A father brings his 10-year-old to
your office because the boy is having a
hard time paying attention at school,
gets in fights with classmates and is
oppositional with his teacher.
As you take the psychosocial history, it’s important
to ask whether the child has been exposed to any
abuse, neglect, abandonment or other traumas, according to the updated AAP clinical report Clinical
Considerations Related to the Behavioral Manifestations of Child Maltreatment.
“Children who have suffered early abuse or neglect
may later present with significant health and behavior problems that may persist long after the abusive
or neglectful environment has been remediated,” according to the report from the AAP Committee on
Child Abuse and Neglect; Council on Foster Care,
Adoption, and Kinship Care; American Academy of
Child and Adolescent Psychiatry; and the National Center for Child Traumatic Stress. The report
is available at https://doi.org/10.1542/peds.2017-
0100 and is published in the April issue of Pediatrics.
Since the original report was published in 2008,
much has been learned about the relationship between adverse childhood experiences and later psychosocial problems. The updated report aims to help
pediatricians recognize and manage behavioral problems in maltreated children.
“This is a tough problem for
pediatricians, but we offer the opportunity to do a world of good for
kids,” said Robert D. Sege, M.D.,
Ph.D., FAAP, a lead author of the
clinical report and a former member of the AAP Committee on
Child Abuse and Neglect. “One
of the things that we now know
is that children’s brains are so malleable, they’re so
capable of growth and healing.”
Effects of maltreatment
More than 25% of U.S. children have experienced
abuse or neglect, according to studies cited in the
report. These children can have symptoms of extreme
distress, including sleep problems, attention issues,
anger, irritability, withdrawal and repeated and intrusive thoughts.
These symptoms can continue long after the maltreatment has ended. For example, research shows
that adolescents who were maltreated early in life are
more likely to attempt suicide, use drugs and engage
in risky sexual behavior.
Studies also show that children who are maltreated
are labeled as “problem children” more frequently
than their peers.
“Pediatricians who are seeing children for these behavior problems should consider whether they might
be the result of past abuse and neglect,” Dr. Sege said.
If trauma has occurred, the pediatrician can help
caregivers understand that the child is not simply
being defiant and may react differently than other
children in a similar situation, according to the report. The provider can explain that the child may not
feel psychologically safe even if he is physically safe
and could have extreme reactions to a minor stimulus
such as a sound, sight or smell that reminds him of
the trauma. In those situations, parents can be taught
to prepare their child for triggers.
The report notes that parents and teachers can
inadvertently exacerbate behavior problems if they
respond harshly or punitively. Instead, caregivers can
be encouraged to use positive parenting strategies,
such as distracting young children who are misbehaving and setting clear rules that children can understand and enforcing them consistently, Dr. Sege said.
If children do not respond to common behavioral
management techniques or severe problems persist,
pediatricians should refer them for a trauma assess-
ment or treatment by a mental health professional.
“Once they’ve assessed that a child has behavior
problems that are a result of past abuse or neglect,
we’re very fortunate there are now evidence-based
therapies that help children heal from these problems,” Dr. Sege said. “We describe in the report what
some of those therapies are and give suggestions on
how a pediatrician might find therapists qualified to
deliver those therapies.”
The report outlines the following clinical consid-
erations for pediatricians:
• Inquiries regarding past traumatic experienc-
es, including child abuse and neglect, may be
included in the social and family histories of
• Treatment for severe or persistent behavioral
consequences of child maltreatment is indicated
• Pediatricians may be able to help parents and
teachers better understand the behavioral consequences of past maltreatment.
• Pediatricians also can help advise social service
agencies on common behavioral problems exhibited by children in foster care who have been
maltreated and advocate for prompt referral to
Children with behavior problems, including attention
issues, anger, irritability and extreme distress, could
be suffering from the effects of abuse or neglect. A
new clinical report offers strategies for treatment.
Evidence-based therapies can ameliorate
behavior problems in maltreated children
by Carla Kemp • Senior Editor
• AAP technical report The Lifelong Effects of Early Child-
hood Adversity and Toxic Stress, http://bit.ly/2lNkjmX
• Information for parents on child abuse, http://bit.
• Information from the Centers for Disease Control and
Resources help identify autism spectrum disorders early
One of the best ways to support families during Autism Awareness Month in April is through early
identification of autism and other developmental disabilities and timely guidance toward services
The Academy is working with the Centers for Disease Control and Prevention’s (CDC’s) Learn
the Signs. Act Early. (LTSAE) program on free resources to help pediatricians identify the one in 68
children with autism spectrum disorder.
Family-friendly materials about typical child development from LTSAE are designed to engage
families in the ongoing process of developmental surveillance, to help all families learn about developmental milestones, celebrate and support their children’s progress, and participate more fully
in developmental screening. Parents are better positioned to act on concerns and follow up on their
Materials to enhance surveillance at health maintenance visits from 2 months to 5 years of age
are available. The English and Spanish materials come in a variety of formats (checklists, booklets,
children’s books and more). Some materials are available in simplified Chinese, Korean, Vietnamese
and other languages. They can be customized with a logo and local contact information.
Visit www.cdc.gov/ActEarly or email ActEarly@cdc.gov. Limited quantities can be ordered and
shipped for free at www.cdc.gov/ActEarly/Orders. The CDC also offers a free Maintenance of Certification Part 2 continuing medical education course at www.cdc.gov/AutismCase Training.