Mental health treatment of child abuse and neglect: the promise of evidence-based practice

Child Sexual Abuse Documentation in Primary Care Settings

Primary care providers (PCPs) can play an important role in the continuity of care for children who experience sexual abuse (SA). We performed a retrospective, chart-based study of children 3 to 17 years old with SA history. Primary care medical records were reviewed for 2 years after a subspecialty SA evaluation. Descriptive statistics and logistic regression were used to assess factors associated with documentation of SA history and mental health management by the PCP. Of 131 included patients, 43% had PCP documentation of their SA history, which was associated with care from resident providers (P < .01). There was greater mental health management and mental health referrals by PCPs for the group with documentation compared with the group without documentation (52% vs 23%, P < .001). Overall, child SA history was poorly documented in primary care settings. Identifying mechanisms to improve communication about a child's SA history with PCPs is important for the child's ongoing care.

Global child and adolescent mental health perspectives: bringing change locally, while thinking globally

Child and adolescent mental health (CAMH) are a global priority. Different countries across the globe face unique challenges in CAMH services that are specific to them. However, there are multiple issues that are also similar across countries. These issues have been presented in this commentary from the lens of early career CAMH professionals who are alumni of the Donald J Cohen Fellowship program of the IACAPAP. We also present recommendations that can be implemented locally, namely, how promoting mental health and development of children and adolescents can result in better awareness and interventions, the need to improve quality of care and access to care, use of technology to advance research and practices in CAMH, and how investing in research can secure and support CAMH professionals and benefit children and adolescents across the globe. As we continue to navigate significant uncertainty due to dynamic circumstances globally, bolstering collaborations by "bringing change locally, while thinking globally" are invaluable to advancing global CAMH research, clinical service provision, and advancement of the field.

Health and public health approach to ending child abuse and neglect

The 30^th anniversary of the United Nations Convention on the Rights of the Child provides an opportunity to reflect on whether the approaches to date in dealing with child abuse and neglect (CAN) have been successful. Initial responsibility in most countries to address CAN has been given to Child Protective Services Agencies. Recently, there have been calls for CPS to take a Public Health Approach in their practice. This paper discusses the potential positive and unintended problems that such a shift in approach might entail.

Women's Auto/Biography and Dissociative Identity Disorder: Implications for Mental Health Practice

Dissociative Identity Disorder (DID) is an uncommon disorder that has long been associated with exposure to traumatic stressors exceeding manageable levels commonly encompassing physical, psychological and sexual abuse in childhood that is prolonged and severe in nature. In DID, dissociation continues after the traumatic experience and produces a disruption in identity where distinct personality states develop. These personalities are accompanied by variations in behaviour, emotions, memory, perception and cognition. The use of literature in psychiatry can enrich comprehension over the subjective experience of a disorder, and the utilisation of 'illness narratives' in nursing research have been considered a way of improving knowledge about nursing care and theory development. This research explores experiences of DID through close textual reading and thematic analysis of five biographical and autobiographical texts, discussing the lived experience of the disorder. This narrative approach aims to inform empathetic understanding and support the facilitation of therapeutic alliances in mental healthcare for those experiencing the potentially debilitating and distressing symptoms of DID. Although controversies surrounding the biomedical diagnosis of DID are important to consider, the lived experiences of those who mental health nurses encounter should be priority.

Association of sleep with emotional and behavioral problems among abused children and adolescents admitted to residential care facilities in Japan

BACKGROUND

The psychological care of abused children in the child protection system is an urgent issue in Japan. Child abuse has a serious impact on children's emotion and behavior, but there is virtually no evidence about how child abuse affects sleep, which is closely related to behavioral and emotional control. In this study, we sought to identify sleep habits and suspected sleep disorders among abused children and adolescents admitted to residential care facilities in Japan and to investigate their association with emotional and behavioral problems.

METHODS

The study targeted 273 abused children and adolescents (age range: 4 to 15 years) who had been admitted to a residential care facility in Japan. They were assessed by physicians and other personnel at facilities with expertise in childcare and abuse. Respondents completed a brief sleep questionnaire on the incidence of problematic sleep habits and suspected sleep disorders as well as a questionnaire on emotional and behavioral issues.

RESULTS

Approximately 40% of the abused children and adolescents had some sleep-related symptoms at bedtime and waking, and 19% had suspected sleep disorder. Abused children with emotional and behavioral problems had a significantly higher incidence of suspected sleep disorders than abused children without such problems, and this incidence was particularly high among those with antisocial behavior and depressive behavior. Our predictive model also showed that antisocial behavior and depressive behavior were significant predictors of suspected sleep disorders.

CONCLUSION

Careful assessment and appropriate therapeutic intervention for sleep disorders are required in abused children and adolescents with emotional and behavioral problems.

Prevalence and associated factors of alexithymia among adult prisoners in China: a cross-sectional study

BACKGROUND

Prison is an extremely stressful environment and prisoners have an increasing risk of suffering from alexithymia. Therefore, this study aims to investigate the prevalence and associated factors of alexithymia among prisoners in China.

METHODS

A cross-sectional study was conducted in five main jails of the district of Zhejiang province in China, and a total of 1705 adult prisoners ultimately took part in the study. Toronto Alexithymia Scale, Childhood Trauma Questionnaire, Beck Depression Inventory, Beck Anxiety Inventory, Beck Hopelessness Scale and several short demographic questions were applied.

RESULTS

Over 30% of prisoners were classified as alexithymics and as high as 96.2% of prisoners suffered from at least one traumatic experience in their childhood, meanwhile, 81.5%, 53.4% and 85.8% were found to be positive for depression, anxiety and hopelessness symptoms respectively. Education, childhood trauma, negative emotional symptoms including depression, anxiety and hopelessness of the respondents, were negatively or positively associated with alexithymia among prisoners.

CONCLUSIONS

The results indicated that high prevalence of alexithymia among prisoners is linked with their level of education, experience of childhood trauma and symptoms of negative emotions. Accordingly, the findings in our study can be used for prevention and intervention of alexithymia among prisoners.

Mental Health Interventions for Children in Foster Care: A Systematic Review

Children in foster care have high rates of adverse childhood experiences and are at risk for mental health problems. These problems can be difficult to ameliorate, creating a need for rigorous intervention research. Previous research suggests that intervening with children in foster care can be challenging for several reasons, including the severity and complexity of their mental health problems, and challenges engaging this often transitory population in mental health services. The goal of this article was to systematically review the intervention research that has been conducted with children in foster care, and to identify future research directions. This review was conducted on mental health interventions for children, ages 0 to 12, in foster care, using ERIC, CINAHL, PsycINFO, PubMed, ProQuest's Dissertation and Theses Database, Social Services Abstracts, and Social Work Abstracts. It was restricted to interventions that are at least "possibly efficacious" (i.e., supported by evidence from at least one randomized controlled trial). Studies were evaluated for risk of bias. Ten interventions were identified, with diverse outcomes, including mental health and physiological. Six interventions were developed for children in foster care. Interventions not developed for children in foster care were typically adapted to the foster context. Most interventions have yet to be rigorously evaluated in community-based settings with children in foster care. Little research has been conducted on child and family engagement within these interventions, and there is a need for more research on moderators of intervention outcomes and subgroups that benefit most from these interventions. In addition, there is not consensus regarding how to adapt interventions to this population. Future research should focus on developing and testing more interventions with this population, rigorously evaluating their effectiveness in community-based settings, determining necessary adaptations, and identifying which interventions work best for whom.

The association between childhood maltreatment experiences and the onset of maltreatment perpetration in young adulthood controlling for proximal and distal risk factors

The evidence for association between child maltreatment victimization and later maltreatment perpetration is both scant and mixed. The objective of the present study was to assess the association between childhood maltreatment experiences and later perpetration of maltreatment in young adulthood controlling for proximal young adult functioning, prior youth risk behaviors, and childhood poverty. The study included 6,935 low-income children with (n=4,470) or without (n=2,465) maltreatment reports prior to age 18 followed from ages 1.5 through 11 years through early adulthood (ages 18-26). Administrative data from multiple regional and statewide agencies captured reports of maltreatment, family poverty and characteristics, system contact for health, behavioral risks and mental health in adolescence, and concurrent adult functioning (crime, mental health and poverty). After controlling for proximal adult functioning, repeated instances of neglect or mixed type maltreatment remained associated with young adult perpetration. Females and subjects with adolescent history of runaway, violent behaviors or non-violent delinquency also had higher risk. Greater caregiver education remained associated with reduced risk. The study concludes that prevention of recurrent neglect and mixed forms of maltreatment may reduce risk of maltreatment for future generations. Intervening to increase parental education and decrease adolescent risk behaviors may offer additional benefit.

Practice parameter for the assessment and management of youth involved with the child welfare system

This Practice Parameter presents principles for the mental health assessment and management of youth involved with the child welfare system. Important definitions, background, history, epidemiology, mental health care use, and functional outcomes are described. Practical guidance regarding child welfare-related considerations for evaluation and management are discussed.

Aspects of abuse: recognizing and responding to child maltreatment

Child maltreatment is a public health problem and toxic stress impacting at least 1 in 8 children by the age of 18 years. Maltreatment can take the form of physical and sexual abuse, neglect, and emotional maltreatment. While some children may experience only one form of maltreatment, others may survive multiple forms, and in some cases particularly complex forms of maltreatment such as torture and medical child abuse. When considering maltreatment, providers should be adept at obtaining a thorough history not only from the parent but when appropriate also from the patient. The most common form of child maltreatment is neglect, which encompasses nutritional and medical neglect, as well as other forms such as physical and emotional neglect. Talking with caregivers about stressors and barriers to care may give insight into the etiology for neglect and is an opportunity for the provider to offer or refer for needed assistance. Familiarity with injury patterns and distribution in the context of developmental milestones and injury mechanisms is critical to the recognition of physical abuse. While most anogenital exam results of child victims of sexual abuse are normal, knowing the normal variations for the female genitalia, and thereby recognizing abnormal findings, is important not only forensically but also more importantly for patient care. Pattern recognition does not only apply to specific injuries or constellation of injuries but also applies to patterns of behavior. Harmful patterns of behavior include psychological maltreatment and medical child abuse, both of which cause significant harm to patients. As health professionals serving children and families, pediatric providers are in a unique position to identify suspected maltreatment and intervene through the health care system in order to manage the physical and psychological consequences of maltreatment and to promote the safety and well-being of children and youth by making referrals to child protective services.

Community-Based Global Health Program for Maltreated Children and Adolescents in Brazil: The Equilibrium Program

The maltreatment of children and adolescents is a global public health problem that affects high- and low-middle income countries ("LMICs"). In the United States, around 1.2 million children suffer from abuse, while in LMICs, such as Brazil, these rates are much higher (an estimated 28 million children). Exposition to early environmental stress has been associated with suboptimal physical and brain development, persistent cognitive impairment, and behavioral problems. Studies have reported that children exposed to maltreatment are at high risk of behavioral problems, learning disabilities, communication and psychiatric disorders, and general clinical conditions, such as obesity and systemic inflammation later in life. The aim of this paper is to describe The Equilibrium Program ("TEP"), a community-based global health program implemented in São Paulo, Brazil to serve traumatized and neglected children and adolescents. We will describe and discuss TEP's implementation, highlighting its innovation aspects, research projects developed within the program as well as its population profile. Finally, we will discuss TEP's social impact, challenges, and limitations. The program's goal is to promote the social and family reintegration of maltreated children and adolescents through an interdisciplinary intervention program that provides multi-dimensional bio-psycho-social treatment integrated with the diverse services needed to meet the unique demands of this population. The program's cost effectiveness is being evaluated to support the development of more effective treatments and to expand similar programs in other areas of Brazil. Policy makers should encourage early evidence-based interventions for disadvantaged children to promote healthier psychosocial environments and provide them opportunities to become healthy and productive adults. This approach has already shown itself to be a cost-effective strategy to prevent disease and promote health.

Child and adolescent abuse and neglect in the city of Curitiba, Brazil

Identify and analyze cases of child and adolescent abuse and neglect in Curitiba, Brazil. This is an exploratory descriptive study that takes a quantitative approach. Secondary data from the reporting registry of the Network for the Protection of Children and Adolescents at Risk for Violence in Curitiba, Brazil, dating from 2004 to 2009, were analyzed. Variables included the victims' sociodemographic profile, place of notification, type, nature and severity of abuse, information about the author of the aggression or abuse, and physical lesions. The frequency distribution and associations between the variables were analyzed using the Chi-square test at a 5% significance level. The analysis of 19,316 records showed that domestic violence, abuse and neglect directed against children and adolescents were the most frequently recorded situation, with 17,082 cases (88.4%) distributed in the following manner: neglect, with 9742 reports (57.0%); physical violence, with 1341 reports (7.9%); sexual violence, with 796 reports (4.7%); psychological violence, with 574 reports (3.4%); and abandonment, with 190 reports (1.1%). Of the total, 43.9% were considered severe cases. The most affected age group was between 5 and 14 years of age, with balance between genders. In the majority of cases, the mother was registered as the author of the abuse or neglect. Physical sequelae (20.2%) mostly affected the head and upper and lower limbs, with consequent lesions manifesting as bruises, cuts, and fractures. An increase in the visibility of domestic violence and children and adolescents abuse and neglect has been observed in the city during the last few years, suggesting the effectiveness of the reporting strategies proposed by the protection network. It is important to increase social security and public welfare policies to prevent child and adolescent abuse and neglect, focusing on family support.

Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: six-month improvement and baseline predictors

This study sought to implement outcomes monitoring and to review outcome data from a community-based rehabilitation program for maltreated children and adolescents in São Paulo, Brazil. Maltreated children and adolescents (N=452) were enrolled in The Equilibrium Program (TEP), a multidisciplinary community-based rehabilitation program. About half (n=230) of the participants were successfully evaluated using the Children's Global Assessment Scale (C-GAS) at entry, 3, and/or 6 months later. Analysis of outcomes used hierarchical linear modeling of functional change from baseline. With a baseline C-GAS score of 51.7 (SD=14.22), average improvement was 2.8 and 5.5 points at 3 and 6 months, respectively (reflecting small to moderate effect sizes=0.20 and 0.39). Improvement was associated with Problems related to upbringing (p<.02) at entry and absence of Physical abuse (p<.05) and Negative life events in childhood (p<.05) but was not associated with sociodemographics or any specific psychiatric diagnosis. This study showed that outcomes monitoring is feasible in a community-based program in a developing country. Although there was no untreated control group for comparison and specific evidence-based treatments were not used, it is notable that significant improvement, with small to moderate effect size, was observed.

Relationships, environment, and the brain: how emerging research is changing what we know about the impact of families on human development

Recent research is providing family therapists with new information about the complex interaction between an individual's biological makeup and his/her social and physical environment. Family and social relationships, particularly during sensitive periods early in life, can affect a child's biological foundation. Additionally, stress during the early years can have a lasting effect on an individual's physical and mental health and contribute to the onset of severe mental illness. Community programs have been developed to intervene early with families who have an at-risk child to prevent or minimize the onset of mental illness including providing partnerships with at-risk mothers of infants to shape attachment relationships. Programs are also developing individual and family interventions to prevent the onset of psychosis. Practicing family therapists can incorporate emerging neuroscience and early intervention research and leverage the growing base of community programs to enhance the effectiveness and sustainability of mental health outcomes for clients. Additionally, family therapy education programs should broaden student training to incorporate the growing body of information about how family relationships affect individual mental health development.

Diagnostic shortfalls in early childhood chronic stress: a review of the issues

Clinical effects of early childhood chronic stress should be regarded as causing a developmental brain injury. However, current diagnostic constructs fail to capture the associated disabilities in emotional-behavioural regulation of stress and attachment functions adequately. We first focus on neglect as a prototypical early childhood chronic stressor; next we explore clinical associations of neglect; and finally we cite research pertaining to possible underlying pathophysiology of the effects of early childhood chronic stress. In addition, we discuss diagnostic labels that children with histories of early childhood neglect commonly acquire, and implications for treatment.

Impact evaluation of a cognitive behavioral group therapy model in Brazilian sexually abused girls

This study evaluated the impact of a cognitive behavioral group therapy model in Brazilian girls who had experienced sexual abuse. The effect of the waiting period before treatment and the enduring effectiveness of the treatment after six and 12 months were also evaluated. Forty-nine female sexual abuse victims between the ages of 9 and 16 completed instruments measuring depression, anxiety, stress, and post-traumatic stress disorder before, during, and after the group therapy. The group therapy had a positive impact on their psychological functioning, significantly reducing symptoms of anxiety, stress, and post-traumatic stress disorder. The therapeutic effects lasted six to 12 months after the treatment ended. The model proved effective for treating young female victims of sexual abuse.

Depression risk of 'left-behind children' in rural China

The study aims to explore the risk of depression in left-behind children in grades four-six in rural China and to identify the factors associated with increased depression risk in this population. In Hubei Xiantao, a school-based sample of 1000 children was recruited with 875 children (590 left-behind children, 285 controls) providing all relevant information. The adjusted mean children's depression inventory (CDI) score of left-behind children was significantly higher than that of controls (P<0.01). Left-behind children's depression risk rate was much higher than control's (P<0.01). Left-behind children had a higher likelihood of depression risk than controls (migrant fathers: adjusted odds ratio (OR)=3.42, 95% confidence interval (CI)=1.86-6.28; migrant mothers: OR=2.62, 95% CI=1.10-6.22; migrant parents: OR=2.73, 95% CI=1.77-4.20). Respondents with low socioeconomic status (SES) (OR=2.64, 95% CI=1.42-4.93) had a higher likelihood of depression risk than the middle SES cohort. With middle levels of social support as the referent, respondents with low levels of social support (OR=5.86, 95% CI=3.90-8.79) had a higher likelihood of depression risk; respondents with high levels of social support (OR=0.50, 95% CI=0.29-0.86) had a lower likelihood of depression risk. The results indicate that the left-behind children are at greater risk for developing depression.

Early pathogenic care and the development of ADHD-like symptoms

Early pathogenic care that is characterised by disregard for the child's basic emotional needs can lead to severe global psychosocial and cognitive dysfunction and deviant developmental trajectories of brain maturation. Reactive attachment disorder (RAD) is a developmental disorder associated with early pathogenic care that is characterised by markedly disturbed ways of relating socially in most contexts. In addition to other severe emotional dysfunctions, children suffering from RAD often display a high number of comorbid attention deficit/hyperactivity disorder (ADHD) symptoms such as inattention, impulsivity and hyperactivity. It is not yet clear whether ADHD-like symptoms in children exposed to pathogenic care represent a true comorbidity of ADHD or similarities in behavioural dysfunction with a different neurodevelopmental pathway in terms of a phenocopy. In this review, we summarise the findings on the neurobiological consequences of early pathogenic care. Pathogenic care is considered a form of care by a primary caretaker involving a lack or a loss of expectable care, e.g., by early separation, frequent change in caregivers, institutionalisation or neglect. The reviewed studies suggest that a primary dysfunction of limbic brain circuits after early pathogenic care might lead to an interference by motivational or emotional cues impinging on prefrontal executive functions resulting in behavioural similarities with ADHD. Thus, the complex phenotype observed after early pathogenic care might be best described by a dimensional approach with behavioural and neurobiological similarities to ADHD coinciding to a certain degree as a function of early experience. Based on this evidence, suggestions for the treatment of ADHD-like symptoms in children after adverse early life experiences are provided.

Prenatal Cocaine Disrupts Serotonin Signaling-Dependent Behaviors: Implications for Sex Differences, Early Stress and Prenatal SSRI Exposure

Prenatal cocaine (PC) exposure negatively impacts the developing nervous system, including numerous changes in serotonergic signaling. Cocaine, a competitive antagonist of the serotonin transporter, similar to selective serotonin reuptake inhibitors (SSRIs), also blocks dopamine and norepinephrine transporters, leaving the direct mechanism through which cocaine disrupts the developing serotonin system unclear. In order to understand the role of the serotonin transporter in cocaine's effect on the serotonergic system, we compare reports concerning PC and prenatal antidepressant exposure and conclude that PC exposure affects many facets of serotonergic signaling (serotonin levels, receptors, transporters) and that these effects differ significantly from what is observed following prenatal SSRI exposure. Alterations in serotonergic signaling are dependent on timing of exposure, test regimens, and sex. Following PC exposure, behavioral disturbances are observed in attention, emotional behavior and stress response, aggression, social behavior, communication, and like changes in serotonergic signaling, these effects depend on sex, age and developmental exposure. Vulnerability to the effects of PC exposure can be mediated by several factors, including allelic variance in serotonergic signaling genes, being male (although fewer studies have investigated female offspring), and experiencing the adverse early environments that are commonly coincident with maternal drug use. Early environmental stress results in disruptions in serotonergic signaling analogous to those observed with PC exposure and these may interact to produce greater behavioral effects observed in children of drug-abusing mothers. We conclude that based on past evidence, future studies should put a greater emphasis on including females and monitoring environmental factors when studying the impact of PC exposure.

Identifying and determining the symptom severity associated with polyvictimization among psychiatrically impaired children in the outpatient setting

Polyvictimization involves experiencing multiple forms of maltreatment or other interpersonal victimization, and places children at risk for severe psychosocial impairment. Children with psychiatric problems are at risk for polyvictimization, and polyvictimized child psychiatric inpatients have been found to have particularly severe psychiatric symptoms. Cluster analysis was used to identify a polyvictimized subgroup (N = 22, 8%) among 295 outpatient admissions in 2007-2009 to a child psychiatry outpatient clinic, based on chart review of documented maltreatment, parental impairment (history of arrest, psychiatric illness, and substance use), and multiple out-of-home placements. Polyvictimization was associated with severe parent-reported externalizing problems and clinician-rated psychosocial impairment, independent of demographics and psychiatric diagnoses. Posttraumatic stress disorder (PTSD) was the only psychiatric diagnosis associated with polyvictimization. Polyvictimization merits further clinical and research assessment with child psychiatry outpatients. Evidence-based PTSD assessment and treatment for polyvictimized children with adaptations to address their severe impairment and externalizing problems also warrants empirical evaluation.

Aggression in sexually abused trafficked girls and efficacy of intervention

The broad objective of this study was to understand the incidence and severity of aggression among sexually abused girls who were trafficked and who were then further used for commercial sexual exploitation (referred to subsequently as sexually abused trafficked girls). In addition, the impact of counseling for minimizing aggression in these girls was investigated. A group of 120 sexually abused trafficked Indian girls and a group of 120 nonsexually abused Indian girls, aged 13 to 18, participated in the study. The sexually abused trafficked girls were purposively selected from four shelters located in and around Kolkata, India. The nonsexually abused girls were selected randomly from four schools situated near the shelters, and these girls were matched by age with the sexually abused trafficked girls. Data were collected using a Background Information Schedule and a standardized psychological test, that is, The Aggression Scale. Results revealed that 16.7% of the girls were first sexually abused between 6 and 9 years of age, 37.5% between 10 and 13 years of age, and 45.8% between 14 and 17 years of age. Findings further revealed that 4.2% of the sexually abused trafficked girls demonstrated saturated aggression, and 26.7% were highly aggressive, that is, extremely frustrated and rebellious. Across age groups, the sexually abused trafficked girls suffered from more aggression (p < .05), compared with the nonvictimized girls. Psychological interventions, such as individual and group counseling, were found to have a positive impact on the sexually abused trafficked girls. These findings should motivate counselors to deal with sexually abused children. It is also hoped that authorities in welfare homes will understand the importance of counseling for sexually abused trafficked children, and will appoint more counselors for this purpose.

The characteristics of AD/HD symptoms, self-esteem, and aggression among serious juvenile offenders in Japan

Eighty-three inmates of a correctional facility, who committed serious offences, participated in this study. They were all male and aged 14-17 years, with a mean age of 15.5 (SD=1.21) years. Eighty-six age- and sex-matched controls were enrolled. Some psychological questionnaires such as on self-esteem and aggression were conducted in both groups. The aims of the present study were as follows: first, to clarify the characteristics of the subjects, such as IQ, psychological traits, and AD/HD symptoms; second, to examine how the subjects' self-esteem and aggression changed and/or improved on admission and at the time of parole (during the correctional educational period). For the results of paired t-tests, the self-esteem of subjects changed little. Therefore, our findings suggest that the improvement of antisocial behavior and transition of self-esteem are not directly linked with each other. Most inmates of the correctional facility showed a borderline IQ, markedly low self-esteem, unstable aggression, and serious AD/HD symptoms. In addition, the low self-esteem of subjects was not consistently elevated during the correctional education period. Moreover, their aggression was strongly correlated with AD/HD symptoms, both on admission and at the time of parole.

Child abuse and neglect: a worldwide concern

PURPOSE OF REVIEW

As knowledge about child abuse and neglect increases worldwide, so does the literature on abuse and neglect. The authors explore many studies published this year, with attention to the advances in understanding which are guiding prevention efforts as well as diagnosis and treatment of abuse and neglect.

RECENT FINDINGS

The evidence base for many forms of child abuse continues to grow. Controversy around the diagnosis of child abuse still continues, with current debate focused on the diagnosis of abusive head injury and whether children with vitamin D deficiency are misdiagnosed with abusive fractures. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented, and researchers are evaluating these efforts with an eye to whether or not they really contribute to prevention.

SUMMARY

The short-term and long-term impact of child maltreatment is significant not only for individuals but for families and communities in which abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children. However, it is clear that specialists in child abuse should also play a role in order for diagnosis and management of abuse to adhere to a high standard of care. This has been validated this year by the creation of Child Abuse Pediatrics as a board certified specialty in the United States. As knowledge about abuse and neglect grows, clinicians are focusing on prevention as well as diagnosis and treatment.

Behavioral and mental health challenges for indigenous youth: research and clinical perspectives for primary care

After first discussing historical, community and epidemiologic perspectives pertaining to mental health problems of Indigenous youth and families, this article reviews available research data on behavioral and mental health interventions and the roles that Native and Indigenous research programs are serving. Given the legacy of transgenerational trauma experienced by Indigenous peoples, community-based research and treatment methods are essential for solving these problems. The primary care provider stands in a unique position within the community to offer a "coinvestigator spirit" to youth and families in the pursuit of improving behavioral health. Strategies are presented for using the research literature, and collaborating with communities and families to help solve behavioral and mental health problems.