Mitigating COVID-19's Rural Impact on Families At-Risk for Violence and Child Maltreatment and Neglect

by Kay Miller Temple, MD

The irony of COVID-19's physical distancing is that many family units now have an increased closeness. For some, perhaps to a degree not previously experienced.

The Center for the Study of Traumatic Stress, a section within the Uniformed Services University's Department of Psychiatry, provided a message addressing COVID-19's impact on family togetherness, stating that this closeness might increase conflicts that occur in usually healthy relationships. However, for children and adults already at risk and living in circumstances of harm, other experts expressed concern that physical distancing is causing an even greater negative impact. To address this likelihood, rural experts who work with children experiencing maltreatment and adults experiencing intimate partner violence have engaged in raising awareness and modified their workflows in order to accommodate the needs of these at-risk populations.

On March 27, New Mexico's gubernatorial school closure announcement actually included a segment dedicated to child abuse and neglect awareness, encouraging state residents to "be extra aware of the safety and well-being of children they know and those in their neighborhoods." Cell phone and landline numbers for reporting any concerns were listed.

Dr. Laurie Carter, a pediatric hospitalist at Community Children's in Missoula, Montana, and member of the American Academy of Pediatrics Committee on Child Abuse and Neglect, said discussions happening on the committee's listserv highlighted the marked decrease in calls to maltreatment hotlines, with some states recording nearly a 50% decrease as early as mid-March. Recognizing that those numbers only reflected decreased reporting rather than a sudden decrease in child maltreatment, she said she realized the need for local action in her own community.

"We really wanted to raise awareness about the ripple effect of stay-at-home orders on the well-being of children," Carter said. "Though the orders were a safe practice to stop the spread of COVID-19, they would also be dangerous for children who are in unsafe home situations."

 
Carter recognized that raising awareness was a logical first step in her rural area and worked with the Community Medical Center's media lead to formulate a press release. The statement generated not only an interview with regional television news but also triggered calls from the area's rural clinicians and community leaders wanting to know more and how to do more. Carter said that shortly following the press release, she noted that several school systems sent letters to parents reminding them of local resources that can help families deal with challenges associated with physical distancing measures. Carter also connected with the state's health and human services officials. As a result, she said she is working with afterschool and childcare program administrators across the state to create a training program that will assist their teams in providing support and resources to families dealing with the pandemic's physical distancing challenges.

What is Child Maltreatment?

According to the Centers for Disease Control and Prevention (CDC), child maltreatment is "any act, intentional or not, that results in harm, the potential for harm, or the threat of harm to a child. The failure to provide for a child's needs or to protect a child from harm or potential harm is also child maltreatment." Experts added that specific definitions are also in state statutes. Other experts shared that though parents, caregivers, or custodians such as coaches, teachers, and clergy are usually considered protectors of children, some may also harm children.

The CDC identified four categories of child maltreatment: physical abuse, sexual abuse, emotional abuse, and neglect.

Dr. Lauren Wilson, Carter's colleague in Missoula, said that in addition to pediatricians' normal work of maltreatment prevention, they also have a role in sharing information with their peers and other professionals about the importance of recognizing specific findings associated with abuse and neglect.

"There are many times when children present with a specific injury, referred to as a sentinel injury," Wilson said. "If these injuries can be recognized in the moment, then future harm can be prevented, especially in times like this when harm can escalate with increasing stressors."

Experts shared that certain behaviors like constant expression of hunger, or certain bruising patterns, fractures, and abdominal injuries are a few of the sentinel indicators and injuries which raise concern about maltreatment. Previous to the current pandemic, Carter and Wilson had already created information on maltreatment for the community's clinicians.

Talk About It: Child Maltreatment Prevention in Rural Areas

Current physical distancing requirements aside, experts said due to rural areas' low population density, children are likely to be surrounded by fewer watchful adults, compared to children in more suburban and urban neighborhoods, especially now when schools are not in session. However, experts also suggested that in rural areas, even a few voices can still have measurable impact, as seen with the Montana example.

Chris Newlin is the executive director of the National Child Advocacy Center, an organization with multiple roles, including training professionals from multiple backgrounds who work with abused children and their families. The center's work specifically emphasizes the multidisciplinary team approach to child maltreatment. Newlin talked about the power of local voices, such as those of community leaders, during the current restrictions.

"Yes, we have to be vigilant in reporting, but if you really want to try to help prevent child abuse, it's even more important to talk about it openly," he said. "There is no setting where this should not be discussed. Keeping silent does not help. Talking about how we need to look out for children and how this is a time when children can be at even more risk can be important. When people who may harm children hear others openly addressing abuse, it actually makes them less likely to harm."

Newlin further explained how important it is to remember that those who harm children are usually not the strangers that children are traditionally taught to avoid.

"The reality is that children are overwhelmingly much more likely to be sexually abused by someone they know and trust and that their parents know and trust," he said. "More than 90% of sexual abuse is committed by individuals known to the child. Individuals we allow our children to be around. It's a sad thing for me to have to say, but literally anyone is capable of sexually abusing a child. And just because we've known someone a long time doesn't mean that they necessarily couldn't or wouldn't do it."

Understanding Relationships: Child Maltreatment and Domestic Violence

According to the National Domestic Violence Hotline, domestic violence (DV) is also referred to as intimate partner violence (IPV), domestic abuse or relationship abuse. Because DV impacts every demographic and includes the maltreatment of children, it is defined as "a pattern of behaviors used by one partner to maintain power and control over another partner in an intimate relationship."

For several clinics in Tillamook County, Oregon, Tides of Change typically provides onsite experts for a warm handoff for intervention when DV is suspected or revealed. Emily Fanjoy is the health programs coordinator for the organization. Referencing the power and control wheel, she explained that child maltreatment is actually part of intimate partner violence and can definitely be impacted by the current physical distancing measures.

"Intimate partner violence is actually a pattern of tactics — tactics that are inclusive of all aspects of life — that a person uses against the other person in the relationship in order to gain and maintain power and control," Fanjoy said. "One slice of the power and control wheel pie is using the children as a manipulation tool in that structure. It's helpful to think of the family structure as represented by one protective parent while the other parent chooses abusive, unhealthy, harmful behavior. A person choosing harmful behaviors often harms children as another way of harming their partner. Child abuse and neglect may be part and parcel of the abuse."

Changing Support Work in Times of COVID-19

With Oregon's physical distancing measures, Fanjoy said her organization had to make a "quick pivot" in three main directions. First, as did all statewide coalition members, Tides of Change withdrew their physical presence and warm handoffs from the three local medical clinics they serve in Tillamook County, though they continue limited emergency community interventions for vetted circumstances.

At the same time Oregon authorities began sharing that child maltreatment reports had dropped nearly 75%, Fanjoy said there were anecdotal reports that police calls for DV were rising, likely indicating an escalation in abuse severity.

"It's not that domestic violence and child abuse suddenly stopped with physical distancing, it's that interaction with safety networks stopped and interaction is being filtered by the people who are causing harm," she said. "Violence has escalated to the extent that they're not reaching out for advocacy services. Instead, they need the police to come and stop this now."

In view of these latter issues, the organization's work pivoted a second time. Working with their funder, they received permission to use monies available from canceled conference attendance to purchase laptops and smartphones to enable team members to work from home. The funding shift also allowed for a wish-list item to be realized: a website chat box, which is recognized as particularly helpful for teens and also for those with limited access to services. Since a chat box does not leave a text chain stored in a person's phone, it's a safer option for people who fear their phone use is being monitored.

Despite having these new tools to allow staff to work from home, the organization still encounters service delivery barriers.

"The challenge with rural areas — and you have to understand the geography of Tillamook County is no exception, being 'squished' between the Pacific Ocean and a mountain range — is that many of our clients reside in locations where there is either no cell phone reception or reception is low."

Fanjoy said the third change has come from increased engagement from outside the county's established multidisciplinary community collaboration.

"In Tillamook, we have robust and established connections in our county network with healthcare, social services, a food bank, housing, childcare, and education for which I am grateful, thankful, and excited," Fanjoy said. "Our regularly scheduled monthly meetings are now call-in meetings with updates. Our last several calls have included additional community representatives. It feels like there is more concern and an increased desire to understand how people are being impacted. That's important for our work."

Domestic Violence Disclosure, Screening, Telehealth, and Provider Assistance

Over the past several decades, research has focused on the impact of DV on chronic physical and mental health conditions and brought clarity to the issue that DV is not just a legal concern, but a public health challenge. The Affordable Care Act included changes for DV screening and counseling.

Experts remind clinicians that even with screening, only a small proportion of survivors — in the language of DV, "survivor" refers to an individual who seeks help during or after leaving a harmful relationship — disclose abuse when screened in healthcare settings. Those same experts also underscore the importance of regular and repeated screening. In a 2018 Rural Monitor interview, Dr. Gregory Della Rocca, an orthopedic trauma surgeon at the University of Missouri, shared his experience with disclosures.

"I get referrals for acute traumatic injuries and injuries that haven't healed correctly," Della Rocca said. "That means I will see patients multiple times until the injury heals, sometimes up to seven times in a year. For some of those patients, that might mean seven screening opportunities, compared to a primary care provider's annual screen or an ER doctor's one-time occasion. It's important to point out that sometimes it's that seventh time when a patient finally has the courage to say, 'I didn't fall down the stairs. I was pushed.'"

Under normal circumstances, a healthcare organization's screening practices might be linked to a mandatory solo patient rooming protocol. However, because of recent distancing requirements that are shifting care to telehealth, Futures Without Violence health program manager Kate Vander Tuig said that rather than screening, clinical teams should consider also shifting to a universal offering of education and resources for DV and child maltreatment.

"Regardless if a patient discloses abuse or not, with new limitations in place due to COVID-19, making sure patients get this messaging becomes even more important," she said. "Survivors and their families are facing increased risks and we understand rural clinicians and healthcare organizations may feel compelled to continue domestic violence and child maltreatment screening when providing care by phone or telehealth. However, we are concerned about the safety of this practice because it's difficult to assess who's in the room. You don't know who is listening or who is monitoring the contact. We recommend offering hotline information as a resource for friends and family using some type of scripted message that provides the information in a universal manner."

 
Vander Tuig also pointed out that clinical staff should be aware that the hotline is not just a resource for patients but can also be a very important resource for the clinicians themselves as they assist and support patients in complicated situations.

"Clinical providers who are also providing telehealth care in isolated surroundings should not feel alone when assisting patients who are in difficult situations," she said. "They don't need to feel like they have to figure this out themselves when hotlines can help them help their patients. Providers who find themselves really struggling with decisions can call the national hotline and get assistance with figuring out the best way to help a patient or a family. They should not feel alone when trying to provide this type of assistance. The hotlines exist for everyone."