For three straight years, Kentucky led the nation in rates of child maltreatment. The latest numbers available from the U.S. Department of Health and Human Services now place the commonwealth at fifth among all states in terms of victimization of children.
But child welfare advocates caution that drop alone doesn’t make for a trend. And the time period the data covers came during the first year of the COVID-19 pandemic, when schools were closed and teachers, who are critical sources of child abuse reports, had much less direct interaction with their students.
“Without our teachers laying eyes on our kids, I think there was significant under-reporting,” says Dr. Melissa L. Currie, chief of Norton Children's Pediatric Protection Specialists in Louisville. “On the other hand, is there a possibility that there some protective factor to COVID as well?”
Currie says with many people working from home in 2020, there could have been more adults around to protect children from potential mistreatment. But she says officials simply won’t know the long-term implications of the pandemic without more data, which is due to be released soon.
Even though incidence rates have decreased, Currie says the severity of cases is getting worse as health care providers see more children – and younger children – who have experienced severe injuries and even torture. That includes cases of pediatric abusive head trauma, or what was commonly known as shaken baby syndrome.
“It is basically any injury to the brain or the contents of skull or the head in general that’s from other than an accidental means,” says Currie. “It can include things like skull fractures and blunt force trauma to the head in addition to shaking or crush mechanisms, and it continues to be the single most deadly form of child physical abuse.”
As violent as the trauma can be, Currie says it’s sometimes difficult for doctors to diagnose. Bruising is a common symptom, especially in babies who are not yet walking, but contusions are not present in all cases. She says other symptoms of abusive head trauma can include disorientation, inability to focus on objects or people, changes to sleep patterns, increased fussiness, or even cardio-pulmonary arrest.
Another disturbing trend in the existing data is the number of children who overdose after accidentally ingesting a prescription drug or illicit substance. Currie says sometimes the incident occurs when a child gets into a family member’s purse or medicine cabinet and takes something they shouldn’t. Sometimes the ingestion is the result of drug abuse within the household.
“We are seeing unfortunately a lot situations where the caregiver is taking [an] illicit substance and they pass out from that, and then the children have access to the remaining substance,” says Heather Wagers of the Kentucky Attorney General’s Office of Trafficking and Abuse Prevention and Prosecution. “These are absolutely some of the most preventable accidents that occur in Kentucky and we can make a difference by something as simple as a storage container or keeping your medicine locked far away from where children have access.”
The problem can extend to drugs used in the medication-assisted treatment for an addiction. While buprenorphine and methadone can facilitate recovery in adults, Currie says they can be deadly to a child who ingests them. Even if ingestion of an illicit drug or a treatment medication is accidental, Currie says the adult is still accountable.
“We try hard to stay away from discussing intent in child abuse pediatrics,” says Currie, “but we can say that things were wanton or reckless, that any reasonable person would have known to keep narcotics off the coffee table, for example, if you have a two-year old home.”
Legislation and Funding Seek to Improve Social Services
State lawmakers have passed legislation in recent years to address child maltreatment in the commonwealth. One sweeping measure, Senate Bill 8 in the 2022 session, updated definitions of abuse and neglect, strengthened kinship care, increased Medicaid services available to vulnerable populations, and directed social workers to intervene sooner with families in crisis and provide them with wraparound services that can prevent abuse from occurring.
“I think the secret sauce to us passing Senate Bill 8 last year is it was holistic in nature,” says state Sen. Julie Raque Adams (R-Louisville), who sponsored the bipartisan measure. “We tried to include every single stakeholder possible.”
The legislation expanded the use fictive care, which is where a child who needs to be removed from their home is placed with someone who knows and loves the child but is not a blood relative. SB 8 also sought to break the stereotype that poor families neglect their children.
“Years ago, we viewed households that were in poverty as somehow more suspect than a household that was affluent,” says Adams. “The truth is sometimes parents who are in poverty love their children just as much as affluent parents do.”
Instead of outright neglect, Adams says the parents or caregivers simply may not have the knowledge needed to create a safe environment for the child. She says that’s where social services can help provide the resources necessary to address the situation before it can escalate.
Providing that kind of prevention assistance can be difficult, though, if parents fear the state may take their child away from them. Shannon Moody of Kentucky Youth Advocates says the trick is to destigmatize the services the state offers at-risk families.
“When we’re talking about primary prevention, which is where we really want things to go, it’s really that universal opportunity within communities for parents and caregivers to ask for help without fear of potential repercussions where Child Protective Services is getting involved,” says Moody.
But to provide these services and interventions takes people and money. Adams says the legislature appropriated $20 million last year to fund this work, but that’s just the start. She says more than 600 state social workers have left their jobs over the last two years due to stress and high workloads. She says fewer people to investigate these cases can result in more bad outcomes, especially for the state’s youngest children.
“You can’t fulfill the obligation of protecting children unless you have the requisite number of social workers,” says Adams. “Not only do you have to have the personnel, which we’re committed to having and shoring up, but you have to have the prevention services.”
Other Child Welfare Challenges
The latest report from the state’s Child Fatality and Near Fatality External Review Panel showed that 75 out of 80 child deaths in the commonwealth during 2020 were potentially preventable through some kind of intervention. About two-thirds of those cases had some previous contact with social services personnel from the Kentucky Cabinet for Health and Family Services.
“That doesn’t necessarily imply that the cabinet did anything wrong during their previous involvement,” says Currie, who is a member of the review panel. “They may have addressed the issues that were at hand... and then something changed with the family.”
Another challenge is how child abuse hotline calls are screened. Currie says hotline operators may not refer a call for investigation if the allegations are not specific enough or if the call is being placed for retaliatory reasons. Even if a call doesn’t meet the criteria for investigation, that doesn’t mean the concern may not be legitimate.
“We certainly have seen a fair number of cases here in Kentucky where the children presented with a fatality or near-fatality and had a history of screened-out referrals, and in some of those cases we questioned why they were screened out,” says Currie.
Currie says screeners should take into account whether the family has had prior engagement with social services. She also says reports coming from teachers, doctors, or nurses should carry more weight in the screening process.
The majority of maltreatment cases – about 87 percent – involve some kind of neglect, which can include inadequate medical care, education, or adult supervision as well as failure to provide for a child’s basic needs. Currie says state officials have seen a sharp jump in recent years in medical neglect, which can be the failure of a caregiver to seek care for a child or failure to adhere to a prescribed treatment plan.
For example, she says health care providers are reporting an increase in pediatric diabetic ketoacidosis, which is a potentially deadly complication that arises when a child does not get the insulin he or she needs.
An issue that could come before lawmakers this session is medical care for youth who want to transition their gender. Currie says that as a child abuse pediatrician she considers the absence of care for a transitioning child to be a form of medical neglect.
“Children deserve the medical care they need for whatever their diagnosis is,” says Currie. “That is a precious decision that happens between a child, their parents, and their doctor.”
But some people argue that gender transition procedures are a form of child abuse, according to Adams. She says there could be legislation proposed on the matter by state House members.
“We’re going to have to listen to testimony from the medical community, we’re going to have to listen to testimony from the phycological community,” says Adams. “Hopefully we can get to where we need to be from a public policy standpoint.”
Another form of maltreatment is the sexual trafficking of children. Wagers says her office has seen trafficking victims that range from infants to teenagers.
“Children are some of our most vulnerable Kentuckians, and so people are looking for opportunities to prey on that,” says Wagers. “We’re also seeing a rise in familial trafficking in Kentucky, and it’s sad to think about that a caregiver or parent may be involved in the trafficking of child.”
Wagers says the opioid epidemic is driving incidents of familial trafficking. She says symptoms of child trafficking including behavior changes like acting out or becoming withdrawn, wearing different clothes, or being secretive with electronic devices.
When an unexpected child fatality does occur, Moody says county coroners should immediately notify state child welfare officials, especially if the death involves unnatural causes. She says that’s critical to establishing a crime scene investigation should one be warranted. Currie says coroners also need more training on how to recognize a suspicious child fatality. For example, she says a child with a complex medical history may have died from natural causes or the death could have been the result of maltreatment or medical neglect.
Given the lingering problems with child welfare and social services in the commonwealth, Adams says lawmakers will continue to focus on these issues in this year’s 30-day General Assembly session. She says it’s important that they hear from stakeholders and medical experts who can guide them on what they can do to improve the plight of young Kentuckians.
“We’re not where we need to be, we’re trying to get there,” says Adams. “So while we’re in session and we have ability to make adjustments to make better public policy, I need for people to come to me and say, ‘Julie, here’s what we need to do.’”