Child Abuse Incidence and Reporting During the COVID-19 Pandemic: Implications for Policy, Advocacy and Practice
Contributed by Health Policy Committee member Ashleigh Bowman, DNP, RN, CRNP, CPNP-AC
The COVID-19 pandemic has inflicted a number of stressors on children and their families. Factors that increase risk of child abuse during the pandemic include an exacerbation of pre-existing mental illness and/or behavior disorders, increased caregiver demands, economic stressors and closures of social outlets for both children and parents1,2. This increased risk for physical and sexual abuse of children is coupled with a drastic decline in opportunities for mandatory reporters to screen and report child abuse1,3. Preliminary data confirms that the number of reported cases of abuse declined during the most intense periods of social isolation in the early phase of the pandemic; however, it is hypothesized that this dramatic underreporting is coupled with an increase incidence of abuse due to the aforementioned risk factors2,4.
The pandemic’s impacts on child abuse incidence and reporting underscore the role pediatric-focused nurse practitioners (NPs) play in promoting optimal child well-being. Surveillance, assessment for risk factors and anticipatory guidance related to child abuse are integral components of well-child care delivered by NPs in pediatric primary care settings5. As children return to routine activities and families seek well-child care that may have been deferred or provided via teleconferencing as a result of the pandemic, NPs should use all available opportunities perform a risk assessment for child abuse. The National Association of Pediatric Nurse Practitioners (NAPNAP) endorses a preventative and proactive strategy that includes risk assessment and intervention for all families, regardless of socioeconomic factors6.
Now more than ever, it is imperative that NPs remain hypervigilant to warning signs and red flags of child abuse. At the microsystem level, screening for child abuse should be conducted at each well-child exam5. This recommendation is in line with national guideline recommendations, including NAPNAP’s position statement on child maltreatment6. Additionally, practices could consider implementing an alert system into the electronic medical record that assists in identifying cumulative risk factors5. At the macrosystem level, further data and research are needed inform policy and advocacy efforts designed to develop well-balanced interventions that both prevent and address child abuse and neglect that has only been exacerbated by the COVID-19 pandemic. Children are inherently considered a vulnerable population, and data collection particularly related to child abuse during the pandemic should be conducted in accordance with very specific considerations and in light of UNICEF recommendations7.
Recent policy efforts have been aimed at bolstering child abuse prevention and treatment services. The Stronger Child Abuse Prevention and Treatment Act (2021; introduced as H.R. 485) was passed in the House earlier this congressional session and is now under committee review in the Senate8. This legislation would reauthorize existing funding as well as establish a national standard for tracking fatalities and near fatalities from child abuse. H.R. 485 allows for sharing of this information across state lines and addresses racial biases in child maltreatment; both of which are current policy deficits.
A summary of policy and advocacy actions for pediatric-focused NPs:
- Screen all families at every available opportunity
- Consider implementing a system that will alert providers of cumulative risks for child maltreatment
- Contribute new data related to child abuse during the COVID-19 pandemic in accordance with UNICEF recommendations
- Support comprehensive policies that address child maltreatment disparities at the system and state level through a nationally established standard (HR 485)
- Pereda, N., & Diaz-Faes, D. A. (2020). Family violence against children in the wake of the COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health, 14(40), 1-7. https://doi.org/10.1186/s13034-020-00347-1
- Rapoport, E., Reisert, H., Schoeman, E., Adesman, A. (2021). Reporting of child maltreatment during the SARS-CoV-2 pandemic in New York City from March to May 2020. Child Abuse & Neglect, 116, 1-7. https://doi.org/10.1016/j.chiabu.2020.104719
- Sharma, S., Wong, D., Schomberg, J., Knudsen-Robbins, C., Gibbs, D., Berkowitz, C., & Heyming, T. (2021). COVID-19: Differences in sentinel injury and child abuse reporting during a pandemic. Child Abuse & Neglect, 116, 1-9. https://doi.org/10.1016/j.chiabu.2021.104990
- Baron, E. J., Goldstein, E. G., & Wallace, C. T. (2020). Suffering in silence: How COVID-19 school closures inhibit the reporting of child maltreatment. Journal of Public Economics, 190, 1-13. https://doi.org/10.1016/j.jpubeco.2020.104258
- Chappell, K. K., Hein, L. C., & Andrews, J. O. (2021). Can we ask everyone? Addressing sexual abuse in primary care. The Journal for Nurse Practitioners, 17, 594-599. https://doi.org/10.1016/j.nurpra.2021.01.017
- National Association of Pediatric Nurse Practitioners (2016). NAPNAP position statement on child maltreatment. Journal of Pediatric Health Care, 30, A15-A17. https://dx.doi.org./10.1016/j.pedhc.2016.05.006
- UNICEF (2020, October). Research on violence against children during the COVID-19 pandemic. https://data.unicef.org/resources/research-on-violence-against-children-during-the-covid-19-pandemic-guidance/
- Stronger Child Abuse Prevention and Treatment Act, H.R. 485, 117th Cong. (2021). https://www.congress.gov/bill/117th-congress/house-bill/485?r=1&s=1
Senate Democrats Seek Agreement on “Build Back Better” Plan
Following the House of Representatives’ Nov. 19 passage of the $1.7 trillion “Build Back Better Act” (H.R. 5376), Senate Democrats are pressing to reach a final agreement on President Biden’s sweeping health care and social spending agenda before they adjourn for the holidays. Majority Leader Chuck Schumer (D-NY) has promised to bring the legislation to the Senate floor before Christmas, but he can’t afford to lose a single Democratic vote to pass the bill – and moderates Sens. Joe Manchin of West Virginia and Kyrsten Sinema of Arizona have yet to commit to supporting the bill.
In addition to negotiating with Manchin and Sinema, Democratic leaders are awaiting rulings from the Senate parliamentarian, the referee of the Senate strict budget reconciliation rules, on provisions of the House-passed bill that need to be amended or dropped entirely. The House will have to vote again on any changes made by the Senate, making it more difficult to get a final bill to the White House by the end of the year – an important deadline with the Dec. 31 expiration of the enhanced child care tax credit provided in the American Rescue Plan Act. The Center on Budget and Policy Priorities estimated that nearly 10 million children could fall back into poverty if the policy isn’t extended.
The House-passed legislation includes provisions to close the health coverage gap in states that haven’t expanded Medicaid programs, expand access to home and community-based services and postpartum coverage, and permanently authorize the Children’s Health Insurance Program, as well as providing $500 million for nursing education enhancement grants, $500 million for Nurse Corps scholarship and loan repayment, and $170 million for diversifying the maternal and perinatal workforce.
Recognize a Grassroots Leader
The NAPNAP Grassroots Advocacy Award is to recognize a member of NAPNAP who has demonstrated sustained advocacy in the area of child health policy or professional practice issues for pediatric-focused APRNs. The ideal recipient leads by example and is a strong role model for involvement in health policy that improves the health and well-being of children and/or advances the role of advanced practice nurses as health care providers. The awardee has a history of encouraging others to participate in health policy advocacy and demonstrates ability to effectively network with other groups or organizations to advance health policy. Apply yourself or nominate a NAPNAP colleague online today. The application deadline has been extended to Dec. 31, 2021.
House Takes Action on Three Infant Health Bills
The House of Representatives voted to approve three bills dealing with infant health issues Dec. 8, including the “Stillbirth Health Improvement and Education (SHINE) for Autumn Act of 2021” (H.R. 5487), which would authorize the Department of Health and Human Services to award grants to support data collection and reporting on stillbirths and contributing risk factors and improve research and training on fetal autopsies. The “Early Hearing Detection and Intervention Act of 2021” (H.R. 5561) would reauthorize hearing loss programs for newborns, infants, and young children, while the “Improving the Health of Children Act” (H.R. 5551) would reauthorize the CDC National Center on Birth Defects and Developmental Disabilities.
Provider Mental Health Aid Measure Clears House
The “Dr. Lorna Breen Health Care Provider Protection Act” (H.R. 1667), which includes several initiatives to improve the mental health of medical professionals and prevent suicide, was approved by the House of Representatives Dec. 8. The bill, which NAPNAP has endorsed, would authorize $10 million annually through 2024 for HHS to create an initiative encouraging medical professionals to seek mental health care and $35 million annually for grants to improve mental health and resiliency among medical professionals.
Health Policy Lesson Learned
Contributed by student member Alexandra Z.
I have learned that policy is not a sprinkle of information to be held in the back of my mind for my personal understanding of the inner workings of how and why regulatory legislation came to be. It is not information meant to support my educational background for abiding by independent practice restrictions. It is certainly not an explanation as to why I must accept limitations to interventions for vulnerable patient populations. Something we do naturally as both humans and nursing professionals when attempting to solve a problem is to trace it to the beginning to identify what the source of the problem is, how we can fix it and how we can prevent it from happening again. We are constantly learning and readjusting to how we can improve. When a root problem is identified, I believe we have two unique choices. We can choose to accept the barrier which limits true problem resolution and continue to do the best that we can within compliance. Another choice is to dig deeper into this problem, identify how the barrier must be modified for better outcomes and do the work required to resolve the problem on a much larger scale.
Administration Vaccine Mandates Blocked by Congress, Courts
Joined by two Democrats, Senate Republicans voted Dec. 8 to block President Biden’s COVID-19 vaccine mandate for private businesses with 100 or more employees, although House Democrats aren’t likely to consider the measure and Biden would certainly veto it. Two Senate Democrats, Jon Tester of Montana and Joe Manchin of West Virginia, joined all 50 Senate Republicans in passing the resolution (S. J. Res. 29) introduced by Indiana Republican Sen. Mike Braun to block the regulations under the Congressional Review Act, a legislative tool allowing Congress to roll back executive branch rules that requires only a simple 51-vote majority for Senate passage.
Biden said in September he would direct the Occupational Safety and Health Administration (OSHA) to require all businesses with 100 or more employees to mandate that their workers are either fully vaccinated or undergo weekly testing for COVID-19 and wear masks. The emergency rule was issued in November, prompting lawsuits from Republican-led states and private employers as well as some liberal leaning unions. A federal appeals court in November temporarily blocked the Biden administration’s vaccine rules, which had been planned to take effect on January 4. Multiple lawsuits against the mandate have since been consolidated and reassigned to a federal appeals court in Ohio in a case expected to reach the U.S. Supreme Court.
A Georgia federal district judge on Dec. 7 temporarily halted an administration rule mandating that federal contractors require their workers to be vaccinated. A Missouri federal district court last month also blocked the implementation of a separate Centers for Medicare and Medicaid Services rule requiring all health care workers in facilities that accept Medicare and Medicaid payment to be fully vaccinated by Jan. 4. The agency is appealing that ruling.
Congress Delays Agency Funding Decisions Until February
With a packed pre-holiday agenda and no consensus on spending priorities, Congress skirted a potential government shutdown by agreeing Dec. 2 to extend current funding levels for federal agencies through Feb. 18. Senate Republicans have refused to negotiate with Democrats on top-line levels for defense and non-defense discretionary spending, threatening to force an extension of fiscal 2021 funding levels through September unless appropriators agree to restore long-standing policy riders limiting abortion funding that House Democrats left out of their fiscal 2022 spending bills. None of the 12 annual appropriations bills have been completed.
The standoff is blocking a host of spending increases and policy changes backed by the Biden administration including significant increases in nursing education and research funding. The House passed legislation in July increasing funding for Title VIII nursing workforce development programs by $50 million, while Senate Democrats proposed an increase of $16.5 million.
Supreme Court Signal Changes in Abortion Ruling
Supreme Court justices appeared to indicate Dec. 1 that they are on the verge of a major shift in the court’s position on access to abortion services and is likely to uphold a Mississippi law that mostly prohibits the procedure after 15 weeks of pregnancy. It was unclear from the oral arguments in Dobbs v. Jackson Women’s Health Organization, however, whether justices would overrule the precedent in Roe v. Wade that women have a fundamental right to end their pregnancies. But none of the six conservatives who make up the court’s majority expressed support for maintaining the rule that states may not prohibit abortion before the point of fetal viability. Chief Justice John Roberts Jr., often the most moderate of the conservatives, said Mississippi’s limit of 15 weeks was not a “dramatic departure” from viability and gave women enough time to make the choice to end their pregnancies.
The court’s liberals warned the institution’s reputation would be irreparably damaged if nearly a half-century of its abortion rulings were dismantled because of a change in the court’s membership. Justice Sonia Sotomayor questioned whether the legitimacy of the Supreme Court would endure if it overturned abortion rights, asking “Will this institution survive the stench that this creates in the public perception that the Constitution and its reading are just political acts?”
In Other News…
Lawmakers Ease Medicare Cuts In Year-End Deal
Congress provided some year-end relief for Medicare providers as part of negotiations connected to raising the federal debt limit. The Senate voted 59 to 34 on Dec. 9 to approve the “Protecting Medicare and American Farmers from Sequester Cuts Act” (S. 610) following its passage in the House Dec. 7 on a 222 to 212 vote. President Biden signed the bill Dec. 10, delaying a scheduled 2 percent cut in Medicare payments due to budget sequestration through March 2022 and putting off a separate round of 4 percent reductions totaling about $36 billion to 2023. The bill also includes a 3 percent increase in payments for advanced practice registered nurses and other providers paid under the Medicare Part B fee schedule.
Congress took action last year to put off the sequestration cuts as part of the federal COVID pandemic response. S. 610 would keep that pause in place until April 1, after which providers would see a one percent cut until June 30 and a two percent cut until the budget sequestration expires in 2031. The separate four percent cut is the consequence of “pay-as-you-go” statutes that requires that any increases in the deficit be offset by raising revenue or reducing spending. The American Rescue Plan Act enacted this year resulted in a larger budget deficit that triggered the spending reductions.
Cadet Nurse Corps Left Out of Final Defense Bill
Congress is pressing to finish the annual defense authorization bill, but it appears the legislation won’t include provisions recognizing the service of members of the World War II-era U.S. Cadet Nurse Corps. The House passed a finalized version of the $768 billion defense bill with overwhelming bipartisan support Dec. 7, moving legislation hamstrung by delays, amendment fights and political discord a step closer to becoming law before the end of the year. The final bill was negotiated by the leaders of the House and Senate Armed Services committees before the full Senate, stalled by scheduling delays and a dispute over amendments, was able to vote on its version of the legislation.
The House amended its version of the bill to include the “United States Cadet Nurse Corps Service Recognition Act of 2021” (S. 1220/H.R. 2568), which recognizes nurses who served in the World War II-era Corps as honorary veterans. But the Senate didn’t include the provisions in its version of the bill, and they were not part of the final agreement. Supporters will continue to push for a separate vote on the legislation.
You can view archived Child Health Policy Learning Collaborative meetings on-demand from our website. CHPLC is a member-only benefit so you must log into napnap.org to view the recorded meetings.