Need Eyes on Our Kids…

There were a staggering 7.8 million children across 4.3 million child abuse and neglect cases referred to Child Protective Services in the U.S. in 2018. Of those cases, 2.4 million were deemed serious enough to require intervention. The Centers for Disease Control and Pevention (CDC) estimated that in 2018 over 678k children were “victimized.” What role can technology play to address this vicious scourge of society, further exacerbated by the pandemic with so many children hidden in the shadows, not in school? Clearly, better analytics and monitoring solutions should improve public healthcare infrastructure’s abilities to fight this type of abuse.

In the very earliest days of the pandemic, before the scope was fully appreciated, school closures in the early spring were thought to be temporary; a significant inconvenience for many, but manageable. The scramble to virtual curricula was challenging, and nearly always a very poor replacement for the in-person classroom experience. By April, though, it became apparent that this impact was going to be meaningfully more devastating with disruption to regular meals, social interactions, and most critically, separation from a social infrastructure of teachers, care givers and other trained professionals.

What a terrible tradeoff: open the schools and risk widespread COVID exposure or keep them closed and introduce a host of other risks. A recent analysis by The 74 Million, a leading non-partisan news site covering the education sector, in partnership with the Organization for Economic Cooperation and Development, found that the long-term economic impact in the U.S. tied directly to school closures to be nearly $14.2 trillion over the rest of this century. Should schools be closed throughout this fall, the cost will increase by another $28 trillion.

What is not fully understood is the incidence of child abuse during the pandemic. Initially, the number of reported abuse cases dropped dramatically. In New York City alone, case count dropped 51% through the summer; California and Texas dropped 45% and 30%, respectively. But while the number of reported cases dropped, the number of actual cases admitted to hospitals remained largely unchanged, a pattern eerily reminiscent of 2008 during the Great Recession. Without the ability of other adults to monitor children, the pandemic has pushed the abuse out of the purview of trained professionals. This week Mayor de Blasio announced a delay to New York City school re-openings and is instituting a “blended learning model” for the 1.1 million school children, 114k of whom are homeless.

What is absolutely understood is the profound emotional and financial costs of child abuse. Often caused by parental stresses, financial pressures, and substance abuse behavior, the CDC considers child abuse (and other domestic violence) “preventable” – really? More than 67% of abuse referrals are made by community professionals such as teachers, law enforcement and social services staff; teachers alone account for over 20% of all referrals. That essential window for many children is now closed.

Importantly, while 83% of abusers are between the ages of 18-44, more relevant is that for 78% of cases, the perpetrators are one of the victim’s parents. Women account for 54% of all abusers. Experts are now most worried about “opportunity crimes” with newly unemployed relatives or quarantining college kids back in homes with housebound children who otherwise would be in school.

The CDC tabulated that the economic costs of child abuse in 2015 (most recent year) to be $428 billion of “lifetime economic burden.” Setting aside the staggering direct financial costs, the other costs from future violence, increase in substance user disorders, lower education and employment levels, and greater likelihood of future victimization are immeassurable. In 2018, over nine per 1,000 children were victimzed; one in five reported being bullied in school while one in seven were “electronically” bullied on social media. Tragically, 1,770 children died of abuse in 2018; 47% of whom were younger than onen year old.

The pandemic has had other devastating implications for child welfare. The last 20 years has seen significant improvement in the reduction of childhood mortality rates (from mid-70 per 1,000 to the mid-30s per 1,000). According to the global health organization PATH, this progress has been jeopardized by the pandemic, principally by the inability for children to access reliable healthcare services. In models that assume the most “severe disruption” the progress has been set back a decade.

Data: PATH estimates from disrupted maternal, newborn and child health services, drawing on modeling from Lancet Global Health; Chart: Axios Visuals

In addition to losing regular connection with many children who are now homebound, there is a staggering incidence of food insecurity. The U.S. Census Bureau estimates that 13.9 million children now suffer from food insecurity, an unprecedented level when compared to 2.5 million in 2018 or 5.1 million during the Great Recession in 2008. In June alone, it is estimated that one in three Black children did not have sufficient food access. Perversely, the Trump administration this month made eligiblity requirements more stringent for low-income students to access meals will not in school.

Technology has a role to play here. As much of healthcare delivery has gone virtual during the pandemic, the ability to be connected with children in-home remotely via Zoom and Facetime has afforded the potential for new insights into what children may be suffering, not unlike what is being experienced with elder care. Obviously, inadequate wireless infrastructure and poor access to devices disproportionately affects low income students. In spite of that, novel behavioral health platforms are being deployed to assist families deemed at-risk. Anecdotally, typical no-show rates for medical appointments dropped from ~30% to low single digits with the advent of virtual visits.

Dr. Christopher Greeley, a leading national expert on child abuse at Baylor College of Medicine (and my brother), points to the emergence of better predictive risk modeling in the field of child welfare. Such an approach allows clinicians and policy makers to identify circumstances that create clusters of common characteristics most associated with child abuse. Determining the “gradient of health” in a certain census tract  facilitates the deployment of resources (i.e., child care centers) into a particular community. Big data analytics allows for the creation of a “Social Vulnerability Index” to determine how best to prioritize resources. This summer the Office of the Inspector General issued guidance to CMS to utilize Medicaid data to better identify patterns of child abuse, acknowledging the potential of these new analytical tools.

Of course, the proliferation of virtual visits and improved analytics does not solve the “last mile” issues, forever chronic with social services. In addition to enhanced public engagement and education campaigns, there needs to be a strong legislative approach. For instance, corporal punishment of children needs to be more aggressively persecuted. Tax policy can play an important role as well. CDC studies have shown that child tax credits can meaningfully move families with children out of poverty: a $1,000 tax credit can lower childhood poverty rates from 26% to 23%; a $4,000 tax credit can lower it to below 15%.

In addition to the various (often inadequate) public safety nets in place, ordinarily families would look to the private childcare industry for assistance. Barron’s recently estimated that school closings may cost the economy up to $700 billion in lost revenue and productivity this year which is approximately 3.5% of GDP. Analysts at the Center for America Progress estimate that roughly half of day care centers will fail which would reduce capacity by 4.5 million slots, leaving 4.2 children for each available slot. The day care industry received $3.5 billion of aid from the CARES Act and only 25% of childcare operators received Paycheck Protection Program loans. Even the private backstops are significantly compromised during COVID.

With everything that we are struggling with today, one thing we absolutely should not have to worry about are ridiculous QAnon conspiracy theories that leading Democratic figures are consuming children for their “Adrenochrome,” a magical psychedelic drug in their blood. There are simply too many real-world problems our children face.



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6 responses to “Need Eyes on Our Kids…

  1. Dan Gebremedhin

    Thoughtful approach to a challenging topic!!!

    Dan Gebremedhin MD, MBA
    Flare Capital Partners | Prudential Tower | 800 Boylston Street, Suite 2310 | Boston, MA 02199
    Office: (617) 607-5057 | Mobile: (617) 686-3820 | Fax: (857) 233-5078
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    Twtr: @dangebremedhin | Linkedin |

  2. thanks – always appreciate your reaction!!

  3. Very insightful. It goes beyond the ability of remote medical visits to see people’s living situations and get insights into social determinants of health (SDOH), which has been an added value of telemedicine.

  4. Bill Asher

    Thanks for raising important issues in this forum that we shouldn’t lose sight of with all the other bad stuff that people have to deal with. I’m happy to be involved with Boston CASA, a local organization that provides “court appointed special advocates” for court-involved kids in the foster care system in Massachusetts in all phases of their lives. Boston CASA has been able to pivot to virtual support of its clients during the pandemic, very successfully despite the challenges. Although technology is not a substitute for face to face support of kids in difficult family situations, used judiciously and creatively it might enable organizations like Boston CASA to extend its reach when things start to revert to normal.

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