pdf) and Safe and Sound (https://www.aap.org/en/patient- significant impact on children’s health.73 Caregivers’ per-
care/foster-care/safe-and-sound-helping-children-who-have- ception of economic stress and helplessness correlate
experience-trauma-and-adversity/). with harsh punishment and child abuse, and mitigation
Patients suffering from toxic stress may present to the of these economic conditions improves child safety.74–76
pediatric HCP in a variety of ways. Early maltreatment may Research has consistently shown that public policies that
lead to cognitive challenges and difficulties with mood reg- alleviate economic stressors are associated with reduc-
ulation, which can persist even after the child is in a safe tions in reports of child abuse and neglect and improved
environment. The resultant problematic behaviors may pre- outcomes.77 A wide variety of programs has been stud-
sent to the pediatric HCP as symptoms of attention deficit/ ied. Paid parental leave at the time of birth or adoption
hyperactive disorder, learning disabilities, depression, or of an infant has been shown to significantly reduce
other mood disorders.6 The presence of such behavioral AHT.74 Refundable earned income tax credits have been
symptoms should raise a pediatric HCP’s concern about associated with fewer reported cases of child neglect78
previous adversity and toxic stress. Chronic activation of and are associated with trends toward lower rates of
the child’s threat response system may produce persistent physical and emotional abuse.79 Families enrolled in the
anxiety that manifests in functional somatic complaints, Supplemental Nutrition Assistance Program (SNAP) are
such as gastrointestinal tract dysfunction, headaches, and involved in significantly fewer reports of child abuse and
sleep disorders.67,68 The patient’s social or medical history neglect.80 States that expanded Medicaid coverage also
may provide additional clues to previous adversities (includ- dramatically decreased reports of child neglect, although
ing those unrelated to maltreatment, such as natural disasters abuse reports remained stable.81 When US states are
or community violence). compared, the incidence of all forms of maltreatment is
Enrollment in foster or kinship care or a history of other inversely correlated with total expenditures on benefit
involvement with the child welfare system signal a need programs for families living in poverty.82 There are

PEDIATRICS Volume 154, number 2, August 2024 7

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 indications that widespread and effective family supports led information for the resource. When time permits or need
to reductions in child abuse during the first phase of the co- is pressing, trained staff can be introduced and briefed to
ronavirus disease 2019 pandemic.83,84 help parents set up an appointment.
AAP policies on the health effects of poverty (https:// After any referral, it is always a good idea to follow-up
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ to address any concerns the family might have. This pro-
poverty/Pages/practice-tips.aspx) and racism23 help pediat- cess helps staff to address possible barriers and under-
ric HCPs link families with sources of support and provide scores that the provider feels the referral (and thus the
further discussions of the pediatrician’s role in policy forma- family’s need) is important. A wealth of practical tips on
tion and advocacy. At the most basic level, the pediatric fam- office-based referral strategies may be found at https://
ily-centered medical home can help families by providing www.aap.org/en/practice-management/bright-futures/bright-
information related to federal benefits (including the Special futures-in-clinical-practice/.
Supplemental Nutrition Program for Women, Infants, and
Children, Supplemental Nutrition Assistance Program, and BARRIERS TO GOOD PREVENTION PRACTICE
the earned income tax credit) and state programs, notably Prevention of child maltreatment builds on skills common
including paid family and medical leave. Nongovernmental to pediatric practice. Nevertheless, some pediatric HCPs
organizations may also assist with legal aid and with shelter, identify multiple barriers to effectively assessing patients
food, and other concrete family supports. Pediatric HCPs and providing adequate support related to safety and rela-
and staff can work to form relationships with local resour- tional health. Many describe a general lack of comfort with
ces and collaborate in providing access to those resources discussing relational topics and feel they lack education and
in a culturally sensitive and trauma-informed fashion. training on evidence-based community resources. Pediatric
The pediatric HCP’s larger role extends to advocacy,
HCPs may sometimes feel that screening and intervention
speaking to policy makers to make services more equita-
for relational issues are beyond their purview or pertain to
ble and accessible for patients. Evidence for policies’ im-
issues beyond remediation or that there is simply too little
pact on child abuse and neglect prevention is available
support and payment for spending the time needed to im-
from the CDC’s publications Preventing Child Abuse and plement best practices.87–89
Neglect: A Technical Package for Policy, Norm, and Pro- Although daunting, these challenges may be addressed
grammatic Activities14 and Preventing Adverse Childhood with education and preparation, to the benefit of all.
Experiences (ACEs): Leveraging the Best Evidence Available.85 When pediatric care teams are equipped with knowledge
of evidence-based interventions, available community re-
UTILIZING RESOURCES OUTSIDE THE MEDICAL FACILITY sources, and best coding practices, they can guide fami-
Familiarity with resources available in one’s community fa- lies without overburdening their practice. Practices that
cilitates referrals. Table 3 lists a few types of widely available have incorporated formal screening measures for family
resources. Ideally, pediatric HCPs can work collaboratively stressors and strengths have reported that they are well
with parents and community agencies without disclosing un- tolerated and provide added satisfaction for both families
necessary personal information. Familiarity with a commu- and office teams.29,90 Continued advocacy is needed to
nity resource ensures a more effective referral. help guarantee that public and private insurers will help
Most families adhere to beliefs or traditions involving support these efforts.
how children should be raised. Many may have relevant Advance planning can greatly improve both efficiency
experience with previous referrals. Careful listening and and effectiveness. Scheduling realistically for complicated
consideration may be useful in helping families contextu- visits, arranging follow-up visits for ongoing issues, and
alize the advice that they receive. Verbally confirming the delegating portions of the appointment (like relational
family’s understanding and intention can be valuable. health questions or education) to others in the office may
Clinics may consider developing parent handouts with in- improve patient flow. Creating easy access to contact infor-
formation on community resources and eligibility criteria mation for family support resources and educating staff on
for common problems (see the AAP Referral Resources their various roles and responsibilities establishes practice
Worksheet at https://downloads.aap.org/AAP/documents/ pathways for commonly encountered situations. Pediatric
STAR-Center-Referral-Resource-Template.docx). Community HCPs and staff should periodically review practice path-
resource information may be displayed in the waiting area ways, policies, and mandated reporting requirements for
for easy access.86 child abuse and neglect.
Medical staff can directly help families overcome the Screening and coordination of services are characteris-
all-too-common logistical challenges of connecting with tic of family-centered medical homes (FCMHs), practices
community resources. They should begin by planning with the ability to follow-up and coordinate referrals for
with a parent what is needed for the referral (eg, income services, maintaining continuity and serving as patient
verification or insurance coverage) and providing contact and family advocates within the community. The AAP

8 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 TABLE 3 Examples of Resources to Assist Practices in Linking Families to Community Resources
Community Resources Needs Addressed Type Examples
National Hotlines and Identifies local resources NGO https://www.foodpantries.org/
Websites Federal govt. https://www.usa.gov/benefits-grants-loans
NGO https://www.childcareaware.org/resources/map/
SNAP Federal program; Provides nutrition benefits Federal govt. https://www.fns.usda.gov/snap/supplemental-
to low-income individuals and families nutrition-assistance-program
through its nationwide network of field
offices
Special Supplemental Federal program; Helps women and children, Federal govt. https://www.fns.usda.gov/wic
Nutrition Program for up to age 5, with free healthy foods,
Women, Infants, and advice on healthy eating and referrals to
Children (WIC) health, welfare, and social services
SAMSHA Treatment Locator Locates resources for drug and mental Federal govt. https://findtreatment.samhsa.gov/
health treatment, by address/zip code
State Government Websites Specific Issues (eg, unhealthy substance use) State govt. https://dhs.maryland.gov/; https://dphhs.mt.gov/
(examples) cfsd/; https://dpbh.nv.gov/Programs/Programs/
County Health Departments Specific Issues (eg, food banks, smoke County govt. https://mentalhealth.westchestergov.com/
(example) alarms, mental health)
City Websites (example) Specific Issues (eg, food banks, smoke Local govt. https://www.fayettevillenc.gov/city-services
alarms, mental health)
Dialing 2-1-1 Widely available; identifies and connects to NGO (United Way) https://www.211.org/
local resources (eg, food banks,
substance use, domestic violence,
employment, health care)
Legal Aid Clinics Help those that are financially eligible with NGO https://www.mdlab.org/
civil legal problems, such as partner
violence, employment, and housing
Aunt Bertha (now Finds resources for problems, such as NGO https://www.findhelp.org
FindHelp.org) finding food, help paying bills; enter zip
code and targeted problem
The Help Me Grow National Links community resources, such as NGO https://helpmegrownational.org
Center education, health care, and family
services
Early Head Start Support parental and infant development Federal govt. https://eclkc.ohs.acf.hhs.gov/center-locator
and can further enable family success,
promoting housing and financial stability
NGO, nongovernmental organization; SAMHSA, Substance Abuse and Mental Health Services Administration.

has long championed the FCMH model.38,91 Broadening the hiring process or recruitment of volunteers, minimizing
access to FCMHs for all patients will entail advocacy to unsupervised time with children, supervising older children
provide more realistic funding for medical services, care with younger children, and recognizing and reporting sus-
coordination, and family health services.92 pected abuse.93 Pediatric HCPs who work with school sys-
tems, summer camps, after-school programs, and religious
SPECIAL TOPICS or cultural programs should be aware of best practices in
preventing sexual abuse.94
Sexual Abuse Prevention Early sexual abuse prevention strategies focused on
In general, children are sexually abused by adults known to the child: helping potential victims recognize abusive sit-
them: the majority are family members, health care pro- uations and resist, escape, and disclose through teaching
viders, coaches, religious leaders, and other trusted adults children about “good” and “bad” touches.95 These pro-
with access to children and adolescents are also perpetra- grams have been criticized for putting the onus of child
tors. Community-based approaches like Darkness to Light’s sexual abuse prevention on the shoulders of victims
“Stewards of Children” (www.d2l.org) seek to educate adults rather than on the adults responsible for ensuring their
to recognize and intervene in situations in which risk for safety.96 The good or bad touch dichotomy also runs the
sexual abuse is high. These directed strategies have led to theoretical risk of leading children to confuse healthy
improved protective practices in child sexual abuse preven- sexual urges with something shameful. Although they
tion, such as more stringent background investigations in have produced increases in awareness and disclosures,

PEDIATRICS Volume 154, number 2, August 2024 9

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 victim education programs have not been shown to pre- overt or covert defiance of perceived authority figures.
vent abuse. Poor interpersonal relationships at home may impair de-
Primary prevention of sexual abuse ideally involves help- velopment of emotional awareness and communication
ing families raise their children around healthy, respectful skills are often delayed. In treating older patients, the pe-
sexual relationships, enhancing a child’s self-esteem and com- diatric HCPs’ focus shifts from preventing the onset of
munication skills, and providing age-appropriate education abuse to building resilience and prevention of further
on sexual development to child and parents. During office vis- victimization.
its, pediatric HCPs can model such respectful behavior. Ask- Certain populations of adolescents may be particularly
ing the parent’s and the child’s permission before a genital vulnerable. Increased independence and the onset of pu-
examination (or any touch), teaching parents to consistently berty raise caregivers’ fears just as hormonal factors amplify
use proper anatomic names, encouraging discussion of mod- teenagers’ emotional responses. Lesbian, gay, transexual, bi-
esty and privacy needs, and providing nonjudgmental antici- sexual, and questioning1 teens may suffer emotional and
patory guidance around sexual issues all may help. Although psychological abuse at home.103 Neurodiverse adolescents
this approach is advocated as good practice by the AAP,15 its and other teenagers with special medical or mental health
value in preventing child sexual abuse and adolescent sexual needs may similarly pay a price for failing to meet care-
assault remains speculative. givers’ expectations.104
Adolescents Teenagers will receive medical care in a variety of ven-
ues, from conventional medical offices to specialized clin-
Prevention of abuse in adolescents can be particularly chal- ics in schools or the child welfare system. Sometimes
lenging. Unlike infants and children, adolescents spend most
caregivers will be present, and other times not. Every at-
of their time out of the home environment and are less
tempt should be made to engage teenagers in their own
likely to present to a medical facility for care. They are older
medical care, interviewing privately and consulting on
than other pediatric patients, so types of maltreatment such
referrals and treatments. Adolescents should be made
as harsh discipline, emotional abuse, and supervisory ne-
aware of what can and cannot remain confidential to
glect are often well established by the time of presentation
avoid violating trust.98,105
to a new pediatric HCP.
Adolescent health care must be trauma-aware. Pediat-
Presentations of child maltreatment vary with age.1
ric HCPs should stay alert to the possibility of earlier ad-
Physical abuse is less common in older children and ado-
versities and their possible consequences on perception
lescents than in younger children but still occurs, usually
and behavior, both in the adolescent patient and the
in the context of discipline. As teenagers gain independence
caregivers.32,106
and the consequences of misbehavior become more threaten-
ing, parents who rely on discipline by physical punishment Coding and Documentation
may feel a need to escalate. Injury may result, especially if the
After the visit, ensuring the practice is compensated for
adolescent responds in kind.97,98
the time and effort spent requires that all services are
Puberty correlates with an increase in reports of sexual
clearly documented and the patient encounter billed to
abuse and assault, seen mostly in female adolescents.99 Child
abuse is committed by adult family members or other adults accurately reflect the care provided and the time spent.
in supervisory capacities (eg, coaches, teachers, and counse- The evaluation and management codes published in Cur-
lors); sexual or physical assault by unrelated adults or peers rent Procedural Terminology allow the bill to reflect the
is more properly termed sexual assault. Such assaults, how- work performed, provided those measures are properly
ever, are more commonly seen after previous experience of documented.107 All pertinent diagnostic codes should be
child sexual abuse, so addressing previous maltreatment is specified. Documentation of risk factors for child mal-
felt to help minimize further victimization.100,101 The AAP treatment or social determinants of health in the pa-
provides guidance for pediatric HCPs on integrating sexuality tient’s record and visit claim form helps document the
and teen health maintenance.102 risk level of the population served and facilitates pay-
Although physical neglect is less common in older pa- ment. Subsequent visits that include addressing such
tients, emotional, educational, and medical neglect remain, problems, such as a visit for asthma that also helps a par-
with identification and intervention both complicated by ent cope with major stress, could rate a higher evaluation
teenagers’ growing independence. Adult protective service and management code.
agencies may be called in to address problems of individu- The AAP resource Coding for Pediatrics 2021 provides
als 18 years or older. comprehensive information.108 The AAP also provides an
Interventions can also be more difficult, given a history array of web-based coding resources at AAP.org. One
of ongoing maltreatment. Insecure attachment styles may such valuable and frequently updated resource is the
undermine trust and may be abetted by long practice of AAP Trauma and Maltreatment Coding Fact Sheet at

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 https://downloads.aap.org/AAP/PDF/Trauma_Coding_Fact_ and know how to respond if a caregiver reports such
Sheet.pdf. problems.
Documentation of sensitive patient or family informa- 7. Encourage caregivers to use their own health care pro-
tion (eg, intimate partner violence or a history of previ- viders as a conduit to needed care. Become knowledge-
ous child abuse) may cause unintentional harm in the able about resources in the community and, when
landscape of data exchange and patient and family por- appropriate, refer families to these resources.
8. Prepare the physician-led team to accommodate the
tals and should be stored carefully. Most modern elec-
complex presentations of families undergoing stress.
tronic record systems have features to protect such
Keeping up-to-date contact information for useful
information against inappropriate disclosure.
community resources saves time, as does training
staff in referral procedures and scheduling follow-up.
SUMMARY 9. Advocate for community programs and resources
Many factors interact to help children and families safely that will provide effective prevention, intervention,
deal with adversity. By prioritizing relational health, pediatric and treatment of child maltreatment and for pro-
HCPs can guard against child maltreatment and increase their grams that address the underlying problems that
patients’ safety, health, and well-being. Trauma-informed, fam- contribute to child maltreatment.
ily-centered pediatric care provides the tools to help pediatric 10. To prevent further maltreatment of a child or adolescent
who has been victimized in the past, offer practical guid-
HCPs prevent child maltreatment and build resilience, using
ance in supporting the child or adolescent to caregivers,
anticipatory guidance and regular, attentive follow-up. Well-
monitor frequently for signs and symptoms of toxic
researched targeted interventions are available for families
stress and continued maltreatment, and recommend
when risk factors for child maltreatment are identified and
therapeutic interventions and mental health services.
can help prevent future morbidity after maltreatment has
been recognized. Familiarity with community resources,
AAP RESOURCES
good anticipatory organization, and planning can mitigate
the complexity of helping families and children at risk for Practice Tips - Screening for Basic and Social Needs and
maltreatment. Connecting Families to Community Resources: https://
www.aap.org/en-us/advocacy-and-policy/aap-health-
initiatives/poverty/Pages/practice-tips.aspx
GUIDANCE FOR THE PEDIATRICIAN
AAP Trauma-Informed Care Resources: www.aap.org/tic
1. Obtain a thorough social history, initially and periodi- AAP Early Relational Health Resources: https://www.aap.
cally, throughout a patient’s childhood, including family org/en/patient-care/early-childhood/early-relational-health/
economic stressors and community conditions. Bright Futures: Brightfutures.aap.org
2. Identify and build on family resilience and protective
factors identified in the social history. Child and par-
LEAD AUTHORS
ent strength and resilience can both prevent mal-
treatment and mitigate its long-term health effects. John Stirling, MD, FAAP
3. Address parents’ concerns while reinforcing effective Amy Gavril, MD, MSCI, FAAP
parenting. Acknowledge the frustration and anger Brian Brennan, MD, FAAP
that may accompany parenting. Provide anticipatory Robert D. Sege, MD, PhD, FAAP
guidance about parenting challenges that may be Howard Dubowitz, MD, MS, FAAP
stressful or serve as a trigger for child maltreatment.
Follow-up on concerns at regular intervals. AAP COUNCIL ON CHILD ABUSE AND NEGLECT, 2020–2023
4. Guide parents in providing effective, nonphysical dis- Suzanne Breen Haney, MD, MS, FAAP, Chairperson
cipline. Encourage parents to use alternatives to cor- Antoinette Laskey, MD, MPH, MBA, FAAP, Chairperson-Elect
poral punishment. Inquire about what methods they Andrea Asnes, MD, MSW, FAAP
have tried, and help parents address particular prob- Verena Brown, MD, FAAP
lematic behaviors. Amy Gavril, MD, MSCI, FAAP
5. When caring for children with disabilities or chronic Rebecca G. Girardet, MD, FAAP
illness, be cognizant of their increased vulnerability Nancy Heavilin, MD, FAAP
and watch for signs of maltreatment. Validate parental Amanda Bird Hoffert Gilmartin, MD, FAAP
challenges and provide parents with techniques to man- Sheila M. Idzerda, MD, FAAP
age stress. Natalie Kissoon, MD, FAAP
6. Be alert to indicators of parental intimate partner vio- Lori Anne Legano, MD, FAAP
lence, unhealthy substance use, and depression. Famil- Stephen Anthony Messner, MD, FAAP
iarize yourself with appropriate community resources Bethany Anne Mohr, MD, FAAP

PEDIATRICS Volume 154, number 2, August 2024 11

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 Patricia Morgan, MD, FAAP STAFF
Shalon Marie Nienow, MD, FAAP Tammy Piazza Hurley
Norell Rosado, MD, FAAP Jeff Hudson, MA

LIAISONS
Rachael Keefe, MD, MPH, FAAP – Council on Foster Care, ABBREVIATIONS
Adoption, and Kinship Care AAP: American Academy of Pediatrics
Brooks Keeshin, MD, FAAP – American Academy of Child ACE: adverse childhood experience
and Adolescent Psychiatry AHT: abusive head trauma
Jennifer Matjasko, PhD – Centers for Disease Control and CDC: Centers for Disease Control and Prevention
Prevention FCMH: family-centered medical homes
Serena Wagoner, DO – Section on Pediatric Trainees HCP: health care provider
Elaine Stedt, MSW, ACSW – Administration for SEEK: Safe Environment for Every Kid
Children, Youth and Families, Office on Child Abuse SNAP: Supplemental Nutrition Assistance Program
and Neglect

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2024 by the American Academy of Pediatrics
FUNDING: No external funding.
FINANCIAL/CONFLICT OF INTEREST DISCLOSURE: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 8. Masarik AS, Conger RD. Stress and child development: a re-
1. US Department of Health and Human Services, Administration view of the Family Stress Model. Curr Opin Psychol. 2017;13:
for Children and Families, Administration on Children, Youth and 85–90
Families, Children’s Bureau. Child maltreatment 2019. Available 9. Garner A, Yogman M; Committee on Psychosocial Aspects of
at: https://www.acf.hhs.gov/cb/report/child-maltreatment-2019. Child and Family Health, Section on Developmental and Behav-
Accessed June 21, 2023 ioral Pediatrics, Council on Early Childhood. Preventing child-
2. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Violence, crime, hood toxic stress: partnering with families and communities to
and abuse exposure in a national sample of children and youth: promote relational health. Pediatrics. 2021;148(2):e2021052582
an update. JAMA Pediatr. 2013;167(7):614–621 10. Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing rela-
3. Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experi- tionships as a moderator of intergenerational continuity of child
ences and the risk of premature mortality. Am J Prev Med. maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):
2009;37(5):389–396 S32–S38
4. Anda RF, Porter LE, Brown DW. Inside the adverse childhood ex- 11. Bethell CD, Gombojav N, Whitaker RC. Family resilience and con-
perience score: strengths, limitations, and misapplications. Am nection promote flourishing among us children, even amid ad-
J Prev Med. 2020;59(2):293–295 versity. Health Aff (Millwood). 2019;38(5):729–737
5. Felitti VJ, Anda RF, Nordenberg D, et al. REPRINT OF: relation- 12. Traub F, Boynton-Jarrett R. Modifiable resilience factors to child-
ship of childhood abuse and household dysfunction to many
hood adversity for clinical pediatric practice. Pediatrics. 2017;
of the leading causes of death in adults: The Adverse Child-
139(5):e20162569
hood Experiences (ACE) Study. Am J Prev Med. 2019;56(6):
774–786 13. World Health Organization, International Society for Prevention
of Child Abuse and Neglect. Preventing child maltreatment: a
6. Sege RD, Amaya-Jackson L; American Academy of Pediatrics
Committee on Child Abuse and Neglect, Council on Foster guide to taking action and generating evidence. Available at:
Care, Adoption, and Kinship Care; American Academy of Child and https://apps.who.int/iris/handle/10665/43499. Accessed June 21,
Adolescent Psychiatry Committee on Child Maltreatment and 2023
Violence; National Center For Child Traumatic Stress. Clinical 14. Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Pre-
considerations related to the behavioral manifestations of child venting child abuse and neglect: a technical package for policy,
maltreatment. Pediatrics. 2017;139(4):e20170100 norm, and programmatic activities. Available at: https://www.cdc.
7. Finkelhor D. Screening for adverse childhood experiences (ACEs): gov/violenceprevention/pdf/CAN-Prevention-Technical-Package.pdf.
cautions and suggestions. Child Abuse Negl. 2018;85:174–179 Accessed November 4, 2021

12 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 15. Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures: Guide- experiences (ACEs) in younger and older children. Child Abuse
lines for Health Supervision of Infants, Children, and Adoles- Negl. 2020;107:104522
cents. 4th ed. American Academy of Pediatrics; 2017 31. Anda RF, Porter LE, Brown DW. Author response to “letter to the
16. Barr RG, Trent RB, Cross J. Age-related incidence curve of hospi- editor regarding ‘inside the adverse childhood experience score:
talized Shaken Baby Syndrome cases: convergent evidence for strengths, limitations, and misapplications’”. Am J Prev Med.
crying as a trigger to shaking. Child Abuse Negl. 2006;30(1):7–16 2021;60(1):e47–e48
17. Legano LA, Desch LW, Messner SA, Idzerda S, Flaherty EG; Council 32. Forkey H, Szilagyi M, Kelly ET, Duffee J; Council on Foster Care,
on Child Abuse and Neglect; Council on Children With Disabilities. Adoption, and Kinship Care; Council on Community Pediatrics;
Maltreatment of children with disabilities. Pediatrics. 2021;147(5): Council on Child Abuse and Neglect; Committee on Psychosocial
e2021050920 Aspects of Child and Family Health. Trauma-informed care. Pedi-
18. Weitzman C, Wegner L; Section on Developmental and Behavioral atrics. 2021;148(2):e2021052580
Pediatrics; Committee on Psychosocial Aspects of Child and 33. Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive
Family Health; Council on Early Childhood; Society for Develop- childhood experiences and adult mental and relational health in
mental and Behavioral Pediatrics; American Academy of Pediat- a statewide sample: associations across adverse childhood ex-
rics. Promoting optimal development: screening for behavioral periences levels. JAMA Pediatr. 2019;173(11):e193007
and emotional problems. Pediatrics. 2015;135(2):384–395
34. Sege RD. Reasons for HOPE. Pediatrics. 2021;147(5):e2020013987
19. Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of
35. Burstein D, Yang C, Johnson K, Linkenbach J, Sege R. Transform-
Child and Family Health; Committee on Early Childhood, Adop-
ing practice with HOPE (Healthy Outcomes from Positive Experi-
tion, and Dependent Care; Section on Developmental and Behav-
ences). Matern Child Health J. 2021;25(7):1019–1024
ioral Pediatrics. The lifelong effects of early childhood adversity
and toxic stress. Pediatrics. 2012;129(1):e232–e246 36. Brazelton TB. How to help parents of young children: the touch-
20. Margolis PA, Lannon CM, Stuart JM, Fried BJ, Keyes-Elstein L, points model. J Perinatol. 1999;19(6 Pt 2):S6–S7
Moore DE Jr. Practice based education to improve delivery sys- 37. Sege RD, Siegel BS; Council on Child Abuse and Neglect; Commit-
tems for prevention in primary care: randomised trial. BMJ. tee on Psychosocial Aspects of Child and Family Health. Effective
2004;328(7436):388 discipline to raise healthy children. Pediatrics. 2018;142(6):
21. Austin AE. Screening for traumatic experiences in health care e20183112
settings: a personal perspective from a trauma survivor. JAMA 38. Medical Home Initiatives for Children With Special Needs Project
Intern Med. 2021;181(7):902–903 Advisory Committee; American Academy of Pediatrics. The medi-
22. Finkelhor D, Berliner L. Screening for traumatic childhood expe- cal home. Pediatrics. 2002;110(1 Pt 1):184–186
riences in health care settings. JAMA Intern Med. 2021;181(7): 39. Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care
903–904 to help prevent child maltreatment: the Safe Environment for Ev-
23. Trent M, Dooley DG, Douge J; Section on Adolescent Health; ery Kid (SEEK) Model. Pediatrics. 2009;123(3):858–864
Council on Community Pediatrics; Committee on Adolescence. 40. Dubowitz H, Lane WG, Semiatin JN, Magder LS. The SEEK model
The impact of racism on child and adolescent health. Pediatrics. of pediatric primary care: can child maltreatment be prevented
2019;144(2):e20191765 in a low-risk population? Acad Pediatr. 2012;12(4):259–268
24. Dowd MD. The relevance of parental adverse childhood experi- 41. Barr RG, Rivara FP, Barr M, et al. Effectiveness of educational
ences in pediatric practice. Pediatr Ann. 2019;48(12):e463–e465 materials designed to change knowledge and behaviors regard-
25. Thakur N, Hessler D, Koita K, et al. Pediatrics adverse childhood ing crying and shaken-baby syndrome in mothers of newborns:
experiences and related life events screener (PEARLS) and health a randomized, controlled trial. Pediatrics. 2009;123(3):972–980
in a safety-net practice. Child Abuse Negl. 2020;108:104685 42. Barr RG, Barr M, Rajabali F, et al. Eight-year outcome of imple-
26. Cooke JE, Racine N, Pador P, Madigan S. Maternal adverse child- mentation of abusive head trauma prevention. Child Abuse Negl.
hood experiences and child behavior problems: a systematic re- 2018;84:106–114
view. Pediatrics. 2021;148(3):e2020044131 43. Zolotor AJ, Runyan DK, Shanahan M, et al. Effectiveness of a
27. Ford K, Hughes K, Hardcastle K, et al. The evidence base for rou- statewide abusive head trauma prevention program in North
tine enquiry into adverse childhood experiences: a scoping re- Carolina. JAMA Pediatr. 2015;169(12):1126–1131
view. Child Abuse Negl. 2019;91:131–146 44. Dias MS, Cappos KM, Rottmund CM, et al. Preventing abusive
28. Wade R Jr, Becker BD, Bevans KB, Ford DC, Forrest CB. Develop- head trauma: can educating parents reduce the incidence? Pe-
ment and evaluation of a short adverse childhood experiences diatr Radiol. 2021;51(6):1093–1096
measure. Am J Prev Med. 2017;52(2):163–172 45. Scott LJ, Wilson R, Davies P, et al. Educational interventions to
29. Gillespie RJ. Screening for adverse childhood experiences in pediat- prevent paediatric abusive head trauma in babies younger than
ric primary care: pitfalls and possibilities. Pediatr Ann. 2019;48(7): one year old: a systematic review and meta-analyses. Child
e257–e261 Abuse Negl. 2022;134:105935
30. Turner HA, Finkelhor D, Mitchell KJ, Jones LM, Henly M. Strength- 46. Earls MF, Yogman MW, Mattson G, Rafferty J; Committee on Psy-
ening the predictive power of screening for adverse childhood chosocial Aspects of Child and Family Health. Incorporating

PEDIATRICS Volume 154, number 2, August 2024 13

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 recognition and management of perinatal depression into pedi- 63. Turner HA, Shattuck A, Finkelhor D, Hamby S. Polyvictimization
atric practice. Pediatrics. 2019;143(1):e20183259 and youth violence exposure across contexts. J Adolesc Health.
47. Duffee JH, Mendelsohn AL, Kuo AA, Legano LA, Earls MF; Council 2016;58(2):208–214
on Community Pediatrics; Council on Early Childhood; Committee 64. Afifi TO, Macmillan HL. Resilience following child maltreatment:
on Child Abuse and Neglect. Early childhood home visiting. Pedi- a review of protective factors. Can J Psychiatry. 2011;56(5):
atrics. 2017;140(3):e20172150 266–272
48. Olds DL, Robinson J, Pettitt L, et al. Effects of home visits by par- 65. Meng X, Fleury MJ, Xiang YT, Li M, D’Arcy C. Resilience and pro-
aprofessionals and by nurses: age 4 follow-up results of a ran- tective factors among people with a history of child maltreat-
domized trial. Pediatrics. 2004;114(6):1560–1568 ment: a systematic review. Soc Psychiatry Psychiatr Epidemiol.
2018;53(5):453–475
49. Scribano PV, Stevens J, Kaizar E; NFP-IPV Research Team. The ef-
fects of intimate partner violence before, during, and after 66. Miller-Graff LE, Scheid CR, Guzman DB, Grein K. Caregiver and
pregnancy in nurse visited first time mothers. Matern Child family factors promoting child resilience in at-risk families liv-
Health J. 2013;17(2):307–318 ing in Lima, Peru. Child Abuse Negl. 2020;108:104639
50. Avellar SA, Supplee LH. Effectiveness of home visiting in improv- 67. Karatzias T, Howard R, Power K, Socherel F, Heath C, Livingstone
ing child health and reducing child maltreatment. Pediatrics. A. Organic vs. functional neurological disorders: the role of
2013;132(Suppl 2):S90–S99 childhood psychological trauma. Child Abuse Negl. 2017;63:1–6
51. Zielinski DS, Eckenrode J, Olds DL. Nurse home visitation and 68. Juruena MF, Eror F, Cleare AJ, Young AH. The role of early life
the prevention of child maltreatment: impact on the timing of stress in HPA axis and anxiety. Adv Exp Med Biol. 2020;1191:
official reports. Dev Psychopathol. 2009;21(2):441–453 141–153
52. Rodriguez ML, Dumont K, Mitchell-Herzfeld SD, Walden NJ, Greene R. 69. Flaherty E, Legano L, Idzerda S; Council on Child Abuse and Ne-
Effects of Healthy Families New York on the promotion of maternal glect. Ongoing pediatric health care for the child who has been
parenting competencies and the prevention of harsh parenting. maltreated. Pediatrics. 2019;143(4):e20190284
Child Abuse Negl. 2010;34(10):711–723 70. Jones VF, Schulte EE, Waite D; Council on Foster Care, Adoption,
53. Fergusson DM, Grant H, Horwood LJ, Ridder EM. Randomized and Kinship Care. Pediatrician guidance in supporting families
trial of the Early Start program of home visitation. Pediatrics. of children who are adopted, fostered, or in kinship care. Pedi-
2005;116(6):e803–e809 atrics. 2020;146(6):e2020034629

54. Macmillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal 71. Forkey H, Inkelas M, Ocampo A, et al. Pediatric approach to
JM, Taussig HN. Interventions to prevent child maltreatment and trauma treatment and resilience (PATTeR) - a novel relationship-
associated impairment. Lancet. 2009;373(9659):250–266 based curriculum and approach to train pediatric professionals
to provide trauma-informed care. Acad Pediatr. 2022;22(2):
55. Arbour M, Mackrain M, Cano C, Atwood S, Dworkin P. National 342–345
home visiting collaborative improves developmental risk detec-
tion and service linkage. Acad Pediatr. 2021;21(5):809–817 72. Cooper K, Stewart K. Does money affect children’s outcomes? A
systematic review. Available at: www.jrf.org.uk/publications/
56. Barth RP. Preventing child abuse and neglect with parent train- does-money-affect-childrens-outcomes. Accessed August 24,
ing: evidence and opportunities. Future Child. 2009;19(2):95–118 2023
57. Coore Desai C, Reece JA, Shakespeare-Pellington S. The preven- 73. Frieden TR. A framework for public health action: the health im-
tion of violence in childhood through parenting programmes: a pact pyramid. Am J Public Health. 2010;100(4):590–595
global review. Psychol Health Med. 2017;22(suppl 1):166–186
74. Klevens J, Luo F, Xu L, Peterson C, Latzman NE. Paid family
58. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Pop- leave’s effect on hospital admissions for pediatric abusive head
ulation-based prevention of child maltreatment: the U.S. triple p trauma. Inj Prev. 2016;22(6):442–445
system population trial. Prev Sci. 2009;10(1):1–12
75. Klevens J, Schmidt B, Luo F, Xu L, Ports KA, Lee RD. Effect of the
59. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Adden- earned income tax credit on hospital admissions for pediatric
dum to “population-based prevention of child maltreatment: the abusive head trauma, 1995-2013. Public Health Rep. 2017;132(4):
U.S. triple p system population trial”. Prev Sci. 2016;17(3):410–416 505–511
60. Green BL, Ayoub C, Bartlett JD, et al. The effect of Early Head 76. Liu Y, Merritt DH. Familial financial stress and child internalizing
Start on child welfare system involvement: a first look at longi- behaviors: The roles of caregivers’ maltreating behaviors and
tudinal child maltreatment outcomes. Child Youth Serv Rev. social services. Child Abuse Negl. 2018;86:324–335
2014;42:127–135
77. Puls HT, Chung PJ, Anderson C. Universal child care as a
61. Mersky JP, Topitzes JD, Reynolds AJ. Maltreatment prevention policy to prevent child maltreatment. Pediatrics. 2022;150(2):
through early childhood intervention: a confirmatory evaluation e2022056660
of the Chicago Child-Parent Center preschool program. Child 78. Kovski NL, Hill HD, Mooney SJ, Rivara FP, Morgan ER, Rowhani-
Youth Serv Rev. 2011;33(8):1454–1463 Rahbar A. Association of state-level earned income tax credits
62. Finkelhor D, Ormrod RK, Turner HA. Polyvictimization and trauma in with rates of reported child maltreatment, 2004-2017. Child Mal-
a national longitudinal cohort. Dev Psychopathol. 2007;19(1):149–166 treat. 2022;27(3):325–333

14 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest
 79. Campbell K. Prevention of child maltreatment as an unexpected 95. Manheim M, Felicetti R, Moloney G. Child sexual abuse victimiza-
benefit of social policies. JAMA Netw Open. 2019;2(6):e195521 tion prevention programs in preschool and kindergarten: impli-
80. Lee BJ, Mackey-Bilaver L. Effects of WIC and Food Stamp pro- cations for practice. J Child Sex Abuse. 2019;28(6):745–757
gram participation on child outcomes. Child Youth Serv Rev. 96. Krugman SD, Lane WG, Walsh CM. Update on child abuse preven-
2007;29:501–517 tion. Curr Opin Pediatr. 2007;19(6):711–718
81. McGinty EE, Nair R, Assini-Meytin LC, Stuart EA, Letourneau EJ. 97. Blum RW, Runyan C. Adolescent abuse: the dimensions of the
Impact of Medicaid expansion on reported incidents of child ne- problem. J Adolesc Health Care. 1980;1(2):121–126
glect and physical abuse. Am J Prev Med. 2022;32(1):e11–e20 98. Alderman EM, Breuner CC; Committee on Adolescence. Unique
82. Puls HT, Hall M, Anderst JD, Gurley T, Perrin J, Chung PJ. State needs of the adolescent. Pediatrics. 2019;144(6):e20193150
spending on public benefit programs and child maltreatment. 99. US Department of Health and Human Services; Administration
Pediatrics. 2021;148(5):e2021050685 for Children and Families; Administration on Children, Youth and
83. Kaiser SV, Kornblith AE, Richardson T, et al. Emergency visits Families; Children’s Bureau. Child maltreatment. Available at:
and hospitalizations for child abuse during the COVID-19 pan- https://www.acf.hhs.gov/cb/research-data-technology/statistics-
demic. Pediatrics. 2021;147(4):e2020038489 research/child-maltreatment. Accessed September 19, 2023
84. Sege R, Stephens A. Child physical abuse did not increase dur- 100. Daigneault I, Hebert M, McDuff P. Men’s and women’s child-
ing the pandemic. JAMA Pediatr. 2022;176(4):338–340 hood sexual abuse and victimization in adult partner relation-
ships: a study of risk factors. Child Abuse Negl. 2009;33(9):
85. Centers for Disease Control and Prevention. Preventing Adverse
638–647
Childhood Experiences: Leveraging the Best Available Evidence.
Centers for Disease Control and Prevention, National Center for 101. Assink M, van der Put CE, Meeuwsen MWCM, et al. Risk factors
Injury Prevention and Control; 2019 for child sexual abuse victimization: a meta-analytic review. Psy-
chol Bull. 2019;145(5):459–489
86. Henize AW, Beck AF, Klein MD, Adams M, Kahn RS. A road map to
address the social determinants of health through community 102. Tulloch T, Kaufman M. Adolescent sexuality. Pediatr Rev. 2013;34(1):
collaboration. Pediatrics. 2015;136(4):e993–e1001 29–37, quiz 38
87. Garg A, Cull W, Olson L, et al. Screening and referral for low-in- 103. Thoma BC, Rezeppa TL, Choukas-Bradley S, Salk RH, Marshal MP.
come families’ social determinants of health by US pediatri- Disparities in childhood abuse between transgender and cisgen-
cians. Acad Pediatr. 2019;19(8):875–883 der adolescents. Pediatrics. 2021;148(2):e2020016907
88. Schickedanz A, Hamity C, Rogers A, Sharp AL, Jackson A. Clini- 104. Brodie N, McColgan MD, Spector ND, Turchi RM. Child abuse in
cian experiences and attitudes regarding screening for social children and youth with special health care needs. Pediatr Rev.
determinants of health in a large integrated health system. Med 2017;38(10):463–470
Care. 2019;57 Suppl 6(Suppl 6 2):S197–S201 105. Mahan JD, Betz CL, Okumura MJ, Ferris ME. Self-management
89. Kerker BD, Storfer-Isser A, Szilagyi M, et al. Do pediatricians ask and transition to adult health care in adolescents and young
about adverse childhood experiences in pediatric primary care? adults: a team process. Pediatr Rev. 2017;38(7):305–319
Acad Pediatr. 2016;16(2):154–160 106. Gilgoff R, Schwartz T, Owen M, Bhushan D, Burke Harris N.
90. Rariden C, SmithBattle L, Yoo JH, Cibulka N, Loman D. Screening Opportunities to treat toxic stress. Pediatrics. 2023;151(1):
for adverse childhood experiences: literature review and prac- e2021055591
tice implications. J Nurse Pract. 2021;17(1):98–104 107. American Medical Association. Current Procedural Terminology.
91. Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical American Medical Association; 2023
home concept. Pediatrics. 2004;113(5 Suppl):1473–1478 108. American Academy of Pediatrics, Committee on Coding and No-
92. Price J, Brandt ML, Hudak ML; Committee on Child Health Fi- menclature. Coding for Pediatrics 2021. American Academy of
nancing. Principles of financing the medical home for children. Pediatrics; 2020
Pediatrics. 2020;145(1):e20193451 109. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief
93. Letourneau EJ, Nietert PJ, Rheingold AA. Initial assessment of depression severity measure. J Gen Intern Med. 2001;16(9):
stewards of children program effects on child sexual abuse re- 606–613
porting rates in selected South Carolina counties. Child Mal- 110. Kroenke K, Spitzer RL, Williams JB. The Patient Health Question-
treat. 2016;21(1):74–79 naire-2: validity of a two-item depression screener. Med Care.
94. Letourneau EJ, Assini-Meytin LC, Kaufman KL, Mathews B, Palmer 2003;41(11):1284–1292
D. Preventing and Addressing Child Sexual Abuse in Youth Serv- 111. Flaherty EG, Stirling J Jr., American Academy of Pediatrics; Com-
ing Organizations: A Desk Guide for Organizational Leaders. mittee on Child and Neglect. Clinical report-the pediatrician’s
Moore Center for the Prevention of Child Sexual Abuse, Johns role in child maltreatment prevention. Pediatrics. 2010;126(4):
Hopkins Bloomberg School of Public Health; 2020 833–841

PEDIATRICS Volume 154, number 2, August 2024 15

Downloaded from http://publications.aap.org/pediatrics/article-pdf/154/2/e2024067608/1685453/peds.2024-067608.pdf
by guest