Invited Commentary: Gaze Aversion and Unnoticed Phenomena

Invited Commentary: Gaze Aversion and Unnoticed Phenomena Abstract Child abuse is a social phenomenon that has been underresearched and undersupported. The scale of the problem is large, with over 3 million US children reported for abuse or neglect each year. An estimated 15% of confirmed victims may be placed in out-of-home care to ensure their safety. Studies have not previously examined the impact of losing a child into foster care on maternal health and mortality. Family and maternal risk factors, such as teen pregnancy, intimate partner violence, or drug and alcohol abuse, have been well documented as risk factors for maltreatment. The findings of Wall-Wieler et al. (Am J Epidemiol. 2018;187(6):1182–1188) are not so much unexpected as they are surprising in that the impact of foster care on maternal health has heretofore been largely unexamined. The innovative use of maternal sisters with children not in foster care as controls provides a powerful control for family genetics, and family environment with likely common early life experiences, in the mortality of the mothers whose children were removed. With over 3 million children reported for suspected maltreatment each year, the related health and social outcomes for both children and their families require more careful examination using public health methods. foster care In this issue of the Journal, Wall-Wieler et al. (1) examined the mortality of mothers who have lost their children into foster care; it is an example of a remarkable and innovative project that reveals important information that was hiding in plain sight. Gaze aversion, or turning our heads away from unpleasant topics, is a phenomenon with which scientists and clinicians working in the field of child abuse are quite familiar (2). Child abuse and neglect occur at higher rates than a host of diseases and conditions that are much better supported in terms of research funding: gaze aversion in action. Fewer research dollars are spent on a per-death or even a per-case basis for stigmatized conditions such as child abuse and neglect or substance abuse than for other conditions (3). As a society, we ignore this unpleasant problem until we are forced to deal with it in a crisis (4). Now we are shown that the experts working in this field, too, have had their form of “gaze aversion.” We turn away from examining the parents’ lives after rescuing the children. We have not noted the premature mortality among biological mothers of foster children even though this will influence the potential for reunification of children with their families. For well over 100 years, society has addressed child maltreatment by rescuing children from homes judged to be hazardous and placing them in new, safer environments (5). Foster-care placement may be about punishing mothers seen to have failed to protect their children as well as ensuring safety of the children (6). Decisions about foster-care placement have been examined with respect to impact of foster care on the children and their safety and development (7). The impact of the removal of a child on the other family members, particularly the mother, has been largely unstudied. The sparse literature on services provided to the biological parents of children taken into care “paint a picture of incomplete and somewhat negligent service delivery to parents of children in care.” (8) The study by Wall-Wieler et al. (1) is remarkable first for the direction of its gaze. In our efforts to keep children safe and protected, the adverse impact of intervention on the mothers should be considered. In the United States in 2016, 3.5 million children were reported at least once for suspected abuse or neglect and an investigation substantiated or indicated that abuse or neglect had occurred for 17% (9). US Department of Health and Human Services estimates that 676,000 children were confirmed as victims of abuse or neglect in the year with the most recent complete data: a rate of 9.1 victims per 1,000 children (10). In the first year of life the rate was 24.8 per 1,000 population of children (10). Neglect, an omission of action by the parent, is the most common form of maltreatment. Risk factors for both abuse and neglect include young parental age, lower parental education, poverty, and substance abuse (11). Only a small proportion of children substantiated as maltreated are removed from the home and placed in out-of-home care; more than 80% of confirmed victims remain in their homes (12). However, there are wide variations in rates of foster-care placement between jurisdictions, with some counties using foster care rarely and others using foster care for one-third or more of substantiated victims (13). In Canada, the location of the reported study, first nations citizens are overrepresented in the foster-care system; aboriginal children represent 7% of Canadian children but account for 48% of all foster children in that country (14). The conditions that pose a risk for the children in families and bring them to the attention of authorities—alcohol and substance abuse, intimate partner violence, teen parenthood, poverty, and environmental hazards—also pose a risk for increased mortality among their mothers. Wall-Wieler et al. (1) innovatively examined the mortality of foster mothers by comparing them to their sisters who did not have a child removed and placed into foster care. Sisters share many common features, including family educational aspirations, circumstances of poverty, drug or alcohol abuse by their families of origin, and genetics. Their own early-life experiences and the influences of their parents are likely to be similar. Teen women whose own mothers and sisters gave birth as teenagers are significantly more likely to have a teen pregnancy (15). They add a significant degree of control to a comparison that would clearly fall short if made with random mothers as a control group. However, poverty, drug abuse, intimate partner violence exposure, and even young parental age are not perfectly controlled, as divergence in these factors may be exactly what protected the control mothers from losing their own children. Careful examination of both risk and protective factors in young children’s lives require the attention of new investigators and clinicians in order to develop interventions to prevent or treat child abuse and neglect. Wall-Wieler et al. (1) have shown us that the biological mothers of foster children are another group meriting study. The use of large data sets and epidemiologic approaches to examine policies and programs in the area of child abuse and neglect are both possible and needed as more than 3 million children are reported for maltreatment in the United States alone each year; there has been relatively little empirical work to guide decisions about intervention and services for a very large number of children and families. Strong epidemiologic research can help us address not only service delivery but prevention as well. Reducing teen childbearing may be among the strategies most likely to prevent child abuse in our society, and we may have a natural experiment with the reductions in teen pregnancy seen in the past 10 years in many states. We find that teen parents use more harsh discipline (D.K.R., unpublished data, 2015) and are more likely to inflict abusive head trauma (16). Teen parents are also more likely to live in poverty and have less health-care access, and their children will have reduced rates of school success (17). While child protective service agencies seek reunification of child and family and try to help parents regain custody through plans that specify steps and training, the children’s parents may not have access to the financial resources, health insurance, and counseling to address the underlying shortcomings in the care of their children. More epidemiologic research is needed to guide public policy development addressing substance abuse treatment, access to medical care, and efforts to reduce poverty in families reported for maltreatment. Policy initiatives such as allowing biological mothers of foster children to receive Medicaid and publically supported mental health services while their children are in care may seem expensive, but they may save money by returning children to their homes sooner and preventing reentry into child protective services systems. Policies and programs reducing teen pregnancy or delaying childbearing may reduce the need for foster care and the risk of mortality among mothers losing custody of their children. This is a field wide open to sound population-based research. ACKNOWLEDGMENTS Author affiliation: Kempe Center for the Prevention and Treatment of Child Abuse and Neglect and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado (Desmond K. Runyan). Conflict of interest: none declared. REFERENCES 1 Wall-Wieler E , Roos LL , Nickel NC , et al. . Mortality among mothers whose children were taken into care by child protection services: a discordant sibling analysis . Am J Epidemiol . 2018 ; 187 ( 6 ): 1182 – 1188 . 2 Krugman RD , Leventhal JM . Confronting child abuse and neglect and overcoming gaze aversion: the unmet challenge of centuries of medical practice . Child Abuse Negl . 2005 ; 29 ( 4 ): 307 – 309 . Google Scholar CrossRef Search ADS PubMed 3 Best RK . Disease politics and medical research funding: three ways advocacy shapes policy . Am Sociol Rev . 2012 ; 77 ( 5 ): 780 – 803 . Google Scholar CrossRef Search ADS 4 Gainsborough J . Scandalous Politics: Child Welfare Policy in America . Washington, DC : Georgetown University Press ; 2010 . 5 Ten Bensel RW , Rheinberger MM , Radbill SX . Children in a world of violence: the roots of child maltreatment. In: Helfer ME , Kempe RS , Krugman RD , eds. The Battered Child . Chicago, IL : University of Chicago Press ; 1997 : 3 – 28 . 6 Ringwalt C , Earp J . Attributing responsibility in cases of father-daughter sexual abuse . Child Abuse Negl . 1988 ; 12 ( 2 ): 273 – 281 . Google Scholar CrossRef Search ADS PubMed 7 American Academy of Pediatrics. Committee on Early Childhood and Adoption and Dependent Care. Developmental issues for young children in foster care . Pediatrics . 2000 ; 106 ( 5 ): 1145 – 1150 . CrossRef Search ADS PubMed 8 Alpert L . Research review: parents’ service experience—a missing element of research in foster care outcomes . Child Fam Soc Work . 2005 ; 10 ( 4 ): 361 – 366 . Google Scholar CrossRef Search ADS 9 Children’s Bureau . Child Maltreatment 2016. Washington, DC: US Department of Human Services; 2018 . https://www.acf.hhs.gov/cb/resource/child-maltreatment-2016. Accessed February 27, 2018. 10 Children’s Bureau . Child Maltreatment 2016. Washington, DC: US Department of Human Services; 2018 . https://www.acf.hhs.gov/sites/default/files/cb/cm2016.pdf#page=10. Accessed February 27, 2018. 11 Brown J , Cohen P , Johnson JG , et al. . A longitudinal analysis of risk factors for child maltreatment: findings of a 17 year prospective study of officially recorded and self-reported abuse and neglect . Child Abuse Negl . 1998 ; 22 ( 11 ): 1065 – 1078 . Google Scholar CrossRef Search ADS PubMed 12 Horwitz SM , Hurlburt MS , Cohen SD , et al. . Predictors of placement for children who initially remained in their homes after an investigation for abuse or neglect . Child Abuse Negl . 2011 ; 35 ( 3 ): 188 – 198 . Google Scholar CrossRef Search ADS PubMed 13 Runyan DK , Gould CL , Trost DC , et al. . Determinants of foster care placement for the maltreated child . Am J Public Health . 1981 ; 71 ( 7 ): 706 – 711 . Google Scholar CrossRef Search ADS PubMed 14 Statistics Canada . Study: living arrangements of Aboriginal children aged 14 and under, 2011. Ottawa, Canada: Statistics Canada; 2016 . http://www.statcan.gc.ca/daily-quotidien/160413/dq160413a-eng.htm?HPA. Accessed February 27, 2018. 15 East PL , Reyes BT , Horn EJ . Association between adolescent pregnancy and a family history of teenage births . Perspect Sex Reprod Health . 2007 ; 39 ( 2 ): 108 – 115 . Google Scholar CrossRef Search ADS PubMed 16 Keenan HT , Runyan DK , Marshall SW , et al. . A population-based study of inflicted traumatic brain injury in young children . JAMA . 2003 ; 290 ( 5 ): 621 – 626 . Google Scholar CrossRef Search ADS PubMed 17 Savio-Beers LA , Hollo RE . Approaching the adolescent-headed family: a review of teen parenting . Curr Probl Pediatr Adolesc Health Care . 2009 ; 39 ( 9 ): 216 – 233 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Epidemiology Oxford University Press

Invited Commentary: Gaze Aversion and Unnoticed Phenomena

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Child abuse is a social phenomenon that has been underresearched and undersupported. The scale of the problem is large, with over 3 million US children reported for abuse or neglect each year. An estimated 15% of confirmed victims may be placed in out-of-home care to ensure their safety. Studies have not previously examined the impact of losing a child into foster care on maternal health and mortality. Family and maternal risk factors, such as teen pregnancy, intimate partner violence, or drug and alcohol abuse, have been well documented as risk factors for maltreatment. The findings of Wall-Wieler et al. (Am J Epidemiol. 2018;187(6):1182–1188) are not so much unexpected as they are surprising in that the impact of foster care on maternal health has heretofore been largely unexamined. The innovative use of maternal sisters with children not in foster care as controls provides a powerful control for family genetics, and family environment with likely common early life experiences, in the mortality of the mothers whose children were removed. With over 3 million children reported for suspected maltreatment each year, the related health and social outcomes for both children and their families require more careful examination using public health methods. foster care In this issue of the Journal, Wall-Wieler et al. (1) examined the mortality of mothers who have lost their children into foster care; it is an example of a remarkable and innovative project that reveals important information that was hiding in plain sight. Gaze aversion, or turning our heads away from unpleasant topics, is a phenomenon with which scientists and clinicians working in the field of child abuse are quite familiar (2). Child abuse and neglect occur at higher rates than a host of diseases and conditions that are much better supported in terms of research funding: gaze aversion in action. Fewer research dollars are spent on a per-death or even a per-case basis for stigmatized conditions such as child abuse and neglect or substance abuse than for other conditions (3). As a society, we ignore this unpleasant problem until we are forced to deal with it in a crisis (4). Now we are shown that the experts working in this field, too, have had their form of “gaze aversion.” We turn away from examining the parents’ lives after rescuing the children. We have not noted the premature mortality among biological mothers of foster children even though this will influence the potential for reunification of children with their families. For well over 100 years, society has addressed child maltreatment by rescuing children from homes judged to be hazardous and placing them in new, safer environments (5). Foster-care placement may be about punishing mothers seen to have failed to protect their children as well as ensuring safety of the children (6). Decisions about foster-care placement have been examined with respect to impact of foster care on the children and their safety and development (7). The impact of the removal of a child on the other family members, particularly the mother, has been largely unstudied. The sparse literature on services provided to the biological parents of children taken into care “paint a picture of incomplete and somewhat negligent service delivery to parents of children in care.” (8) The study by Wall-Wieler et al. (1) is remarkable first for the direction of its gaze. In our efforts to keep children safe and protected, the adverse impact of intervention on the mothers should be considered. In the United States in 2016, 3.5 million children were reported at least once for suspected abuse or neglect and an investigation substantiated or indicated that abuse or neglect had occurred for 17% (9). US Department of Health and Human Services estimates that 676,000 children were confirmed as victims of abuse or neglect in the year with the most recent complete data: a rate of 9.1 victims per 1,000 children (10). In the first year of life the rate was 24.8 per 1,000 population of children (10). Neglect, an omission of action by the parent, is the most common form of maltreatment. Risk factors for both abuse and neglect include young parental age, lower parental education, poverty, and substance abuse (11). Only a small proportion of children substantiated as maltreated are removed from the home and placed in out-of-home care; more than 80% of confirmed victims remain in their homes (12). However, there are wide variations in rates of foster-care placement between jurisdictions, with some counties using foster care rarely and others using foster care for one-third or more of substantiated victims (13). In Canada, the location of the reported study, first nations citizens are overrepresented in the foster-care system; aboriginal children represent 7% of Canadian children but account for 48% of all foster children in that country (14). The conditions that pose a risk for the children in families and bring them to the attention of authorities—alcohol and substance abuse, intimate partner violence, teen parenthood, poverty, and environmental hazards—also pose a risk for increased mortality among their mothers. Wall-Wieler et al. (1) innovatively examined the mortality of foster mothers by comparing them to their sisters who did not have a child removed and placed into foster care. Sisters share many common features, including family educational aspirations, circumstances of poverty, drug or alcohol abuse by their families of origin, and genetics. Their own early-life experiences and the influences of their parents are likely to be similar. Teen women whose own mothers and sisters gave birth as teenagers are significantly more likely to have a teen pregnancy (15). They add a significant degree of control to a comparison that would clearly fall short if made with random mothers as a control group. However, poverty, drug abuse, intimate partner violence exposure, and even young parental age are not perfectly controlled, as divergence in these factors may be exactly what protected the control mothers from losing their own children. Careful examination of both risk and protective factors in young children’s lives require the attention of new investigators and clinicians in order to develop interventions to prevent or treat child abuse and neglect. Wall-Wieler et al. (1) have shown us that the biological mothers of foster children are another group meriting study. The use of large data sets and epidemiologic approaches to examine policies and programs in the area of child abuse and neglect are both possible and needed as more than 3 million children are reported for maltreatment in the United States alone each year; there has been relatively little empirical work to guide decisions about intervention and services for a very large number of children and families. Strong epidemiologic research can help us address not only service delivery but prevention as well. Reducing teen childbearing may be among the strategies most likely to prevent child abuse in our society, and we may have a natural experiment with the reductions in teen pregnancy seen in the past 10 years in many states. We find that teen parents use more harsh discipline (D.K.R., unpublished data, 2015) and are more likely to inflict abusive head trauma (16). Teen parents are also more likely to live in poverty and have less health-care access, and their children will have reduced rates of school success (17). While child protective service agencies seek reunification of child and family and try to help parents regain custody through plans that specify steps and training, the children’s parents may not have access to the financial resources, health insurance, and counseling to address the underlying shortcomings in the care of their children. More epidemiologic research is needed to guide public policy development addressing substance abuse treatment, access to medical care, and efforts to reduce poverty in families reported for maltreatment. Policy initiatives such as allowing biological mothers of foster children to receive Medicaid and publically supported mental health services while their children are in care may seem expensive, but they may save money by returning children to their homes sooner and preventing reentry into child protective services systems. Policies and programs reducing teen pregnancy or delaying childbearing may reduce the need for foster care and the risk of mortality among mothers losing custody of their children. This is a field wide open to sound population-based research. ACKNOWLEDGMENTS Author affiliation: Kempe Center for the Prevention and Treatment of Child Abuse and Neglect and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado (Desmond K. Runyan). Conflict of interest: none declared. REFERENCES 1 Wall-Wieler E , Roos LL , Nickel NC , et al. . Mortality among mothers whose children were taken into care by child protection services: a discordant sibling analysis . Am J Epidemiol . 2018 ; 187 ( 6 ): 1182 – 1188 . 2 Krugman RD , Leventhal JM . Confronting child abuse and neglect and overcoming gaze aversion: the unmet challenge of centuries of medical practice . Child Abuse Negl . 2005 ; 29 ( 4 ): 307 – 309 . Google Scholar CrossRef Search ADS PubMed 3 Best RK . Disease politics and medical research funding: three ways advocacy shapes policy . Am Sociol Rev . 2012 ; 77 ( 5 ): 780 – 803 . Google Scholar CrossRef Search ADS 4 Gainsborough J . Scandalous Politics: Child Welfare Policy in America . Washington, DC : Georgetown University Press ; 2010 . 5 Ten Bensel RW , Rheinberger MM , Radbill SX . Children in a world of violence: the roots of child maltreatment. In: Helfer ME , Kempe RS , Krugman RD , eds. The Battered Child . Chicago, IL : University of Chicago Press ; 1997 : 3 – 28 . 6 Ringwalt C , Earp J . Attributing responsibility in cases of father-daughter sexual abuse . Child Abuse Negl . 1988 ; 12 ( 2 ): 273 – 281 . Google Scholar CrossRef Search ADS PubMed 7 American Academy of Pediatrics. Committee on Early Childhood and Adoption and Dependent Care. Developmental issues for young children in foster care . Pediatrics . 2000 ; 106 ( 5 ): 1145 – 1150 . CrossRef Search ADS PubMed 8 Alpert L . Research review: parents’ service experience—a missing element of research in foster care outcomes . Child Fam Soc Work . 2005 ; 10 ( 4 ): 361 – 366 . Google Scholar CrossRef Search ADS 9 Children’s Bureau . Child Maltreatment 2016. Washington, DC: US Department of Human Services; 2018 . https://www.acf.hhs.gov/cb/resource/child-maltreatment-2016. Accessed February 27, 2018. 10 Children’s Bureau . Child Maltreatment 2016. Washington, DC: US Department of Human Services; 2018 . https://www.acf.hhs.gov/sites/default/files/cb/cm2016.pdf#page=10. Accessed February 27, 2018. 11 Brown J , Cohen P , Johnson JG , et al. . A longitudinal analysis of risk factors for child maltreatment: findings of a 17 year prospective study of officially recorded and self-reported abuse and neglect . Child Abuse Negl . 1998 ; 22 ( 11 ): 1065 – 1078 . Google Scholar CrossRef Search ADS PubMed 12 Horwitz SM , Hurlburt MS , Cohen SD , et al. . Predictors of placement for children who initially remained in their homes after an investigation for abuse or neglect . Child Abuse Negl . 2011 ; 35 ( 3 ): 188 – 198 . Google Scholar CrossRef Search ADS PubMed 13 Runyan DK , Gould CL , Trost DC , et al. . Determinants of foster care placement for the maltreated child . Am J Public Health . 1981 ; 71 ( 7 ): 706 – 711 . Google Scholar CrossRef Search ADS PubMed 14 Statistics Canada . Study: living arrangements of Aboriginal children aged 14 and under, 2011. Ottawa, Canada: Statistics Canada; 2016 . http://www.statcan.gc.ca/daily-quotidien/160413/dq160413a-eng.htm?HPA. Accessed February 27, 2018. 15 East PL , Reyes BT , Horn EJ . Association between adolescent pregnancy and a family history of teenage births . Perspect Sex Reprod Health . 2007 ; 39 ( 2 ): 108 – 115 . Google Scholar CrossRef Search ADS PubMed 16 Keenan HT , Runyan DK , Marshall SW , et al. . A population-based study of inflicted traumatic brain injury in young children . JAMA . 2003 ; 290 ( 5 ): 621 – 626 . Google Scholar CrossRef Search ADS PubMed 17 Savio-Beers LA , Hollo RE . Approaching the adolescent-headed family: a review of teen parenting . Curr Probl Pediatr Adolesc Health Care . 2009 ; 39 ( 9 ): 216 – 233 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

American Journal of EpidemiologyOxford University Press

Published: Mar 28, 2018

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