Abstract
Introduction
Child abuse and neglect is a significant issue, with health, economic and social implications, which impacts a substantial number of children globally.1,2 According to data published by the World Health Organization in 2017, 1 approximately 25% of adults globally experienced physical abuse throughout their childhood. Child abuse and neglect have a significant and long-lasting impact on the psychological, emotional, and physical well-being of children, as well as their social functioning. 3 Moreover, it is crucial to acknowledge that this phenomenon has significant social and economic implications for broader society. 4 Ensuring the creation of a safe and nurturing environment for children is a shared responsibility of governmental entities, local communities, numerous professionals, and families. 4 As a result, several nations have employed regulations and strategies with the objective of detecting and remedying cases of child abuse and neglect. 5 Nevertheless, the execution of these policies and plans can face many challenges. For example, in some countries, there is a lack of adequate funding and resources to support child protection services, leading to insufficient staff numbers and overburdened systems that cannot effectively address all reported cases.6,7 Additionally, cultural stigmas and social norms in certain communities may prevent victims and witnesses from reporting abuse, thereby undermining the effectiveness of these policies.8,9
This review focuses on child abuse and neglect (CAN) in the Washington DC, Maryland, and Virginia (DMV) region. The District of Columbia (Washington DC), Maryland, and Virginia make up the DMV area, which is also known as the metropolitan DC area. It is one of the largest combined statistical areas in the US and is centered around the National Capital Region. 10 This region was selected for review due to the notably high rate of reported CAN cases in Washington DC, which surpasses the national average and underscores the need for targeted interventions. 11 Moreover, the DMV area’s diverse demographic and socio-economic population, encompassing urban, suburban, and rural communities, provides valuable insights into how various factors influence CAN and the effectiveness of policies.12,13 This diversity includes significant immigrant populations, varying income levels, and a range of cultural backgrounds, all of which impact the prevalence and reporting of CAN. This makes the region an important focus for comprehensive and culturally competent policy development. 14
Furthermore, examining this phenomenon both globally and within the United States is imperative in order to obtain a thorough comprehension of this crucial matter. Comparing these perspectives can yield useful insights into the distinct issues encountered by various areas, as well as the shared underlying factors. Additionally, it has the potential to yield noteworthy considerations and contribute to the formulation of recommendations specific to the DMV region. This, in turn, can aid in the development of more efficient policies and programs aimed at ensuring the protection and well-being of children in the area. Accordingly, this narrative review aims to:
Identify the rates of CAN in the DMV and compare them with national US and international levels.
Identify the potential costs of CAN at the DMV, US, and international levels.
Explore the potential factors that are associated with CAN at the DMV and compare them with US national and international levels.
Investigate the tools used for CAN screening in the DMV and US context.
Methods
Design
This narrative literature review aims to comprehensively and critically examine studies concerning CAN in the DMV region, the US, and internationally. The narrative approach was chosen for its flexibility and capacity to provide a broad, in-depth exploration of the literature. 15 This approach enables the inclusion of diverse studies, facilitating a detailed overview and critical analysis of key findings, trends, and themes. It supports thematic exploration and offers valuable insights for researchers, practitioners, and policymakers involved with this critical issue.
Search Strategies
Literature was searched from December 2023 to January 2024 to find current evidence about CAN in light of the study aims in the DMV area. These findings were compared with data from from other areas within the US and also from international sources. 16 The research team searched various databases, including PubMed, CINAHL, PsychINFO, and the Web of Science. The combinations of keywords used included child abuse and neglect, abuse, neglect, physical abuse, sexual abuse, children, child, maltreatment, DMV, DC metropolitan, Virginia, Maryland, Washington DC, District of Columbia, prevalence, incidence, reporting, mortality, risk factors, impact, policy, identification, cost, screening, tools, assessment, investigation, regulations, and law. Additionally, the websites of various public and private agencies that are concerned with child protection in the DMV area were searched, including the Child Welfare League of America, US Department of Health & Human Services, the Centers for Disease Control and Prevention, DC Action for Children, Stop Child Abuse Now (SCAN) of Northern Virginia, the Child and Family Services Agency (CFSA), and the Administration of Children and Families (ACF). These agencies were included to add more information specific to the DMV area due to the limited number of peer-reviewed publications available.
Inclusion and Exclusion Criteria
The inclusion criteria for this review were peer-reviewed research articles focusing on CAN, published in English by scientific journals from 2013 to 2023. The exclusion criteria included non-English articles, non-peer-reviewed articles, and publications outside the 2013 to 2023 timeframe. Additionally, articles that did not align with the review purpose and articles that lacked sufficient data, or exhibited poor methodology were excluded to uphold the relevance and rigor of the review.
Study Selection
The research team consisted of 5 reviewers who independently screened the titles and abstracts of the identified studies for relevance. The initial broad search resulted in 1500 records. After removing 200 duplicates, 1300 records were screened. Of these, 900 records were excluded based on their relevance to the topic. The remaining 400 full-text articles were assessed for eligibility based on the inclusion and exclusion criteria. Discrepancies were reconciled through discussion and consensus, with a third reviewer arbitrating when necessary.
Data Extraction and Data Synthesis
The selected studies (N: 37) were reviewed by the research team, who extracted key information from each study, including study design, population and setting, key findings and outcomes, and risk factors. The derived data were then organized by themes, and the findings were summarized and critiqued. Patterns and gaps were identified, and the findings were analyzed and interpreted to pinpoint key concepts relevant to the research purpose. Implications for research, practice, and policy were highlighted, and recommendations were provided based on these insights.
Results
Rates of Child Abuse and Neglect
Child abuse is a serious public health concern in Northern Virginia, with 9831 reported cases between 2015 and 2016. 17 Neglect was the most frequently reported type of abuse in Virginia, which was consistent with national statistics. African Americans, Pacific Islanders, and children of multiple races experienced the highest rates of abuse, as did children under the age of 1 year. 18 In the State of Maryland, 53 277 abuse or neglect cases were reported to child protection services in 2017. Of these, 22 037 were referred for full investigation. This reflected an 8.4% increase in such cases from the previous year. 19 Maryland State reported 41 deaths resulting from child abuse in 2017. 19 The rate of child maltreatment in DC in 2017 was 1639 or 13.2 per 1000 children, with first-time victims rising from 989 in 2016 to 1202 the following year. 20 In 2022, the incidence of child abuse and neglect varied across the DMV area. Virginia reported 5.8 victims per 1000 children, Maryland 7.2 victims per 1000 children, and Washington DC recorded 10 victims per 1000 children. 11 Nevertheless, it is crucial to acknowledge that determining the comprehensive rate of child maltreatment in the DMV area is challenging as each state has separate reporting systems, which may contribute to gaps in current scientific literature regarding child abuse and associated factors in this region. An understanding of these factors is important for creating programs and tools to reduce the abuse and neglect of children living in this region.
In the whole of the US, there were 7.8 million reports of CAN to US child protection services in 2018, with 678 000 of these reports being confirmed cases of abuse or neglect of a child. 21 The Center for Disease Control and Prevention estimates that 1 in 7 children in the US become victims of CAN during childhood. 22 In addition, approximately 2000 child deaths in the US each year were reported to result from abuse or neglect. 23 Nearly 57% of child homicides are thought to be perpetrated by one or both parents. 24
The “Our World in Data” report 25 provides evidence of elevated levels of child abuse and neglect in various countries, as indicated by the United Nations data. The report highlights the high prevalence of physical punishment and psychological aggression by caregivers toward children aged 1 to 14 years old in specific countries, including Ghana, Nigeria, and Central African Republic. In England and Wales, 1 in 5 adults had experienced a form of child abuse before the age of 16. 26 In continental Europe, there is wide variation in the reporting of child abuse, which suggests that the incidence of abuse may not be indicative of its true prevalence. In comparison with many other parts of Europe, the UK has improved the reporting of child maltreatment following new guidelines from the National Institute of Health and Care Excellence (2016-2017) aimed at improving the administrative reporting of child abuse. 27 Moreover, the UK government published the “Working Together to Safeguard Children” document in 2018, 28 which acts as a guide to inter-agency collaboration to safeguard and promote child welfare. This guide includes practitioners, encompasses child protection legislation, and provides a framework for local authorities (including clinicians, nurses, and police) for identifying and responding to child abuse cases.
The reporting of child abuse and neglect cases is limited in many nations, which makes comparison of statistics across countries difficult. 29 Collecting accurate statistics in some countries is also challenged by underreporting, possibly because of factors such as the societal stigma associated with disclosing trauma or abuse in many cultures. 27 It is also important to note that the Covid-19 pandemic further complicated the documentation of child abuse worldwide, with the reporting of abuse decreasing during the pandemic despite the higher risk of it occurring, 30 presumably due to less exposure to health care and school settings and the psychological impacts of lockdowns. For example, Alenezi et al 31 reviewed the epidemiology of child maltreatment during the COVID-19 pandemic in Saudi Arabia and found that while reports of physical child abuse reduced by 47.7%, children were 1.69 times more likely to experience sexual abuse in comparison to pre-pandemic statistics. They also highlighted the need for a systematic and practical system to screen and document child maltreatment cases within the community, particularly during times of crisis.
The Cost of Child Abuse and Neglect
The cost of child abuse and neglect in the DMV area reflects a significant financial commitment to safeguarding vulnerable children. For instance, in Washington, DC, the Child and Family Services Agency (CFSA) has allocated a substantial budget of $220 644 166 for the Fiscal Year 2024. 32 Within this budget, a notable portion, $24 972, is dedicated to child abuse investigations. This allocation underscores the financial resources required to address and mitigate the impacts of child abuse within the district. Such investments are critical for ensuring the safety and well-being of children, highlighting the broader regional commitment to combating child abuse and providing the necessary support to affected families. The review could not locate the budgetary allocations to these services in Maryland and Northern Virginia, but similar budget allocation is expected in these states.
The monetary cost of CAS at the US national level, which highlights the societal and financial burdens associated with it, has been estimated at $104 billion annually. 33 Many studies suggest that adverse childhood events, such as different forms of abuse and neglect, are associated with poor long-term physical and mental health outcomes, 34 which may further increase the economic burden on societies worldwide. The life-time economic cost of child abuse per victim in the US was estimated at $830 928 in 2015, with the estimated cost per homicide as a result of child abuse being $16.6 million, equating to $428 billion in life-time costs acquired annually. 35 Another US study found that trauma related to the physical abuse of children had significantly higher costs compared with non-physical abuse trauma, which was related to the higher costs of evaluation, treatment, and the assessment of disposition in child abuse cases. 23 Other developed countries reported similar costs related to child abuse. For example, in the UK, the approximate life-time cost per child abuse victim was reported as GBP 89 390, with an estimated life-time cost per death resulting from child abuse or neglect of GBP 940 798. Similar to the US, UK reporting suggests these costs were related to healthcare expenses as well as the lost productivity of the child and those involved with the abuse. 36
Factors Associated With Child Abuse and Neglect
A comprehensive understanding of the factors associated with child abuse and neglect is important to inform the development of effective programs and tools to reduce them in the DMV area as well as more broadly in the US and internationally. These factors are often categorized as parent-, child-, and environmental-related factors, 37 see Table 1.
Risk factors for child abuse and neglect according to the literature.
Parent-related factors
Parent-related factors commonly cited in the literature include drug and alcohol abuse, physical or mental health problems, unemployment, intimate partner violence in the home, and caregivers having suffered abuse as children. 1 Other studies noted that younger maternal age, 38 low parental education status, problematic parenting beliefs (eg, in corporal punishment), maternal smoking, and poor psychosocial functioning or coping37,39,40 were associated with child abuse or neglect. In a recent publication, Lawson et al 41 suggested that the incidence of child maltreatment increased in the US during the COVID-19 pandemic. This was thought to be related to parental job loss and psychological distress.
Child-related factors
Our review showed that factors associated with abuse related to the children’s characteristics included the age of the child, developmental status, and the presence of chronic illness or disabilities. 1 Among infants and toddlers, a younger age was associated with higher rates of mortality, specifically from head trauma or shaking.33,42,43 Among adolescents, factors associated with abuse included poor peer relationships, antisocial behavior, difficulty bonding with parents, adolescent stressors, and difficulty with education. 44
Environmental factors
Environmental characteristics associated with child abuse and neglect include family dynamics, socioeconomic status, social context, community characteristics and cultural norms. 45 Internationally, the principal factor associated with the physical abuse of children was lower socioeconomic status, irrespective of the child’s sex, culture, ethnicity, country, or the continent studied. 2 This was consistent with findings from DC that suggested that the high rate of child abuse may be related to the district’s child poverty rate, which was reported as being over 27%. 46 A recent study from Scotland also found that adverse childhood experiences, including abuse, were associated with a low family income. 38 Furthermore, the SCAN of Northern Virginia 17 highlighted specific characteristics often associated with child abuse, consistent with national statistics. These indicators encompass a low socioeconomic level, substance misuse (drug or alcohol), and the existence of physical or mental health conditions in either the child or the parent. It is important to note that these characteristics can be viewed as factors related to both parents and children.
Crouch et al
47
investigated the prevalence of adverse childhood experiences among children (N = 45 287) in the US and the relationship between family characteristics and exposure to such experiences using data from the National Survey of Children’s Health. Their findings indicated that family structure and income were among the main factors that predicted children’s exposure to adverse experiences or abuse in childhood. Child abuse and neglect in the US correlated with lower family income level and income inequality, which were considered the most important environmental factors.37,48-50 Eckenrode et al
49
examined 3142 counties in the US and found that the level of poverty was significantly correlated with child abuse and neglect (
Child abuse and neglect is found among all races and ethnicities in the US. As previously noted, the highest rates of abuse in Virginia were experienced among children of African American or Pacific Islander ethnicity, and children with multiple races. 18 It is thought that reports to Child Protective Services may be influenced by cultural or race/ethnic factors, but there are insufficient data to clearly understand correlations between any specific race/ethnicity and child maltreatment. 39 Further research is necessary to explore this topic in more depth, especially as some studies reported higher incidences of child abuse and neglect among racial minorities in the US. 43
Screening for Child Abuse and Neglect
Screening for child maltreatment involves the use of various tools and methods to identify potential cases of abuse or neglect. In the US, including the DMV area, screening for potential child abuse and neglect cases mostly occurs in the emergency department (ED) at the time of injury. Tools used in such cases include the Escape Instrument, which is an effective six-question tool used by ED clinical staff to determine if a child’s injury is consistent with abuse. 51 Parents complete other tools, such as the Child Abuse Potential Inventory, to assess the likelihood of abuse in a particular family. Although these tools are useful to identify the potential for child abuse, they require willing participation from parents or caregivers and are not intended to be used by healthcare professionals who work with children to identify the risk of abuse.
Moreover, in various states in the US, including the DMV area, guidelines such as the Child Abuse Prevention and Treatment Act (CAPTA) and comprehensive risk assessments are used. 52 Healthcare professionals use these standardized tools for pediatric assessments and mandatory reporting. 53 Teachers and school personnel also observe signs of maltreatment and promptly report them. Additionally, community resources like Child Protective Services and hotlines help to investigate cases. 53 Hence, it is crucial to create instruments that help these experts fulfill their responsibilities. Furthermore, it is imperative to require professional training and enforce intersectoral collaboration.
Currently, there is a scarcity of tools available to individuals working with children in the US and DMV area that can assist in identifying risk factors for child abuse and neglect. A tool designed to assess the likelihood of child abuse prior to the manifestation of trauma or neglect would have the dual function of identifying and safeguarding children from potential harm. The evidence in this review emphasizes the significance of conducting additional research on the contextual factors surrounding child abuse and neglect in the DMV area. It also proposes the development of customized screening tools that are based on identified risk factors for child abuse and neglect. Such an instrument would assist healthcare and other relevant professionals in effectively detecting these cases at an early stage, which will empower them to safeguard children with greater efficacy.
Discussion
This literature review demonstrates that CAN is a complex public health challenge in the DMV area, caused by the combination of high occurrence rates as well as significant underreporting and societal stigma. The DMV area, like other regions, struggles with disparate reporting systems, making it difficult to obtain a comprehensive understanding of child maltreatment rates. This gap necessitates robust, integrated reporting mechanisms and standardized data collection across jurisdictions. Furthermore, international comparisons highlight the need for globally harmonized reporting standards to better understand and address CAN.
Moreover, the review indicated that the economic burden of child abuse is staggering, with substantial costs associated with healthcare, lost productivity, and long-term physical and mental health consequences. These financial implications underscore the urgent need for preventive measures and early intervention strategies. Investment in public health initiatives, education, and support services for at-risk families could potentially reduce the incidence of child abuse and its associated costs.54,55
Understanding the multifaceted factors associated with CAN is crucial for developing effective prevention and intervention programs.56,57 Parent-related factors such as substance abuse, mental health issues, and a history of being abused highlight the intergenerational nature of abuse, and the importance of family-centered strategies; addressing these issues through targeted support and counseling can help break the cycle of abuse.58,59 Additionally, child-related factors, particularly those affecting vulnerable populations such as infants and children with disabilities, require specialized care and monitoring. 60 Training healthcare professionals to recognize signs of abuse in these high-risk groups is essential for early detection and intervention. 61 Lastly, environmental factors, especially socioeconomic status, play a significant role in the prevalence of child abuse. Policies aimed at alleviating poverty and improving social services can have a profound impact on reducing abuse rates.61,62 Community-based programs that provide support and resources to low-income families are critical in mitigating the risk factors associated with child abuse. 63
Moreover, effective screening tools are vital for the early identification of CAN. 64 The current tools used in emergency departments and by child protective services need to be complemented with new instruments that can predict and prevent abuse before it occurs. 65 Developing and validating such tools requires a deep understanding of the contextual factors influencing child abuse in the DMV area, which can be achieved through qualitative research involving healthcare and other professionals as well as the affected families. Healthcare professionals specializing in pediatric care have consistently played a crucial role as primary responders in evaluating cases of abuse and neglect across diverse communities seeking medical assistance.66-68 Consequently, they possess a favorable position to examine and assess the contextual variables linked to the mistreatment and disregard of children on a global scale. 69 Nevertheless, intersectoral collaboration among healthcare providers, educators, social workers, and law enforcement is necessary to create a comprehensive safety net for children. 70 Therefore, training these professionals to use standardized screening tools and recognize signs of abuse can significantly improve early detection rates and outcomes for children.70-72 Overall, a multifaceted approach that includes prevention, early detection, intervention, and policy reform is essential to combat CAN. Collaboration across sectors and continuous research will be key to safeguarding children and promoting their well-being.
Further research is needed to explore the specific cultural and regional factors influencing child abuse in different localities within the DMV area. Comparative studies across various regions can inform the development of universally applicable yet adaptable screening tools. Additionally, the impact of the COVID-19 pandemic on child abuse rates and reporting mechanisms requires ongoing investigation in order to understand the long-term effects and develop resilient systems for future crises.
Recommendations
This review suggests that to address CAN in the DMV area effectively, it is crucial to develop and implement standardized reporting mechanisms and harmonized international standards to enable accurate data collection and comparisons. Increasing economic investment in public health initiatives, education, and support services for at-risk families can alleviate the financial burden and reduce CAN incidence. Targeted support and counseling for parents struggling with substance abuse, mental health issues, and a history of abuse is essential to breaking the intergenerational cycle. Specialized care and monitoring for vulnerable populations, including infants and children with disabilities, along with training healthcare professionals in early detection, are critical. Poverty alleviation policies and community-based programs supporting low-income families can mitigate socioeconomic risk factors. Investing in the development of predictive screening tools and fostering intersectoral collaboration among healthcare providers, educators, social workers, and law enforcement will create a comprehensive safety net for children. Continuous research on cultural and regional factors and the impact of the COVID-19 pandemic on CAN rates will inform resilient systems for future crises.
Limitations
The findings in this review are subject to 2 main limitations. First, this review employed a narrative review approach, which, by its nature, may be susceptible to subjectivity; narrative reviews rely on selecting studies based on relevance to the research question, potentially overlooking those published in less prominent journals. 73 Second, the inclusion of studies was constrained by time limitations, prompting the research team to prioritize those studies deemed most pertinent. Despite our efforts to ensure comprehensive coverage through organized search strategies and inclusion criteria, the exclusion of some studies could have introduced bias and impacted the findings. Future reviews could benefit from broader inclusion criteria and more exhaustive, systematic search strategies to mitigate these limitations and provide a more balanced perspective on the topic.
Conclusion
This narrative review highlights the complexity and urgency of addressing CAN in the DMV area. The multifaceted nature of this public health challenge, compounded by high rates of abuse, significant underreporting, and societal stigma, necessitates a comprehensive and coordinated approach. The key findings of this review indicate that disparities in reporting systems hinder a clear understanding of CAN rates, underscoring the need for standardized and integrated data collection methods. The substantial economic burden associated with child abuse further emphasizes the importance of preventive measures and early intervention strategies. Addressing parent-related factors, child-related factors, and environmental influences through targeted support, specialized care, and poverty alleviation policies can significantly reduce the prevalence of child abuse. A robust strategy to combat CAN requires effective screening tools, intersectoral collaboration, and continuous research. Training healthcare professionals and stakeholders to recognize and address CAN is crucial for early detection and improved outcomes. A multifaceted approach involving prevention, early detection, intervention, and policy reform is vital for safeguarding children and promoting their well-being. Collaborative efforts and continuous research can create a safer environment for children in the DMV area and beyond.
Supplemental Material
sj-docx-1-gph-10.1177_2333794X241284029 – Supplemental material for Insights Into Child Abuse and Neglect in the Washington DC, Maryland, and Virginia (DMV) Area: Evidence and Opportunities
Supplemental material, sj-docx-1-gph-10.1177_2333794X241284029 for Insights Into Child Abuse and Neglect in the Washington DC, Maryland, and Virginia (DMV) Area: Evidence and Opportunities by Intima Alrimawi, Elizabeth Bettini, Clishia Taylor, Ahmad Rajeh Saifan and Nabeel Al-Yateem in Global Pediatric Health
Footnotes
Author Contributions
Declaration of Conflicting Interests
Funding
Ethical Statement
ORCID iD
Supplemental Material
References
Supplementary Material
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