Child Abuse as a Public Health Issue

By Richard A. Aronson, MD, MPH

In 1909, President Theodore Roosevelt articulated a governmental and societal responsibility for the health and safety of the nation's children. He stated that "each child represents a potential addition to the productive capacity...of the nation or, if allowed to suffer from neglect, a potential addition to the destructive forces of a community". Roosevelt made clear that society has a vested interest in seeing that all children do well. We all benefit when children grow up to become healthy, productive, and compassionate adults. The interests of society as a whole - indeed, its very security - depend on the welfare of our children, and ride on the extent to which we invest in children as our most precious resource. Roosevelt, in effect, was making the case, with which I strongly agree, that the prevention of child abuse and neglect, in all of its manifestations, is fundamentally a public health issue that should be front and center on our agenda as a nation and a world.

The stakes are high. A study conducted by Vincent J. Felitti and Robert Anda at Kaiser Permanente’s Department of Preventive Medicine revealed that “adverse childhood experiences are vastly more common than recognized or acknowledged, and [they] have a powerful relation to adult health a half-century later.” The child abuse categories of the Adverse Child Experiences (ACE) Study were: physical, emotional, and sexual abuse. Other ACE's included in the study were an alcohol and/or drug abuser in the household; an incarcerated household member; someone who has severe mental illness; mother treated violently; one or no parents; and emotional or physical neglect. The study revealed that a survivor of four or more of these adverse childhood experiences has a higher likelihood of smoking, chronic obstructive pulmonary disease, using intravenous drugs, and attempting suicide. Depression and obesity were also found more likely among individuals with exposure to childhood trauma.

This study’s findings highlight the public health urgency and challenge to prevent childhood trauma and, when it happens, to promote healing. We turn, for example, to Emmy Werner’s groundbreaking research on resilience. The Kauai Longitidunal Study followed 700 high risk children born in 1955 on the Hawaiian island of Kauai, addresses two fundamental questions: 1) What are the long-term effects of adverse perinatal and early child-rearing conditions on physical, cognitive, and psychosocial development in mid-life? 2) Which protective factors allow most individuals who are exposed to multiple childhood risk factors to do well in adulthood? The study followed a group of high risk children who had been exposed to chronic economic poverty, birth complications, parenntal psychopathology, and family discord as well as comparison groups.

The news from the study was, on one hand, good. A loving home environment makes all the difference. The long-term outcomes depended, increasingly, on the quality of the child-rearing environment and the emotional support provided by family members, friends, teachers, and adult mentors. One out of three who seemed headed for “disaster” didn’t turn out that way. These individuals, in addition to the quality of the child-rearing environment, had the following protective factors: 1) Charisma! They had an ability to be self-confident and attractive to other people. “Look, I’m worth something.” They took responsibility for themselves and others from an early age. 2) Self-efficacy: I can make things happen. I can make a difference. 3) At least one loving consistent adult. 4) Mentor: A teacher, coach, or other adult is extremely important. As Jacqueline kennedy Onassis once said, "If you bungle raising your children, nothing else in life matters very much".

On the other hand, the research by Werner and others highlights the urgency and necessity of putting our resources into programs and services that create humane worlds for children. We need to back up our words about investing in children with action and policy at all levels. All children benefit from humane resilience promoting systems in education, child care, health care, and parent support. Home visitation programs, when carried out under specific criteria, have been shown to prevent child abuse. Andd yet our society is lacking in its commitment to providing these and other services to all families.

Research on social support shows that a child needs someone who is absolutely crazy about him or her. But research also shows that youth and adults need that level of intimacy too. Thus, to prevent child abuse, for example, adults must have their own close relationships that encourage and support them to engage in safe parenting practices. Otherwise, a program to prevent child abuse is bound to fail.

The Humane Worlds Center provides consultation to communities, organizations, and others who seek to translate research, some of which I have reviewed above, into humane and culturally competent strategies to prevent child abuse.