Which approach should the nurse take when interacting with a caregiver of a child with suspected maltreatment?

Prevention and Treatment of Child Maltreatment –The Role of the School Nurse

Position Statement

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SUMMARY   

It is the position of the National Association of School Nurses (NASN) that prevention, early identification, intervention and care of child maltreatment are critical to the physical/emotional well-being and academic success of students. Registered professional school nurses (hereinafter referred to as school nurses) practice within the NASN Framework for 21st Century School Nurse Practice™ and serve a vital role in the recognition of early signs of child maltreatment, assessment, identification, intervention, reporting, referral, and follow-up of children in need.  Serving as members of interdisciplinary teams, school nurses also collaborate with school personnel, community stakeholders, healthcare professionals, students, and families to promote the safety and protection of children.  The presence of a school nurse in every school all day, every day allows the school nurse to build trusting and supportive relationships with children/youth who may be victims of child maltreatment.  Research has shown that these relationships can optimize student health, safety, and learning (CDC, 2014; Maughan et al., 2017).

BACKGROUND

Child maltreatment was initially recognized as a significant social problem in the 1960s when Henry Kempe published his article on battered child syndrome (Child Welfare Information Gateway, 2017).  His work led to the adoption of a formal reporting system at the state and federal level and ultimately the passage in 1974 of the Child Abuse and Prevention and Treatment Act (CAPTA), the primary federal legislation addressing child abuse and neglect. CAPTA was most recently reauthorized in 2015 by the Justice for Victims of Trafficking Act and in 2016 by the Comprehensive Addiction and Recovery Act of 2016 (Child Welfare Information Gateway, 2017). CAPTA defines child maltreatment as the following:

"Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, (including sexual abuse as determined under section 111) or an act or failure to act which presents an imminent risk of serious harm" (U.S. Department of Health and Human Services [USDHHS], Administration for Children and Families [ACF], Administration on Children, Youth and Families [ACYF], Children’s Bureau, 2017, p. 7).

While this is the federal definition, it is important to understand that each state defines child maltreatment in its own state statutes and policies (Child Welfare Information Gateway, 2016). A child is defined as a person who has yet to reach the age of 18 years and who is not an emancipated minor. However, in the case of sexual abuse, the age of the child is specified by the child protection law of the state in which the child resides (Child Welfare Information Gateway, 2017).

Child maltreatment may present in a variety of forms (Child Welfare Information Gateway, 2017): 

• Physical Abuse - intentional use of physical force against a child that results in or has the potential to result in physical injury
• Sexual Abuse – any completed or attempted (non-completed) sexual act, sexual contact with or exploitation of a child by adult
• Psychological Abuse - intentional caregiver behavior that conveys to a child that he/she is worthless, flawed, unloved, unwanted, endangered or valued only in meeting another’s needs
• Neglect - the failure to provide for a child’s basic physical, emotional, or educational needs or to protect child from harm or potential harm
  • Failure to provide - failure by a caregiver to meet the child’s basic physical, emotional, medical/dental or educational needs, or combination thereof
  • Failure to supervise - failure by the caregiver to ensure a child’s safety within and outside the home given the child’s emotional and developmental needs
• Trafficking- The term sex trafficking, another form of child maltreatment, means the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act. The term “severe forms of trafficking in persons” means sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age (Child Welfare Information Gateway, 2018)

All 50 states, the District of Columbia, and the U.S. territories have mandatory child maltreatment reporting laws that require certain professionals who have frequent contact with children to report suspected maltreatment to a Child Protective Services agency. These professionals are legally designated as mandatory reporters and include school nurses and other school staff.  In 2016, the highest percentage (18.4%) of suspected child maltreatment reports came from education personnel (USDHHS, ACF, ACYF, Children’s Bureau, 2018).

Child Maltreatment 2016 reports the number and rate of victims of maltreatment has fluctuated during the past five years with a 3% overall increase in the number of victims from 2012 to 2016.  During 2016 an estimated 1,750 children died as a result of child maltreatment (USDHHS, ACF, ACYF, Children’s Bureau, 2018).

The National Child Abuse and Neglect Data System identified the incidence of four types of child abuse during 2016 (USDHHS, ACF, ACYF, Children’s Bureau, 2018).  Neglect constituted the highest number of cases (74.8%), followed by physical abuse (18.2%), sexual abuse (8.5%) and other types of maltreatment such as psychological abuse, lack of supervision, and substance abuse exposure (6.9%) (USDHHS, ACF, ACYF, Children’s Bureau, 2018)

While recent trends show a slight increase in the number of child maltreatment reports, long term trends in rates have decreased markedly since 1992.  In the years 1992-2016, sexual abuse declined 65%, physical abuse decreased 53%, and neglect dropped 12%.  These long-term trends may reflect the success of various public policy and public awareness initiatives (Finkelhor, Saito, & Jones, 2018).  School nurses should advocate for continued analysis, research, and development of evidence-based policy initiatives to prevent and address the overwhelming negative effects of child abuse and neglect. 

RATIONALE

The negative impact of child maltreatment on the child, the family, and society as a whole cannot be underestimated.  Maltreated children suffer both immediate and long-term impairments to their mental, emotional, physical, educational, and social well-being (Jordan, MacKay, & Woods, 2016).  The seminal Adverse Childhood Experiences (ACEs) study demonstrated that childhood trauma, in the form of child maltreatment and family dysfunction, are linked to leading causes of adult morbidity and mortality (Gilbert et al., 2015).  The ACEs study shifted the focus of the child maltreatment field from the effect of individual types of childhood victimization to the cumulative effect of ACEs on child and adult well-being and called for strategies to prevent the occurrence of ACEs and their adverse impacts at every level (Oral, Ramirez, & Coohey , 2016).   Trauma Informed Care (TIC), a crisis response strategy to help students return to school and resume learning, is an approach that schools and school nurses can promote.  TIC realizes the widespread impact of trauma, recognizes the signs and symptoms of trauma, and responds appropriately (Substance Abuse and Mental Health Services Administration , 2015).

Child maltreatment prevention efforts have traditionally focused on a secondary prevention model that emphasizes reducing the risk of recurrence of child abuse and neglect (Center for Social Policy, 2014). Current efforts center on preventing maltreatment from occurring in the first place, thereby placing the focus on primary prevention and community awareness.   This approach is represented by the Strengthening Families Approach and Protective Factors Framework developed by the Center for Social Policy (2014).  There are five Strengthening Families protective factors:

• parental resilience
• social connections
• knowledge of parenting and child development
• social and emotional competence of children
• concrete support in times of need   

School nurses have the education and skills to implement TIC and to strengthen the five protective factors.  For example, school nurses may educate parents about positive behavior interventions, appropriate health care, and early literacy interventions for their children.  Continued educational offerings with school nurses to increase their knowledge, confidence, attitude, and self-efficacy regarding child maltreatment are needed.  There is clear evidence that clinical practice changes can contribute to the goal of overcoming child maltreatment (Jordan et al., 2016).    

School nurses can be involved in prevention, early identification, reporting, and treatment related to child maltreatment because of their opportunity to interact with children daily.   School nurses are professionally and ethically accountable to do the following:

• know local laws, regulations, policies, and procedures for reporting child maltreatment.
• know the signs and potential indicators of child maltreatment including sexual exploitation.
• provide clear nursing documentation that includes questions asked and answers given and use a body diagram when appropriate for suspected child maltreatment and sexual exploitation.
• provide students with personal body safety education and advocate for school health education policies that include personal body safety.
• educate and support staff regarding the signs and symptoms of child maltreatment.
• identify students with frequent somatic complaints which may be indicators of maltreatment.
• provide support to victims of child maltreatment.
• facilitate the linkage of victims and families to community resources, including a medical home (American Academy of Pediatrics, 2016).
• collaborate with community organizations to raise awareness and reduce the incidence of child abuse and neglect.

CONCLUSION

Students are central to NASN’s Framework for 21st Century School Nursing Practice™. School nurses implement the Framework principle of care coordination through direct care of the maltreated child, serving on interdisciplinary teams, and  educating faculty and staff in the recognition and reporting of child maltreatment; the Framework principle of community/public health is illustrated by the school nurse’s implementation of evidence-based prevention models such as the Strengthening Families Approach and TIC (NASN, 2016).  School nurses develop long-term, trusting relationships with students, which allow for detection of signs of abuse and disclosure.  School nurses are uniquely positioned to positively affect the academic achievement of students by keeping them healthy, safe, and ready to learn. 

REFERENCES

American Academy of Pediatrics. (2016). Role of the school nurse in providing school health services (Position Statement).  Retrieved from http://pediatrics.aappublications.org/content/early/2016/05/19/peds.2016-0852

Child Welfare Information Gateway. (2016). Definitions of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children's Bureau. Retrieved from https://www.childwelfare.gov/pubPDFs/define.pdf

Child Welfare Information Gateway. (2017). Child maltreatment prevention: Past, present, and future. Washington, DC: U.S. Department of Health and Human Services, Children's Bureau. Retrieved from https://www.childwelfare.gov/pubPDFs/cm_prevention.pdf

Child Welfare Information Gateway. (2018). 2018 prevention resource guide. Washington, D.C.: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from https://www.childwelfare.gov/pubPDFs/guide_2018.pdf

Center for Social Policy. (2014). The strengthening families approach and protective factors framework: Branching out and reaching deeper. Retrieved from https://www.cssp.org/reform/strengtheningfamilies/2014/The-Strengthening-Families-Approach-and-Protective-Factors-Framework_Branching-Out-and-Reaching-Deeper.pdf  

Centers for Disease Control and Prevention. (2014). Essentials for childhood: Steps to create safe, stable, nurturing relationships and environments. Retrieved from https://www.cdc.gov/violenceprevention/pdf/essentials_for_childhood_framework.pdf

Gilbert, L.K., Breiding, M.J., Merrick, M.T., Thompson, W.W., Ford, D.C., Dhingra, S.S., & Parks, S.E. (2015). Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010. American Journal of Preventive Medicine, 48(3), 345-349.  doi: 10.1016/j.amepre.2014.09.006

Finkelhor, D., Saito, K., & Jones L. (2018). Updated trends in child maltreatment. Durham, NH: Crimes Against Children Research Center.  Retrieved from http://www.unh.edu/ccrc/pdf/Updated%20trends%202014.pdf

Jordan, K., MacKay, P., & Woods, S. (2016). Child maltreatment: Optimizing recognition and reporting by school nurses.  NASN School Nurse, 32(3), 192-199; doi:10.1177/1942602X16675932

Maughn E.D., Cowell J., Engelke M.K., McCarthy, A.M. Bergren, M.D., Murphy, M. K., … Vessey J.A. (2017). The vital role of school nurses in ensuring the health of our nation’s youth. Nursing Outlook, 66(1), 94-96. doi:https://doi.org/10.1016/j.outlook.2017.11.002

National Association of School Nurses. (2016). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-53. doi: 10.1177/1942602X15618644

Oral, R.,  Ramirez, M., & Coohey, C.  (2016). Adverse childhood experience and trauma informed care: The future of health care. Pediatric Research, 79(1). doi:10.1038/pr.2015.197

Substance Abuse and Mental Health Services Administration. (2015). SAMHSA’s concept of trauma and guidance for a trauma-informed approach.  Retrieved from http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf

United States Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2017). The Child Abuse Prevention and Treatment Act. Retrieved from https://www.acf.hhs.gov/cb/resource/capta2016

U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2018). Child maltreatment, 2016. Retrieved  from https://www.acf.hhs.gov/sites/default/files/cb/cm2016.pdf

Acknowledgment of Authors

Mary Freeland, RN

Traci Easterling, MSN, RN, NCSN

Kathy Reiner, MPH, BSN, RN

Christine Amidon, BSN, RN, NCSN

Adopted:  June 2018

This document replaces the position statement Care of Victims of Child Maltreatment: The School Nurse’s Role (adopted January 2014).

Suggested citation: National Association of School Nurses. (2018). Prevention and intervention of child maltreatment —The role of the school nurse (Position Statement). Silver Spring, MD: Author.

All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.

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