Health and public health approach to ending child abuse and neglect.

The 30th 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.

Commentary: taking a deep breath before reflecting on differential response.

Although there are certainly limitations to each and every research and evaluation project in child welfare, as with other fields of study, understanding DR as a CPS reform has been fostered through many thoughtful and rigorous studies that have employed random control trial evaluation designs. For each assumption addressed in this commentary, we have raised a few questions. For all interested in CPS reform, other questions arise because child protection and child welfare professionals are trying to encourage more scientific ways of thinking as a means of engendering improvements: 1. Has the research on DR spotlighted the inadequacy of CPS interventions, either AR or IR? A high percentage of CPS responses are short-term. Is it reasonable to expect significant differences between AR and IR families and improvements in the CPS population, given that families often present with problems characterized as intractable but the intensity of the CPS response, coupled with limited service availability and accessibility, may not be sufficient to meet family needs? 2. Has the DR research, which has mainly focused on AR families, also highlighted the glaring absence of quality research in what is effective in producing positive outcomes for families that receive traditional child abuse and neglect investigations? 3. Does the implementation of DR move the CPS field ahead in terms of making better triage decisions, identifying especially those that require CPS involvement as compared to those who will benefit from but might not absolutely need intervention? Is 'triage' an explicit assumption of the DR innovation? Is it an implicit assumption of DR, however defined? If triage is not part of the research, does the ability of child protection to respond both differentially and also correctly to cases needing most, some, or no attention remain unknown? Until there is a reliable and valid way for determining for which families services are most urgently needed, are many reforms in CPS at risk of not producing the outcomes desired? 4. Are there other unintended consequences of either accepting or rejecting DR that might not have been considered? Our current perspective is to state the obvious and point out that rarely are scientifically or "evidence-based" changes in practice achieved or discredited in a decade or two, much more a scant few years. Breathing deeply from time to time, and even pausing for reflection once in awhile, are useful habits for taking on long-range and difficult human endeavors.

Child maltreatment law and policy as a foundation for child advocacy.

Advocacy for children is a fundamental pediatric concern and activity. Notwithstanding achievements for children to date, pediatrics can do more in the twenty-first century to advocate for children and promote research on ways in which advocacy for children can be improved. Evidence-based advocacy should take many directions including legislation, system change in local and state agencies such as social services and health departments, financial assistance including Medicaid, evidence provided to courts at trial and on appeal through "friend of the court" participation, family guidance, public education, and the promotion of pediatric law and bioethics.

Managing pediatric dental patients: issues raised by the law and changing views of proper child care.

The purpose of this paper was to examine legal issues regarding the management of pediatric dental patients and changing views of proper child care. Standards of care in pediatric dentistry are not static. They change in response to research, patterns of reimbursement, patient and parental expectations of reasonable care, and consensus among practitioners. The law pertaining to accountability for pediatric dental patient treatment largely reflects standards of care established by the pediatric dentistry profession. However, the law can also reflect changes in public expectations of reasonable care that can effectively outrun the discipline's efforts to reflect new knowledge or changing public concerns. A major impetus for considering the care of children in all settings has been the increasing recognition of suboptimal children's care, as well as concerns that children have either been abused or neglected in a number of settings. Too often, practices towards children have been untested and based only on the assumption that what is done is "for the child's own good." Pediatric dentists can respond to changing standards of reasonable care for pediatric dental patients, as expressed in legal decisions. They can also usefully consider how attention to child maltreatment has sensitized parents to be better consumers of services on their children's behalf. Rather than reacting only to public pressures for better means of behavior management, the challenge is to exceed expectations via new research and thoughtful anticipation of improvements that can be made.

Medicolegal aspects of child abuse and neglect.

Neurosurgeons that see children and care for those with traumatic injury are highly likely to see cases of child abuse and neglect. That fact makes it inevitable that they will encounter the legal system. It is hoped that this article has demystified the legal process and systems that one encounters in day-to-day practice. Avoiding the diagnosis of abuse because of lack of knowledge or phobia of the legal system is hazardous to the health and well-being of children.