Did child abuse go up or down during the COVID-19 pandemic?

SALT LAKE CITY — As COVID-19 infections raged and families flocked home from work and school early on, experts predicted a tsunami of child abuse was about to hit amid the stress of social isolation, increased unemployment, housing insecurity and school closures.

It didn't happen.

Puzzled experts began to speculate that without the watchful eyes of teachers and day care providers, the tsunami was indeed happening but wasn't being reported.

Since then, however, some medical experts have reached a different conclusion: As child abuse reports went down significantly during the pandemic, they believe some pandemic-era supports and other factors may have protected some of the nation's most vulnerable children. Two years into the pandemic, cases started to climb again, about the time that those supports were ending, they say.

In a commentary on a study of severe physical abuse, both just published in the journal JAMA Pediatrics, Dr. Kristine A. Campbell, of Primary Children's Medical Center and the University of Utah, along with colleagues from Pennsylvania, called the pandemic a "natural experiment in social welfare policy."

Campbell is a child abuse pediatrician for University of Utah Health and Intermountain Primary Children's Hospital's Center for Safe and Healthy Families in Salt Lake City.

'Patterns and severity of child abuse'

After decades of steadily rising, rates of child welfare referral rates dropped 10% from 2019 to 2020, "with these reductions occurring almost exclusively in the post-lockdown era beginning in late March 2020," wrote Campbell and her co-authors and fellow child abuse experts, Dr. Joanne N. Wood, of the University of Pennsylvania in Philadelphia, and Dr. Rachel P. Berger, of the University of Pittsburgh.

They wrote: "While a complete understanding of the patterns and severity of child abuse over the course of the COVID-19 pandemic will continue to evolve in the coming years, evidence for the anticipated shadow pandemic of child abuse," including abusive head trauma, "has not emerged."

Experts predicted more abuse in part because of historical patterns of an increase in child abuse during crises, including the 2008 recession, which had a "4.5% increase in serious maltreatment for each percentage point increase in the foreclosure rate," as well as during natural disasters like Hurricane Katrina.

The three doctors suggest in their commentary that the difference with COVID-19 arises from pandemic supports, "an array of unprecedented social welfare policies previously identified as possible child abuse prevention strategies, including paid family leave, basic income and child tax credits, extension of eligibility for government health insurance and protection from eviction and foreclosure."

A proxy for physical abuse

The commentary was prompted by the Yale School of Medicine study in the journal issue that looked specifically at abusive head trauma in children under age 5 as a proxy for physical abuse. The researchers said that's a serious injury that would lead parents to seek treatment and not attempt to keep the injury hidden, so it would reflect trends in physical abuse. The pandemic brought a decrease in those injuries, though it was transient for children younger than 1.

Campbell's commentary team wrote that "while rare," abuse-related head injury "may be the form of abuse that is easiest to quantify" as it requires medical care and doesn't rely on state-specific mistreatment definitions. "The decrease in (abusive head trauma) rates at the height of the pandemic and the gradual return to pre-pandemic levels as the pandemic era social welfare policies were lifted strongly support an association between public policy and child abuse prevention."

The Yale study authors said two factors likely led to decreased abuse: more women at home with children, since perpetrators of abusive head injuries are more often fathers or male domestic partners. Plus, moms at home are less likely to recruit outside help with child care. The commenters note that parents at home can offer "a layer of protection from abuse to some infants and young children due to decreased reliance on nonbiologic parents, who are common perpetrators of (abusive head trauma) and other violence in infants."

Campbell said she also thinks that during COVID-19, with more people home, parents might have been able to tag team better, like, "Sweetie, please help me. He's crying again."

Maltreatment and neglect

The second protective factor cited in the study was financial relief, resulting in a temporary 40% decrease in child poverty. "Previous studies have demonstrated that antipoverty programs have resulted in a decrease in the occurrence of child maltreatment, especially neglect," the study said.

Limitations were noted, including that the cases studied came from tertiary children's hospitals and might not have captured abusive head injuries treated at other hospitals or been nationally representative. Nor could the researchers show cause for the decrease in abuse, just association. "Future work to define the association between abuse and poverty reduction could strengthen the evidence regarding the effectiveness of these programs and better define the implications of our study," the authors wrote.

The researchers and commenters all see a need for further studies to figure out why child abuse apparently decreased during the pandemic.

But it may be difficult to ever know for sure because the pandemic itself has been complicated.

"Overall, I think it is hard to assess the causes of trends during the pandemic," said Angela Rachidi, a poverty expert and senior fellow at the American Enterprise Institute, who was not involved in the research but has studied and written extensively on the impact of policies on poverty and family struggles.

"The potential causes outlined in the article seem plausible, but it could also be something else. I agree that we should look at the effects of increased financial assistance on child abuse more, preferably in a controlled environment," Rachidi told the Deseret News.

A doctor's call to action

Campbell said she hopes policymakers see a call to action in the findings, though more study is needed. Her wish is especially strong for her own state, Utah, which she said places high value on family and worries about child welfare.

She thinks findings that child abuse at worst leveled off and seems to have declined when family-support policies were in place was the pandemic's "bright light." What the Yale study adds to other research, she said, is that it extended the time frame to see what happened as those policies were being slowly removed, people returning to work and seeking child care and maybe not having their financial needs as well supported.

"COVID provided us with a lot of bad things. Some of them were really bad for children. But it might have provided an unexpected experiment in showing us what we could do for kids," Campbell told the Deseret News.

She believes the child care support, resources of cash and time, as well as making sure adults and children had access to health care were likely the most valuable in reducing family stress and child abuse.

Good, high-quality child care is expensive and can be hard to find, Campbell said. "I routinely see children in my emergency room, in my hospital, in my ICU who have been seriously hurt" by someone who was trusted to provide care but "was not ready to take care of yet another infant or that particular infant."

Campbell also said that babies are "developmentally wired to cry, to scream, to have reflux and throw up and do all those things that are really stressful in the middle of the night." That puts a child at risk for serious physical abuse, depending on who the caregiver is. While parents are with the child the most and may "succumb to those stresses and injure a child, not meaning to in almost all cases," she said that proportionately, an unrelated caregiver is even more likely to cause injury to the child.

Later milestones that create stress, like toilet training or a child learning to talk and then talking back may also rub caregivers who have "inappropriate expectations" or don't understand child development the wrong way, she added.

Campbell said she hopes policymakers look at the study and others and provide support to families that make a difference, including health care help. She said we do a decent job covering kids, but parents with chronic medical or mental health conditions who can't access needed care can't care for the children the way they need to, potentially leading to abuse, accidental injuries or neglect.

Highly expensive and intensive programs can't be provided to every family, Campbell said. "That's not cost-effective. What we can do is create programs that support all our families and make sure that everyone's brought up to that sort of baseline human existence where you can actually find happiness in raising a child."

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