T Symposium on Childhood Trauma
Child Abuse and Neglect A Priority Problem for the Private Physician
Frederick C. Green, MD. *
The intentional and willful abuse and neglect of children, either individually or collectively, by kith or kin, or by the policies and regulations of institutions of society, is an inexcusable affront to common decency. Such brutalization of children has become the subject of considerable attention in both the professional literature and the mass media, particularly during the past decade. Since Dr. C. Henry Kempe 10 coined the term, "The Battered-Child Syndrome," in 1962, a term that was responsible for enhancing public awareness of this condition, a number of synonyms have been proposed such as the Child Abuse and Neglect (CAN) Syndrome, the Maltreated Child Syndrome5 and Trauma X/ 3 to name a few. Regardless of the name however, this syndrome is now a major cause of death and disability among children. It is the clear responsibility of all physicians serving children to be aware of, to recognize, and to properly manage any child who has been the victim of abuse. It is not the physician's responsibility to assign guilt. The purpose of this article is to aid the practicing physician to achieve these goals.
DEFINITION Since 1963 there have been laws and statutes mandating the reporting of child abuse in every state of the union; however, there has been little uniformity between states as to the definition of this condition; as to who could legally report; as to the agency to receive the report; and as to the ultimate accountability for case management. In some states, the unborn child is included under the provisions of their statutes (e.g., the newborn of a narcotically addicted mother), whereas in other states, differing clearly delineated age groups of the developmental period are identified. 'Associate Director, Children's Hospital National Medical Center; Professor of Child Health and Development, George Washington University Medical School, Washington, D.C.
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Underlying this national disarray has been the uniform inadequacy of states to allocate adequate resources to effectively manage the identified cases. The recently enacted Public Law 93-247 (The Child Abuse Prevention and Treatment Act) defines the syndrome in the following way: "Child abuse and neglect mean the physical and mental injury, sexual abuse, negligent treatment or maltreatment of a child under the age of 18 by a person who is responsible for the child's welfare under circumstances which indicate that the child's health and welfare is harmed or threatened thereby, as determined in accordance with regulations prescribed by the Secretary [of HEWJ."
This definition is constructed on the basis of the effect of the abuse. There are some who prefer a definition constructed on the broader perspective of the cause. An example of such a definition is one used in the state of Massachusetts that considers child abuse as "an external expression of family dysfunction. "13 One may even expand the concept to include an unresponsive and dysfunctional society. This latter concept would be consistent with David Gil's6 contention that institutional abuse is so inextricably bound to personal abuse that both issues must be addressed simultaneously for maximal effectiveness. Although the federal law contains a definition of child abuse and neglect, this does not deny a state the right to develop its own definition providing it is consistent with the federal statutes. Katz 9 noted that in 1907 the state of Indiana enacted neglect statutes in such a comprehensive way that they have remained basically intact since that time, archaic language notwithstanding. The neglected child is defined as: " ... any boy under the age of sixteen (16) years or any girl under the age of seventeen (17) years, who has not proper parental care or guardianship; or who habitually begs or receives alms; or who is found living in any house of ill fame, or with any vicious or disreputable persons; or who is employed in any saloon; or whose home, by reason of neglect, cruelty or depravity on the part of its parent or parents, guardian or other person in whose care it may be, is an unfit place for such child; or whose environment is such as to warrant the state, in the interest of the child, in assuming its guardianship."
There is a significant lack of clarity as to the true incidence of child abuse and neglect. Kempe estimates a level of 380 cases per million population or 60,000 reported cases per year; whereas Eli Newberger estimates the level to be significantly higher (250,000 to 400,000 per year). The author thinks the latter figure more accurately represents the true picture even in the absence of firm empirical data to support this belief. The key word is "reported." We know that 98 per cent of such cases are reported from public agencies and that such agencies predominantly serve the poor and marginal income families. The remaining 2 per cent are reported from private physicians and agencies. Unless we assume that child abuse and neglect is literally nonexistent in our more affluent population, we are inescapably led to the conclusion that our present cohort of reported cases is seriously biased and underreported. It has also been suggested that for every reported case of child abuse, there are four cases of child neglect. 1 Available evidence also suggests that the majority of reported cases are in children under the age of three, although nonaccidental injury occurs throughout the de-
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velopmental period. Unfortunately, we know far too little about the magnitude of this problem in the school-aged child. Further evidence suggests a preponderance of males over females being physically abused with the reverse being true for sexual abuse. Mothers and other female caretakers are the most frequent abusers, as would be expected because of their greater numbers; however, abuse by fathers and other male caretakers results in more serious injury to the child. Green8 reports that an abused child returned to his home without proper therapeutic precautions being taken, runs "a 50 per cent chance of repeated abuse and a 10 per cent chance of death." Deaths attributable to child abuse are estimated to number 200 to 400 per year nationally. Again this may be a low estimate since Dr. Vincent Fontana5 reports that in New York City alone, one child per week is killed by a parent or caretaker. From a purely clinical point of view, our experience at Children's Hospital National Medical Center in Washington, D.C., is comparable with other investigators in that approximately: 10 per cent of emergency room trauma in children under three years of age is inflicted rather than accidental; 30 per cent of fractures in children under two years of age is nonaccidental; 50 per cent of established abuse cases shows evidence of prior abuse. There is some recent evidence indicating that when reported data is critically analyzed,u the incidence of the child abuse and neglect syndrome is in fact comparably rarer in the Black community, contrary to popular belief. Dr. Clement SInith14 suggests that child abuse and neglect is basically a disease of adults that finds expression in a child. To expand on this premise, Helfer postulates that the etiology of child abuse and neglect may be expressed as a triadic equation consisting of a particular kind of parent, a particular kind of child, plus an anxiety-provoking event (crisis). It is the author's belief that the etiology of this syndrome should reflect not only the child within the context of his family but also the family within the context of the community. Therefore, the author suggests that the equation be quadratic, with the additional fourth factor being a cultural tolerance for severe corporal punishment. Special Parent
+ Special Child + Cultural Tolerance =
Child Abuse and Neglect
1. A Special Parent-one who may have been abused as a child or subjected to distorted nurturing experiences (cyclic phenomenon); an individual who may be young, single, dependent, or who is addicted to alcohol or narcotics. 2. A Special Child-perhaps unexpected and unwanted, chronically ill or handicapped, or who is hyperactive and cries excessively, such behavior being in-" appropriately interpreted by the parents, e.g., persistent crying as being accusatory. 3. Crisis - either major or minor, e. g., death, divorce, loss of job or broken television set, with the child being an accessible target upon which to vent rage and frustration. 4. Cultural Tolerance-living in a community that accepts or actively encourages corporal punishment as a legitimate disciplinary method.
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CLINICAL FINDINGS The syndrome of child abuse is protean in its manifestations, abstruse in its etiology, and complex in its management. It is not the severely battered child nor the child that is dead on arrival that presents the diagnostic difficulties. It is the child that presents with the more subtle physical findings associated with discriminative characteristics in the parents, that is most clinically demanding. Physicians should suspect the child abuse and neglect syndrome under the following circumstances: A discrepancy between the history and the degree of physical injury. A prolonged interval between the occurrence of an injury and the seeking of help. A history of repeated trauma treated in different health facilities. An inappropriate response or compliance of parents to the advice of the health personnel, including the abandonment of the child in the health facility. The following list of clinical findings demonstrated by the child is by no means exhaustive and certainly most of them can occur accidentally; however, these findings should indicate more intensive investigation and observation. Failure to thrive Perioral injuries Odor of alcohol Fracture or fractures in children under three years of age Evidence of frequent injuries-accident prone (scars) and old healed fractures on x-ray Bizarre injuries (bites, cigarette burns, rope marks, branding burns such as with grates or irons) Advanced unattended disease Trauma to genital and perineal areas Major clearly demarcated second and third degree burns Subdural hematomas Skull fractures Ruptured viscus (internal organs) Dead on arrival Morris et al. 12 have described 28 distinctive behavioral characteristics of neglecting, abusing parents regarding their childrens' injuries that the author has found most helpful. A few of the more important are as follows: Evasive and contradictory concerning the circumstances of the child's injury. Failure to volunteer information regarding injury. Critical of and angry with child for being injured. Demonstrates little concern about injury, treatment, or prognosis. Seldom touches or looks at child. Inappropriate or no response to the crying child. Behavioral characteristics of the neglected and abused child: Either cries hopelessly under treatment or examination or cries very little. Does not look to parents for reassurance. Wary of any physical contact with adults. Constantly on the alert for danger.
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In summary, the clinician must maintain a high degree of suspicion. in the face of any injury particularly to the young child and must remain alert for telltale inappropriate behavioral characteristics in the parents or the child. It always helps to ask ourselves the question- Would a loving and prudent parent behave in the manner we observe? If the answer is no, then we are morally and legally responsible to act on our suspicion to serve the best interest of the child and his or her family.
MANAGEMENT The complete physician functions not only as a therapist concerned with the well being of children under his direct care but also as an advocate, concerned with the well being of all of the children of his community. The overarching objectives of any physician acting as an advocate for the children of his or her community should be to initiate a program that will: 1. Eliminate or sharply reduce the incidence of child abuse and neglect in the community. 2. Assure unimpeded access to all of the necessary therapeutic modalities for all people in need of such services.
The physician, acting in his traditional role of a therapist, should have three very specific objectives: 1. To protect the child against initial or repeated violence. 2. To provide the parents or caretakers with the necessary support and therapy to enable them to cope with the causes of their aberrant behavior. 3. To enable the earliest return possible of the child to his rehabilitated and safe natural home.
Effective management is composed of five basic components-prevention, early identification, treatment, follow-up, and rehabilitation. The objectives of management have been previously stated, however, the effectiveness of this management should be measured by the speed with which an abused child can be returned to his rehabilitated biologic parents in his natural home. Prevention If optimal health care were available and accessible to every child, regardless of race, site of residence, or socioeconomic status-a care that assured early diagnosis, treatment, and health maintenance, the problem of child abuse could be significantly ameliorated. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program of Medicaid, a program that assures regular total health assessment of all children and youth, particularly those who are vulnerable due to poverty, has been the law of the land since 1967. The full implementation of this program and the expansion of this concept to cover all children, regardless of the reimbursement mechanism employed, would significantly advance our efforts to achieve this goal.
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A second key to prevention is the ability to identify vulnerable children and parents before an episode of serious abuse. This requires the development of predictive instruments. Such efforts are now going forward in a number of institutions. For example, a number of interesting and important observations are now being recorded on the normal and abnormal maternal-infant bonding process by some investigators. The development of such predictive instruments does call our attention to certain unresolved issues, not the least of which is the fact that we do not now take care of our presently identified abused and neglected children very well. Since the purpose of a predictive instrument is to identify or label children and parents who are at risk, there is the expectation that a sequence of steps will be taken to prevent the predicted outcome. It is precisely this latter process that requires us to pose certain disturbing questions. 1. Will the predictive instrument used to identify or label the at risk population be free of cultural bias? 2. Who will use these instruments? What qualifications will be required of these "labelers"? 3. What will be the form of the preventive intervention? (Remember the debacle of labeling children predelinquent!) 4. How will the label of a potentially abusing parent impact on the lives of his family?
Finally, prevention can be enhanced by broadening the dissemination and utilization of knowledge concerning this syndrome to professionals and laity alike. Medical school curricula and teaching hospital training programs must give young physicians more than the cursory treatment of this subject that has been the rule in the past. In addition, postgraduate medical education programs should also give priority to this subject. The same recommendations apply to the curricula and training programs of the other concerned professional disciplines. The development of state or regional model Child Abuse Centers, as mandated in Public Law 93-247, available for exemplary case management; the education of child abuse teams, and the collection and analysis of pertinent data, will meaningfully enhance our overall efforts. Unquestionably the laity must become better informed regarding all facets of the child abuse and neglect syndrome. Unfortunately, the mass media has tended to treat the subject sensationally and episodically. Although people are made aware of the subject in this manner, it tends to arouse such overwhelming emotions of revulsion that vengeance rather than therapy is demanded. Hopefully, future media coverage will emphasize the value of not only protecting the child against future injury but also of restoring the capability of parents, if possible, to properly nurture their children. It has become painfully apparent to many practicing physicians who feel impelled to report suspected nonaccidental injury to children, particularly if they do it on a number of occasions, that the public is capable of carrying out economic reprisals. Therefore, improvements in our efforts to prevent child abuse is dependent upon the effectiveness of our public educational initiatives.
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Identification Under the varying state laws a variety of professional and nonprofessional individuals who serve or have direct contact with children may identify children at risk; however, confirmation of labeling should or must be done by professionals, sensitive to the needs and lives of those they serve. After the identification, the new law recommends a central registry for abused children. This is desirable because these children are usually treated by a variety of health facilities, with each unaware of the activities and findings of the other. However, when a suspected case is proved to be spurious, there must be a process of removing (delabeling) this family from such a registry. Great emphasis must be placed on the issues of confidentiality of such records including the rights of the family to access and an awareness of all agencies and institutions that receive such reports. Tangential to the issue of a central registry is the issue of the agency or agencies to whom reports of child abuse and neglect must be made. Basically, such reports must be made either to Protective Services Units of the state or local governments or to local police departments. All cases, however, are adjudicated in a civil or criminal court. There are many who favor the reporting of child abuse and neglect cases to a Protective Services Unit because traditionally it has been therapeutically oriented. Although many law enforcement agencies have developed exemplary units to deal with this problem, many of us feel that implicit within reporting to such agencies, is a punitive approach to case management that in the long run may be counterproductive. There is also the possibility of placing the child at greater risk by adjudication through the criminal courts, in that our system demands proof of guilt "beyond a reasonable doubt" and in the author's experiences, even in clear-cut cases, this may be difficult or impossible to accomplish. Because of this inability, the child may be returned to a dangerous home situation in which the parent may feel vindicated in taking the action he or she did, thereby reinforcing such brutalizing tendencies. Under such circumstances the child is placed at greater risk for more serious injury or even death. Judge James Delaneylo summarizes this issue very well. He states: " ... the criminal process as a solution to child abuse is usually totally ineffective. Probably it has some deterrent effect on the parent capable of controlling his conduct, but its chief value lies in satisfying the consciences of the community that the wrong to the child has been avenged. That the true causes of the battering parents' conduct have not been sought out and treated is of little concern."
Treatment Because the problem of child abuse and neglect is multidimensional in its etiology, it is mandatory that its management be carried out by a multidisciplinary team. In general the basic team is composed of a social worker, nurse, pediatrician, and psychiatrist. Depending upon the institution, additional disciplines may be included such as lawyers, psy-
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chologists, law enforcement agents, community representatives, and educators. At the Children's Hospital National Medical Center, our team is composed of a pediatrician, social worker, public health nurse, psychiatrist, and a child life worker. The police officer is included on our team because in the District of Columbia, it is mandatory to report all cases to a special unit of the police department (youth division). The function of the team is to substantiate cases of child abuse and neglect, to develop a plan of action, and to monitor the implementation of such a plan. In the majority of hospitals in which the author has visited and worked, such teams are noteworthy for their lack of significant Black (or other minority) participants, particularly in those hospitals that serve a large Black population. This is important because such teams make profound decisions - enforceable by law - that may have serious consequences on the Black family's integrity. Such decisions are often made in a milieu so culturally divorced from and insensitive to those being served, that the author has serious reservations that the best interests of the child are being consistently served. It seems reasonable that in every case of child abuse and neglect, management is not complete without a home visit by a team member to assure a clear understanding of all aspects of the case. I specifically recommend, therefore, that knowledgeable Black people be represented on every team serving a predominantly Black community (the same applies for the Spanish, native Americans, and oriental minority groups) and that such representation not be of the window-dressing variety, incapable of making meaningful input into the decision-making process. Aggressive efforts must be made to recruit such professionals and allied health workers. In the final analysis, it is the judge that ultimately decides the presence or absence of child abuse and neglect; therefore, it is imperative that the judiciary be thoroughly educated to the multiple facets of this problem. Effective lines of communication must be established among all participating agencies, institutions, and individuals handling such cases with the establishment of a clear focal point of accountability for overall coordination. For the sake of completeness, other basic management modalities as suggested by Kempe and others are: 1. Parents Anonymous Group-the same self-help concept used in Alcoholics Anonymous. 2. Crisis nurseries-24 hour facilities open to mothers for temporary care of their children when they are in need of such support. 3. Lay therapists-competent nonjudgmentallaymen capable of giving sympathetic support on a continuing basis. 4. Therapeutic Day Care Centers-facilities in which abusing parents can enhance their nurturing skills. 5. Family Resource Centers - multiservice neighborhood centers accessible to families for the resolution of crisis.
Follow-up and Rehabilitation After the acute episode, the child should return to the health facility at regular intervals for health assessments without emphasis being
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placed on a "watch dog" role. Parallel to this activity, the parent or abusive surrogate parents should receive continued support through an effective modality of care. It is well to remember that only 10 per cent of abusive parents are so psychotic or sociopathic that they require institutionalization. Ninety per cent of the parents can be helped to reestablish an effective, functional nurturing role. Every effort should be made to insure the availability in every community of high quality foster care and residential care facilities for those children who must be removed from their homes. We are now contemplating the development of a special training program for foster parents who will exclusively serve the needs of abused children.
MEDICOLEGAL ASPECTS OF CHILD ABUSE From the point of view of the physician, most medicolegal aspects are related to: (1) reporting, (2) investigation, (3) management, and (4) adjudication.
Reporting In spite of the fact that most state laws require reporting on suspicion of abuse, as well as the granting of immunity to those who report "without malice," many physicians, both in institutional and private practice, are reluctant to comply for several reasons: a. The inability to comprehend the fact that any parent or caretaker is capable of such brutality toward any child. This same conceptual block exists in many judges who consequently return children to their natural homes, often with disastrous results. h. The personal time commitment that may be required as part of the adjudication process. c. The concern for assuring the confidentiality between the physician and his patient and family. d. The possible deleterious economic impact on their practice. e. The conceptual approbation of severe corporal punishment as a legitimate disciplinary method. f. The reluctance to place a patient's name on a central registry or to report to a law enforcement agency.
Dr. Vincent De Francis 3 pointed out that approximately one half of the state statutes contain a penalty clause that subjects a physician, as well as other designated persons required to report, to criminal liability (fine and/or imprisonment). However, since 1963 when reporting became legally mandated, there has been no criminal action brought against a physician for reporting inappropriately or for failure to report. However, there have been a number of civil suits brought against physicians for failure to report. A most recent one being from the state of California in which action was taken against a hospital and an attending physician for failing to report a case of a young child brutalized so severely that he suffered permanent brain damage. The case was settled out of court for approximately $600,000. A number of states have initiated statewide, toll-free hot lines, open
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to receive reports of suspected child abuse from any citizen, with anonymity guaranteed. All reported cases are promptly investigated. This system has resulted in a sharp increase in the number of identified abused and neglected children. The state of Florida has developed such a program. As would be expected, such as open system lends itself to abuse, thereby resulting in a number of spurious reports; however, the number of such cases decline as the novelty of the system diminishes. 4 Investigation In any case in which nonaccidental injury is considered part of the differential diagnosis, it is imperative that the records should be accurate, legible, and have clearly differentiated subjective and objective findings, as well as a carefully constructed complete data base. In essence, a Problem Oriented Medical Record (POMR) model is an invaluable adjunct to the proper disposition of the cases. The lack of appropriate medical documentation may lead to inappropriate case resolution with resultant liability of the physician to malpractice proceedings. Management and Adjudication The courts have consistently held that the welfare of the child is paramount to all rights of the parents. For that reason, when a physician has a reasonable suspicion that the child has been abused and is at risk for further injury if he returns to his home, he is obligated after reporting to the proper authorities, to assume custody of the child until there is a preliminary judicial hearing. Again, it is not the duty of the physician to assign guilt. Under no circumstances can treatment be withheld on the basis of religious practices of the parent. It has been held that "when a child's right to live and his parent's religious belief collide, the former is paramount and the religious doctrine must give way.''2 "The defense that the parent was entitled to abide by his religious conviction has never been accepted by the courts when the consequences to the child were serious." Many state statutes include exemptions to prosecution "providing the parent's actions are consonant with an established religious belief." Such exemptions may result in serious harm to the child and we in medicine should vigorously protest their inclusion. Finally, there is another disturbing problem that must be addressed. In many parts of our country, more and more primary pediatric care (first contact) is being delivered by allied health professionals (physician assistants and clinical nurse practitioners), supposedly under the supervision of a physician. However, the fact is that many of these valuable associates function with an inordinate degree of independence. There is no question concerning the culpability of the supervising physician if an abused child is treated inappropriately. Therefore, it behooves those of us who work with such primary practitioners to carefully instruct them that all physical injuries in a young child should personally be evaluated by the physician.
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SUMMARY Child abuse and neglect is a complex, multi-dimensional entity that should be clearly understood by any physician (pediatrician, surgeon, etc.) who is consistently functioning as a primary care physician. We have many of the tools and enough understanding to significantly ameliorate this preventable tragedy.
REFERENCES 1. Child Abuse Prevention Act, 1973: Hearing Before the Subcommittee on Children and Youth of the Committee on Labor and Public Welfare, United States Senate 93rd Congress, First session on S:1191. 2. Clark: 185 NE:21 128, Ohio 1962. 3. De Francis, V.: Personal comments (President of American Humane Association). 4. Federal Registry: Vol. 39: No. 168; Wed. August 28, 1974. 5. Fontana, V.: The Maltreated Child: The Maltreatment Syndrome in Children, 2nd ed., Springfield, Ill., Charles C Thomas, 1971. 6. Gil, D.: Violence Against Children: Physical Child Abuse in the United States (Commonwealth Fund Serv) 1970, Harvard Press. 7. Green, F. C.: Hearings before the Select Subcommittee on Education of the Committee on Education and Labor, House of Representatives, 93rd Congress; First Session on HR 6379, HR 10552, and HR 10968: To Establish a National Center on Child Abuse and Neglect. 8. Green, M., and Haggerty, R. J. (eds.): Ambulatory Pediatrics. Philadelphia, W. B. Saunders Co., 1968. 9. Katz, S. N.: When Parents Fail: The Law's Response to Family Breakdown. Boston, Beacon Press, 1971. 10. Kempe, C. H., and Helfer, R. E.: Helping the Battered Child and His Family. Philadelphia, J. B. Lippincott Co., 1972. 11. Lauer, B., Ten Broech, E., and Grossman, M.: Battered child syndrome. Pediatrics, 54 :6770,1974. 12. Morris, M. G., Gould, R. W., and Matthews, P. J.: Toward prevention of child abuse. Children, March and April, 1964. 13. Newberger, E.: The myth of the battered-child syndrome. Curro Med. Dialogue, 40:327, 1973. 14. Smith, C.: The battered child. New Eng. J. Med., 299:322,1973. Associate Director Children's Hospital National Medical Center 2125 13th Street, N.W. Washington, D.C. 20009
Child Abuse and Neglect A Priority Problem for the Private Physician
Frederick C. Green, MD. *
The intentional and willful abuse and neglect of children, either individually or collectively, by kith or kin, or by the policies and regulations of institutions of society, is an inexcusable affront to common decency. Such brutalization of children has become the subject of considerable attention in both the professional literature and the mass media, particularly during the past decade. Since Dr. C. Henry Kempe 10 coined the term, "The Battered-Child Syndrome," in 1962, a term that was responsible for enhancing public awareness of this condition, a number of synonyms have been proposed such as the Child Abuse and Neglect (CAN) Syndrome, the Maltreated Child Syndrome5 and Trauma X/ 3 to name a few. Regardless of the name however, this syndrome is now a major cause of death and disability among children. It is the clear responsibility of all physicians serving children to be aware of, to recognize, and to properly manage any child who has been the victim of abuse. It is not the physician's responsibility to assign guilt. The purpose of this article is to aid the practicing physician to achieve these goals.
DEFINITION Since 1963 there have been laws and statutes mandating the reporting of child abuse in every state of the union; however, there has been little uniformity between states as to the definition of this condition; as to who could legally report; as to the agency to receive the report; and as to the ultimate accountability for case management. In some states, the unborn child is included under the provisions of their statutes (e.g., the newborn of a narcotically addicted mother), whereas in other states, differing clearly delineated age groups of the developmental period are identified. 'Associate Director, Children's Hospital National Medical Center; Professor of Child Health and Development, George Washington University Medical School, Washington, D.C.
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Underlying this national disarray has been the uniform inadequacy of states to allocate adequate resources to effectively manage the identified cases. The recently enacted Public Law 93-247 (The Child Abuse Prevention and Treatment Act) defines the syndrome in the following way: "Child abuse and neglect mean the physical and mental injury, sexual abuse, negligent treatment or maltreatment of a child under the age of 18 by a person who is responsible for the child's welfare under circumstances which indicate that the child's health and welfare is harmed or threatened thereby, as determined in accordance with regulations prescribed by the Secretary [of HEWJ."
This definition is constructed on the basis of the effect of the abuse. There are some who prefer a definition constructed on the broader perspective of the cause. An example of such a definition is one used in the state of Massachusetts that considers child abuse as "an external expression of family dysfunction. "13 One may even expand the concept to include an unresponsive and dysfunctional society. This latter concept would be consistent with David Gil's6 contention that institutional abuse is so inextricably bound to personal abuse that both issues must be addressed simultaneously for maximal effectiveness. Although the federal law contains a definition of child abuse and neglect, this does not deny a state the right to develop its own definition providing it is consistent with the federal statutes. Katz 9 noted that in 1907 the state of Indiana enacted neglect statutes in such a comprehensive way that they have remained basically intact since that time, archaic language notwithstanding. The neglected child is defined as: " ... any boy under the age of sixteen (16) years or any girl under the age of seventeen (17) years, who has not proper parental care or guardianship; or who habitually begs or receives alms; or who is found living in any house of ill fame, or with any vicious or disreputable persons; or who is employed in any saloon; or whose home, by reason of neglect, cruelty or depravity on the part of its parent or parents, guardian or other person in whose care it may be, is an unfit place for such child; or whose environment is such as to warrant the state, in the interest of the child, in assuming its guardianship."
There is a significant lack of clarity as to the true incidence of child abuse and neglect. Kempe estimates a level of 380 cases per million population or 60,000 reported cases per year; whereas Eli Newberger estimates the level to be significantly higher (250,000 to 400,000 per year). The author thinks the latter figure more accurately represents the true picture even in the absence of firm empirical data to support this belief. The key word is "reported." We know that 98 per cent of such cases are reported from public agencies and that such agencies predominantly serve the poor and marginal income families. The remaining 2 per cent are reported from private physicians and agencies. Unless we assume that child abuse and neglect is literally nonexistent in our more affluent population, we are inescapably led to the conclusion that our present cohort of reported cases is seriously biased and underreported. It has also been suggested that for every reported case of child abuse, there are four cases of child neglect. 1 Available evidence also suggests that the majority of reported cases are in children under the age of three, although nonaccidental injury occurs throughout the de-
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velopmental period. Unfortunately, we know far too little about the magnitude of this problem in the school-aged child. Further evidence suggests a preponderance of males over females being physically abused with the reverse being true for sexual abuse. Mothers and other female caretakers are the most frequent abusers, as would be expected because of their greater numbers; however, abuse by fathers and other male caretakers results in more serious injury to the child. Green8 reports that an abused child returned to his home without proper therapeutic precautions being taken, runs "a 50 per cent chance of repeated abuse and a 10 per cent chance of death." Deaths attributable to child abuse are estimated to number 200 to 400 per year nationally. Again this may be a low estimate since Dr. Vincent Fontana5 reports that in New York City alone, one child per week is killed by a parent or caretaker. From a purely clinical point of view, our experience at Children's Hospital National Medical Center in Washington, D.C., is comparable with other investigators in that approximately: 10 per cent of emergency room trauma in children under three years of age is inflicted rather than accidental; 30 per cent of fractures in children under two years of age is nonaccidental; 50 per cent of established abuse cases shows evidence of prior abuse. There is some recent evidence indicating that when reported data is critically analyzed,u the incidence of the child abuse and neglect syndrome is in fact comparably rarer in the Black community, contrary to popular belief. Dr. Clement SInith14 suggests that child abuse and neglect is basically a disease of adults that finds expression in a child. To expand on this premise, Helfer postulates that the etiology of child abuse and neglect may be expressed as a triadic equation consisting of a particular kind of parent, a particular kind of child, plus an anxiety-provoking event (crisis). It is the author's belief that the etiology of this syndrome should reflect not only the child within the context of his family but also the family within the context of the community. Therefore, the author suggests that the equation be quadratic, with the additional fourth factor being a cultural tolerance for severe corporal punishment. Special Parent
+ Special Child + Cultural Tolerance =
Child Abuse and Neglect
1. A Special Parent-one who may have been abused as a child or subjected to distorted nurturing experiences (cyclic phenomenon); an individual who may be young, single, dependent, or who is addicted to alcohol or narcotics. 2. A Special Child-perhaps unexpected and unwanted, chronically ill or handicapped, or who is hyperactive and cries excessively, such behavior being in-" appropriately interpreted by the parents, e.g., persistent crying as being accusatory. 3. Crisis - either major or minor, e. g., death, divorce, loss of job or broken television set, with the child being an accessible target upon which to vent rage and frustration. 4. Cultural Tolerance-living in a community that accepts or actively encourages corporal punishment as a legitimate disciplinary method.
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CLINICAL FINDINGS The syndrome of child abuse is protean in its manifestations, abstruse in its etiology, and complex in its management. It is not the severely battered child nor the child that is dead on arrival that presents the diagnostic difficulties. It is the child that presents with the more subtle physical findings associated with discriminative characteristics in the parents, that is most clinically demanding. Physicians should suspect the child abuse and neglect syndrome under the following circumstances: A discrepancy between the history and the degree of physical injury. A prolonged interval between the occurrence of an injury and the seeking of help. A history of repeated trauma treated in different health facilities. An inappropriate response or compliance of parents to the advice of the health personnel, including the abandonment of the child in the health facility. The following list of clinical findings demonstrated by the child is by no means exhaustive and certainly most of them can occur accidentally; however, these findings should indicate more intensive investigation and observation. Failure to thrive Perioral injuries Odor of alcohol Fracture or fractures in children under three years of age Evidence of frequent injuries-accident prone (scars) and old healed fractures on x-ray Bizarre injuries (bites, cigarette burns, rope marks, branding burns such as with grates or irons) Advanced unattended disease Trauma to genital and perineal areas Major clearly demarcated second and third degree burns Subdural hematomas Skull fractures Ruptured viscus (internal organs) Dead on arrival Morris et al. 12 have described 28 distinctive behavioral characteristics of neglecting, abusing parents regarding their childrens' injuries that the author has found most helpful. A few of the more important are as follows: Evasive and contradictory concerning the circumstances of the child's injury. Failure to volunteer information regarding injury. Critical of and angry with child for being injured. Demonstrates little concern about injury, treatment, or prognosis. Seldom touches or looks at child. Inappropriate or no response to the crying child. Behavioral characteristics of the neglected and abused child: Either cries hopelessly under treatment or examination or cries very little. Does not look to parents for reassurance. Wary of any physical contact with adults. Constantly on the alert for danger.
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In summary, the clinician must maintain a high degree of suspicion. in the face of any injury particularly to the young child and must remain alert for telltale inappropriate behavioral characteristics in the parents or the child. It always helps to ask ourselves the question- Would a loving and prudent parent behave in the manner we observe? If the answer is no, then we are morally and legally responsible to act on our suspicion to serve the best interest of the child and his or her family.
MANAGEMENT The complete physician functions not only as a therapist concerned with the well being of children under his direct care but also as an advocate, concerned with the well being of all of the children of his community. The overarching objectives of any physician acting as an advocate for the children of his or her community should be to initiate a program that will: 1. Eliminate or sharply reduce the incidence of child abuse and neglect in the community. 2. Assure unimpeded access to all of the necessary therapeutic modalities for all people in need of such services.
The physician, acting in his traditional role of a therapist, should have three very specific objectives: 1. To protect the child against initial or repeated violence. 2. To provide the parents or caretakers with the necessary support and therapy to enable them to cope with the causes of their aberrant behavior. 3. To enable the earliest return possible of the child to his rehabilitated and safe natural home.
Effective management is composed of five basic components-prevention, early identification, treatment, follow-up, and rehabilitation. The objectives of management have been previously stated, however, the effectiveness of this management should be measured by the speed with which an abused child can be returned to his rehabilitated biologic parents in his natural home. Prevention If optimal health care were available and accessible to every child, regardless of race, site of residence, or socioeconomic status-a care that assured early diagnosis, treatment, and health maintenance, the problem of child abuse could be significantly ameliorated. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program of Medicaid, a program that assures regular total health assessment of all children and youth, particularly those who are vulnerable due to poverty, has been the law of the land since 1967. The full implementation of this program and the expansion of this concept to cover all children, regardless of the reimbursement mechanism employed, would significantly advance our efforts to achieve this goal.
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A second key to prevention is the ability to identify vulnerable children and parents before an episode of serious abuse. This requires the development of predictive instruments. Such efforts are now going forward in a number of institutions. For example, a number of interesting and important observations are now being recorded on the normal and abnormal maternal-infant bonding process by some investigators. The development of such predictive instruments does call our attention to certain unresolved issues, not the least of which is the fact that we do not now take care of our presently identified abused and neglected children very well. Since the purpose of a predictive instrument is to identify or label children and parents who are at risk, there is the expectation that a sequence of steps will be taken to prevent the predicted outcome. It is precisely this latter process that requires us to pose certain disturbing questions. 1. Will the predictive instrument used to identify or label the at risk population be free of cultural bias? 2. Who will use these instruments? What qualifications will be required of these "labelers"? 3. What will be the form of the preventive intervention? (Remember the debacle of labeling children predelinquent!) 4. How will the label of a potentially abusing parent impact on the lives of his family?
Finally, prevention can be enhanced by broadening the dissemination and utilization of knowledge concerning this syndrome to professionals and laity alike. Medical school curricula and teaching hospital training programs must give young physicians more than the cursory treatment of this subject that has been the rule in the past. In addition, postgraduate medical education programs should also give priority to this subject. The same recommendations apply to the curricula and training programs of the other concerned professional disciplines. The development of state or regional model Child Abuse Centers, as mandated in Public Law 93-247, available for exemplary case management; the education of child abuse teams, and the collection and analysis of pertinent data, will meaningfully enhance our overall efforts. Unquestionably the laity must become better informed regarding all facets of the child abuse and neglect syndrome. Unfortunately, the mass media has tended to treat the subject sensationally and episodically. Although people are made aware of the subject in this manner, it tends to arouse such overwhelming emotions of revulsion that vengeance rather than therapy is demanded. Hopefully, future media coverage will emphasize the value of not only protecting the child against future injury but also of restoring the capability of parents, if possible, to properly nurture their children. It has become painfully apparent to many practicing physicians who feel impelled to report suspected nonaccidental injury to children, particularly if they do it on a number of occasions, that the public is capable of carrying out economic reprisals. Therefore, improvements in our efforts to prevent child abuse is dependent upon the effectiveness of our public educational initiatives.
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Identification Under the varying state laws a variety of professional and nonprofessional individuals who serve or have direct contact with children may identify children at risk; however, confirmation of labeling should or must be done by professionals, sensitive to the needs and lives of those they serve. After the identification, the new law recommends a central registry for abused children. This is desirable because these children are usually treated by a variety of health facilities, with each unaware of the activities and findings of the other. However, when a suspected case is proved to be spurious, there must be a process of removing (delabeling) this family from such a registry. Great emphasis must be placed on the issues of confidentiality of such records including the rights of the family to access and an awareness of all agencies and institutions that receive such reports. Tangential to the issue of a central registry is the issue of the agency or agencies to whom reports of child abuse and neglect must be made. Basically, such reports must be made either to Protective Services Units of the state or local governments or to local police departments. All cases, however, are adjudicated in a civil or criminal court. There are many who favor the reporting of child abuse and neglect cases to a Protective Services Unit because traditionally it has been therapeutically oriented. Although many law enforcement agencies have developed exemplary units to deal with this problem, many of us feel that implicit within reporting to such agencies, is a punitive approach to case management that in the long run may be counterproductive. There is also the possibility of placing the child at greater risk by adjudication through the criminal courts, in that our system demands proof of guilt "beyond a reasonable doubt" and in the author's experiences, even in clear-cut cases, this may be difficult or impossible to accomplish. Because of this inability, the child may be returned to a dangerous home situation in which the parent may feel vindicated in taking the action he or she did, thereby reinforcing such brutalizing tendencies. Under such circumstances the child is placed at greater risk for more serious injury or even death. Judge James Delaneylo summarizes this issue very well. He states: " ... the criminal process as a solution to child abuse is usually totally ineffective. Probably it has some deterrent effect on the parent capable of controlling his conduct, but its chief value lies in satisfying the consciences of the community that the wrong to the child has been avenged. That the true causes of the battering parents' conduct have not been sought out and treated is of little concern."
Treatment Because the problem of child abuse and neglect is multidimensional in its etiology, it is mandatory that its management be carried out by a multidisciplinary team. In general the basic team is composed of a social worker, nurse, pediatrician, and psychiatrist. Depending upon the institution, additional disciplines may be included such as lawyers, psy-
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chologists, law enforcement agents, community representatives, and educators. At the Children's Hospital National Medical Center, our team is composed of a pediatrician, social worker, public health nurse, psychiatrist, and a child life worker. The police officer is included on our team because in the District of Columbia, it is mandatory to report all cases to a special unit of the police department (youth division). The function of the team is to substantiate cases of child abuse and neglect, to develop a plan of action, and to monitor the implementation of such a plan. In the majority of hospitals in which the author has visited and worked, such teams are noteworthy for their lack of significant Black (or other minority) participants, particularly in those hospitals that serve a large Black population. This is important because such teams make profound decisions - enforceable by law - that may have serious consequences on the Black family's integrity. Such decisions are often made in a milieu so culturally divorced from and insensitive to those being served, that the author has serious reservations that the best interests of the child are being consistently served. It seems reasonable that in every case of child abuse and neglect, management is not complete without a home visit by a team member to assure a clear understanding of all aspects of the case. I specifically recommend, therefore, that knowledgeable Black people be represented on every team serving a predominantly Black community (the same applies for the Spanish, native Americans, and oriental minority groups) and that such representation not be of the window-dressing variety, incapable of making meaningful input into the decision-making process. Aggressive efforts must be made to recruit such professionals and allied health workers. In the final analysis, it is the judge that ultimately decides the presence or absence of child abuse and neglect; therefore, it is imperative that the judiciary be thoroughly educated to the multiple facets of this problem. Effective lines of communication must be established among all participating agencies, institutions, and individuals handling such cases with the establishment of a clear focal point of accountability for overall coordination. For the sake of completeness, other basic management modalities as suggested by Kempe and others are: 1. Parents Anonymous Group-the same self-help concept used in Alcoholics Anonymous. 2. Crisis nurseries-24 hour facilities open to mothers for temporary care of their children when they are in need of such support. 3. Lay therapists-competent nonjudgmentallaymen capable of giving sympathetic support on a continuing basis. 4. Therapeutic Day Care Centers-facilities in which abusing parents can enhance their nurturing skills. 5. Family Resource Centers - multiservice neighborhood centers accessible to families for the resolution of crisis.
Follow-up and Rehabilitation After the acute episode, the child should return to the health facility at regular intervals for health assessments without emphasis being
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placed on a "watch dog" role. Parallel to this activity, the parent or abusive surrogate parents should receive continued support through an effective modality of care. It is well to remember that only 10 per cent of abusive parents are so psychotic or sociopathic that they require institutionalization. Ninety per cent of the parents can be helped to reestablish an effective, functional nurturing role. Every effort should be made to insure the availability in every community of high quality foster care and residential care facilities for those children who must be removed from their homes. We are now contemplating the development of a special training program for foster parents who will exclusively serve the needs of abused children.
MEDICOLEGAL ASPECTS OF CHILD ABUSE From the point of view of the physician, most medicolegal aspects are related to: (1) reporting, (2) investigation, (3) management, and (4) adjudication.
Reporting In spite of the fact that most state laws require reporting on suspicion of abuse, as well as the granting of immunity to those who report "without malice," many physicians, both in institutional and private practice, are reluctant to comply for several reasons: a. The inability to comprehend the fact that any parent or caretaker is capable of such brutality toward any child. This same conceptual block exists in many judges who consequently return children to their natural homes, often with disastrous results. h. The personal time commitment that may be required as part of the adjudication process. c. The concern for assuring the confidentiality between the physician and his patient and family. d. The possible deleterious economic impact on their practice. e. The conceptual approbation of severe corporal punishment as a legitimate disciplinary method. f. The reluctance to place a patient's name on a central registry or to report to a law enforcement agency.
Dr. Vincent De Francis 3 pointed out that approximately one half of the state statutes contain a penalty clause that subjects a physician, as well as other designated persons required to report, to criminal liability (fine and/or imprisonment). However, since 1963 when reporting became legally mandated, there has been no criminal action brought against a physician for reporting inappropriately or for failure to report. However, there have been a number of civil suits brought against physicians for failure to report. A most recent one being from the state of California in which action was taken against a hospital and an attending physician for failing to report a case of a young child brutalized so severely that he suffered permanent brain damage. The case was settled out of court for approximately $600,000. A number of states have initiated statewide, toll-free hot lines, open
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to receive reports of suspected child abuse from any citizen, with anonymity guaranteed. All reported cases are promptly investigated. This system has resulted in a sharp increase in the number of identified abused and neglected children. The state of Florida has developed such a program. As would be expected, such as open system lends itself to abuse, thereby resulting in a number of spurious reports; however, the number of such cases decline as the novelty of the system diminishes. 4 Investigation In any case in which nonaccidental injury is considered part of the differential diagnosis, it is imperative that the records should be accurate, legible, and have clearly differentiated subjective and objective findings, as well as a carefully constructed complete data base. In essence, a Problem Oriented Medical Record (POMR) model is an invaluable adjunct to the proper disposition of the cases. The lack of appropriate medical documentation may lead to inappropriate case resolution with resultant liability of the physician to malpractice proceedings. Management and Adjudication The courts have consistently held that the welfare of the child is paramount to all rights of the parents. For that reason, when a physician has a reasonable suspicion that the child has been abused and is at risk for further injury if he returns to his home, he is obligated after reporting to the proper authorities, to assume custody of the child until there is a preliminary judicial hearing. Again, it is not the duty of the physician to assign guilt. Under no circumstances can treatment be withheld on the basis of religious practices of the parent. It has been held that "when a child's right to live and his parent's religious belief collide, the former is paramount and the religious doctrine must give way.''2 "The defense that the parent was entitled to abide by his religious conviction has never been accepted by the courts when the consequences to the child were serious." Many state statutes include exemptions to prosecution "providing the parent's actions are consonant with an established religious belief." Such exemptions may result in serious harm to the child and we in medicine should vigorously protest their inclusion. Finally, there is another disturbing problem that must be addressed. In many parts of our country, more and more primary pediatric care (first contact) is being delivered by allied health professionals (physician assistants and clinical nurse practitioners), supposedly under the supervision of a physician. However, the fact is that many of these valuable associates function with an inordinate degree of independence. There is no question concerning the culpability of the supervising physician if an abused child is treated inappropriately. Therefore, it behooves those of us who work with such primary practitioners to carefully instruct them that all physical injuries in a young child should personally be evaluated by the physician.
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SUMMARY Child abuse and neglect is a complex, multi-dimensional entity that should be clearly understood by any physician (pediatrician, surgeon, etc.) who is consistently functioning as a primary care physician. We have many of the tools and enough understanding to significantly ameliorate this preventable tragedy.
REFERENCES 1. Child Abuse Prevention Act, 1973: Hearing Before the Subcommittee on Children and Youth of the Committee on Labor and Public Welfare, United States Senate 93rd Congress, First session on S:1191. 2. Clark: 185 NE:21 128, Ohio 1962. 3. De Francis, V.: Personal comments (President of American Humane Association). 4. Federal Registry: Vol. 39: No. 168; Wed. August 28, 1974. 5. Fontana, V.: The Maltreated Child: The Maltreatment Syndrome in Children, 2nd ed., Springfield, Ill., Charles C Thomas, 1971. 6. Gil, D.: Violence Against Children: Physical Child Abuse in the United States (Commonwealth Fund Serv) 1970, Harvard Press. 7. Green, F. C.: Hearings before the Select Subcommittee on Education of the Committee on Education and Labor, House of Representatives, 93rd Congress; First Session on HR 6379, HR 10552, and HR 10968: To Establish a National Center on Child Abuse and Neglect. 8. Green, M., and Haggerty, R. J. (eds.): Ambulatory Pediatrics. Philadelphia, W. B. Saunders Co., 1968. 9. Katz, S. N.: When Parents Fail: The Law's Response to Family Breakdown. Boston, Beacon Press, 1971. 10. Kempe, C. H., and Helfer, R. E.: Helping the Battered Child and His Family. Philadelphia, J. B. Lippincott Co., 1972. 11. Lauer, B., Ten Broech, E., and Grossman, M.: Battered child syndrome. Pediatrics, 54 :6770,1974. 12. Morris, M. G., Gould, R. W., and Matthews, P. J.: Toward prevention of child abuse. Children, March and April, 1964. 13. Newberger, E.: The myth of the battered-child syndrome. Curro Med. Dialogue, 40:327, 1973. 14. Smith, C.: The battered child. New Eng. J. Med., 299:322,1973. Associate Director Children's Hospital National Medical Center 2125 13th Street, N.W. Washington, D.C. 20009
