A Q&A with Dr. Valerie Maholmes
April is National Child Abuse Prevention Month, a time to acknowledge the importance of families and communities working together to prevent child abuse and neglect.
Valerie Maholmes, Ph.D., the head of NICHD's Pediatric Trauma and Critical Illness Branch, has dedicated her career to thinking about how to take care of children in difficult circumstances. When she was a child, her parents took in several foster children who were escaping difficult family situations, including abuse. This experience helped inspire her to spend her professional life helping children. She now works to support research and training in pediatric trauma, injury, and critical illness.
In this interview, Dr. Maholmes discusses child abuse and neglect, ongoing research efforts to help children live healthy lives, and the role of the community in preventing child abuse.
How big a problem is child maltreatment in the U.S. today?
Although we are making some strides with interventions and research, it certainly is a significant public health problem. The Department of Health and Human Services publishes a regular report on child maltreatment, based on data from Child Protective Services in each state. In 2013, 9 out of every 1,000 U.S. children were maltreated, according to the report. So that's nearly 1% of children who have experienced abuse and neglect.
How can maltreatment affect children's health and development?
It depends partly on the nature of the abuse. Some children live in homes where they are physically abused over a long period of time and may be dealing with untreated injuries. Those can have long-term effects.
Of course, there's psychological abuse as well. Some research suggests that emotional abuse is much worse in the long term than physical abuse. You can heal from your physical wounds, but it's harder to heal from the psychological damage.
We're also learning more and more about the effects of child sexual abuse. One of our researchers, Dr. Cathy Widom of John Jay College of Criminal Justice, in New York City, has discovered that sexual abuse has long-term health consequences. Mostly these are health problems associated with stress, such as cardiovascular and respiratory conditions. One of the points that she makes in her research is that when you see chronic conditions in adulthood, it's important to look back to whether that person had trauma as a child.
We look at a broad scope of consequences to understand the long-term effects of maltreatment. We have a new grant about the health effects of sexual abuse. So, for example, researchers are looking at the impact: If a girl has been sexually assaulted in childhood or early adolescence, how might that affect her reproductive health in the long term? We also have grantees looking at how violence against women intersects with HIV and other sexually transmitted infections.
What other kinds of studies on child abuse, neglect, and maltreatment does NICHD support?
It's really important, when children have medical care, that we get an accurate assessment of whether injuries or bruises are a result of child maltreatment. Some professionals are reluctant to report suspected abuse because they're not confident in their diagnostic tools or not certain about what the child is telling them. When they report suspected abuse, that activates the child protective system, and that can have major effects on the child and the family. We want to be sure that we're making a correct diagnosis.
One way to do that is through research on how we understand what children say, so that we can ask the right questions of children and ask them in the right way. On the physical side, we're funding a study by Dr. Mary Clyde Pierce at Lurie Children's Hospital of Chicago. She's looking at assessing bruises and injuries, so we can learn whether some kinds of injuries are associated with abuse or if they're from the kind of childhood falls and bangs and scrapes that you'd normally expect kids to have.
We're funding studies looking at parent-child interactions to understand how families work and how they break down. We also have studies looking at interventions that would help a parent understand their own threshold for stress—and, if they cross that threshold, how they can change their behavior so that they don't strike out at a child. Stress also can lead to depression and anxiety for the parents, and they may even neglect their children. We want to understand that kind of dynamic so we can prevent maltreatment.
We're looking at the neurobiology of child abuse and neglect. What is the impact on the brain of having those kinds of experiences? Does it affect a child's thinking and cognitive abilities or his or her ability to regulate behaviors and emotion? We also want to look at how the psychological trauma interacts with the physical trauma, and whether or not that psychological trauma may impede healing and recovery.
We have been looking at how children respond to abuse as they enter adolescence and early adulthood—how does that affect their ability to function? They may turn to alcohol, or they may be victims of abuse in intimate-partner relationships. They may even be perpetrators of abuse in intimate-partner relationships or with their own children.
You've observed that children respond to adversity in different ways. What makes some children more resilient?
There is a strong statistical association between adverse childhood experiences and poor outcomes. Children who are abused may have poor performance in school, poor relationships, difficulty making decisions, and other psychosocial problems. But some children don't have those problems; they fare well despite those early adversities. Those kids have resilience.
Resilience happens through protective factors. A child may have other supportive adults in their family or in the community. A strong relationship with a teacher or a mentor can help mitigate the risks associated with abuse.
Children really do respond differently. For example, sometimes children are taken out of the home and put in foster or adoptive care. For some kids, being taken away from home is traumatic. Despite the fact that their parents were abusing them, they still have that strong parent-child bond. For other kids, that kind of experience is protective—taking them out of a very violent home and placing them in one that is calmer and more nurturing, where they have good relationships not only with the adults, but also with peers or foster siblings.
Are there ways to help children become more resilient?
Getting abused children the treatment they need, whether it's addressing mental health or physical health, helps them have better physical and developmental outcomes. Sometimes it is better for that care to be given while keeping the family intact. For example, in a home-visiting intervention, the clinician works with the parents to engage better with the child and works with children on their own issues.
We're funding a study by Dr. Kenneth Dodge at Duke University on interventions at the community level that provide support for families. A child lives in the context of a family and a community. If the community is healthy and has safe havens where kids aren't exposed to chronic violence, that really goes a long way toward reducing interpersonal violence in the family.
We want to be able to support more research on understanding how children overcome these experiences.
What's your message to teachers, after-school providers, and others who may work with children who have been abused or maltreated?
We need to pay attention to children. Their behavior really tells us something. If anything looks awry, or if a child is becoming more internally focused, quiet, or anxious—appearing demure, perhaps even depressed—that may be a sign that something is wrong. Ask a child what they are experiencing. Listen to what they're saying, and really follow up and pay attention. Children may not tell us through their words what they're experiencing, but they tell us through their actions and their behaviors.
We don't want to jump to conclusions and make assumptions. But we do want to pay attention to them and use some of the evidence-based interventions that are available to help us have these conversations with children.
"Children may not tell us through their words what they're experiencing, but they tell us through their actions and their behaviors."
As I mentioned, having strong relationships with caring and nurturing adults makes a really big difference in the life of a child. If you think about it, relationships are so important in all of our lives. When children are developing, they're trying to get a vision of who they are in the world and how they're valued in the world. They get that through us, through the way we interact with them and the way we respond to them.
Are there any factors that put families or communities at greater overall risk for child abuse? What can community leaders do to strengthen and support families?
A risk factor for communities is poverty. The kind of stress and difficulties that you see in those communities are very much associated with abuse. When parents have to work multiple jobs to manage their households, that is very stressful. They may live with food insecurity. Families are overwhelmed by the trauma and the stress of their daily lives. That stress is kind of an incubator for violence in a family.
Also, if parents were abused themselves or witnessed domestic violence in their families, you see those cycles of violence perpetuated. Undiagnosed and untreated mental health issues are another risk factor. We need much more research in those areas to help devise evidence-based interventions that can work in these contexts.
A community needs places where people can go to have their voices heard, to get help, to get relief from the stress that gives rise to the violence. Whether these are family advocates or leaders of support groups, the person who runs the local YMCA or the pastor of a church, community leaders need to create places where people can go to talk about their issues and challenges and to get help when they need it.
You meet other people at conferences who work in this area, too. What have been your major takeaways from your conversations with them?
In one of the small group sessions I attended recently, I learned that a lot of the individuals who are now providing services had themselves overcome adversity. And, boy, what a powerful story that is—to now have the wherewithal to help other families take the positive path you have taken.
One of the ways we're going to help families overcome adversity is by providing opportunities for people to mentor each other and to guide each other through the storms of their lives. These people have so much more to offer than those of us who are researching this in the ivory tower; we can give them the evidence-based tools they need to help their fellow parents and community members take better paths and make better decisions. That is just really important.
Children are vulnerable, and they rely on us to protect them.
- National Child Abuse Prevention Month
- Child Maltreatment Prevention Information from the CDC
- NICHD Resources
- Division of Extramural Research
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- Previous Features on Child Abuse
Originally Posted: April 14, 2015