A further three Comments are included with The Lancet Series on Child Maltreatment, the first written Professor Dorothy A Scott, Director of the Australian Centre for Child Protection, University of South Australia, Australia. Professor Scott says: "In recent decades there has been a massive change in statutory child-protection services, particularly in English-speaking countries, which have introduced very extensive mandatory reporting laws, and invested more in detection, investigation, and legal intervention than western European systems. Consequently, these statutory child-protection systems have become over-whelmed and unsustainable, with more than one in five children reported as suspected victims of child maltreatment by the age of 18 years."
She discusses the large contribution of alcohol and substance abuse to child maltreatment; and also discusses that while sexual and physical abuse of child have the highest public profile, it is actually neglect and emotional abuse that are the most common reasons children enter child protection systems.
Professor Scott says: "The problem of child maltreatment will not be solved solely by services when social inequality is the under-lying social determinant. A public-health approach will add to the existing responses that cannot cope with such a complex, large-scale problem.Further opportunities that need to be explored include social marketing campaigns and national measures to reduce parental alcohol abuse, such as banning alcohol advertising and increasing taxes on beverages with a high content of alcohol."
She concludes: "In the 21st century, will a public-health approach be the third wave of the child-protection movement? To achieve this goal we need a collective commitment to make children central to our culture. We have come a long way in a century, but we have a very long way to go."
In the second Comment, Carole Jenny, Professor of Paediatrics at Warren Alpert Medical School of Brown University, Providence, RI, USA, discusses the importance of supporting paediatricians who work in child maltreatment. She says: "This Series is one indication of how far society has come in recognising an obligation to its young and vulnerable members. However, as a society we still might not want to acknowledge that individual children are being harmed. How else can we explain how easy it has been to vilify paediatricians who venture to say that an individual child might need protection from his or her carers?"
Professor Jenny discusses the difficulties paediatricians face in their diagnoses, when confronted with an injured child — for example, parents saying things like 'he rolled off the sofa' or 'she bruises easily' or 'he eats constantly, I don't know why he is so thin', to hide the truth of maltreatment. She says: "Imagine trying to make a diagnosis when the history presented is not only wrong but also presented in a way that will mislead the doctor away from the true diagnosis."
For how paediatricians in these difficult circumstances can be supported, Professor Jenny offers a number of suggestions. First, that people recognise the nature of evidence available to paediatricians when they make their diagnosis, and understand that this is often different to that for other clinical dilemmas. Second, the regulation of professionals — Professor Jenny believes rogue expert witnesses for the defence or prosecution should be required to present sound science before their pet theories are presented in court. Third, the current policy that experts should limit their testimony to their specific area of expertise should be changed — this currently allows experts to ignore obvious evidence disproving their assertions — for example, in the UK a radiologist can testify about radiological evidence from the bones, yet ignore obvious physical injuries on the skin saying such injuries are "outside their remit".
Finally, she calls for something to be done about the mass media, concluding: "The press are more likely to highlight stories about parents who are 'wrongly accused' by paediatricians, and paediatricians have no means to protect themselves from press attacks in view of the rules on patients' confidentiality. Trying cases in the press before they get to court is inappropriate and unfair. Paediatricians play an important part in protecting children—such doctors should be valued, encouraged, and supported as part of the safety net that safeguards vulnerable citizens."
The final Comment, by Children's Commissioner for England, Professor Sir Albert Aynsley-Green, 11MILLION, London, UK and Professor Sir David Hall, School of Child and Adolescent Health, University of Cape Town, South Africa, and University of Sheffield, UK, is a call to action for safeguarding children.
They say: "Many of the children at high risk of maltreatment grow up with multiple disadvantages: lack of vital preschool learning opportunities, behavioural problems, harsh inconsistent parenting, poor schools, food insecurity, unhealthy diet causing undernutrition or obesity and dental disease, and an increased risk of illness and death from sudden infant death syndrome, infections, substance abuse, suicide, and violent crime. The apparent success of the Nurse Family Partnership (currently undergoing a replication trial in the UK) suggests that for many families a focus only on preventing maltreatment is less effective than a positive approach of building child-care skills, self-esteem, and financial independence. However, such programmes are expensive, need scarce human resources, and must be targeted to those most likely to benefit."
The authors discuss the vast challenges for governments of the featureless estates of industrialised nations, and shanty towns of developing nations alike; and also the human rights approach discussed in the fourth paper of the Series.
They conclude: "Population pressures are likely to increase the risks of child maltreatment, particularly in developing countries. Climate experts question whether the world can sustain current levels of consumption and the projected population increase. To improve quality of life and reduce maltreatment in all its manifestations, child-health professionals should advocate not only for the Millennium Development Goal of child survival but also for family planning services, which currently are inaccessible to millions of couples. Children who are wanted and planned according to parental and environmental resources must surely have a better chance of enjoying their childhood free of maltreatment or neglect."
Professor Dorothy A Scott, Director, Australian Centre for Child Protection, University of South Australia, Australia T) + 61 8 8302 4030 E) Dorothy.a.scott@unisa.edu.au
Professor Carole Jenny, Warren Alpert Medical School of Brown University, Providence, RI, USA T) +1 401 255-0794 E) cjenny@lifespan.org
Professor Sir David Hall, School of Child and Adolescent Health, University of Cape Town, South Africa and University of Sheffield, UK T) (temp) +44 (0)1582 712802 / +44 (0) 7836 799918. E) david.hall@uct.ac.za / d.hall@sheffield.ac.uk
For comments please see: http://press.thelancet.com/childmaltreatmentcomments.pdf
For Series web extra material please see: http://press.thelancet.com/childmaltreatmentwebextra.pdf
Journal
The Lancet