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Wednesday Jul 03, 2013

Child Abuse: We Have a Role to Play

Sometimes, child abuse is painfully obvious. Broken bones, suspicious marks and bruises are things we all are trained to identify, treat and question.

Other times, though, the red flags are more subtle. When the patient is being examined during a well-child visit, what is the interaction like between the parent and child? What is the demeanor of the child? How is he or she doing in school?

Physicians in all 50 states are required to report suspected maltreatment of a child. Reporting one such suspicion once cost my practice more than a dozen patients from one family. My suspicion was determined to be "founded," and the child and family got needed help. Although losing a group of patients is never easy, especially when you are fulfilling a difficult job requirement, it is critical to remember that we have a professional obligation to children and their future well-being. 

According to HHS, roughly 680,000 children were confirmed victims of maltreatment in 2011. Note the emphasis on "confirmed." How many abused children went undetected, unreported and untreated? What role should we play?

The AAFP and the U.S. Preventive Services Task Force recently issued final recommendations stating that current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent maltreatment in asymptomatic children.

Unfortunately, the red flags often aren't easy to see. Most children are asymptomatic. Children heal quickly. Those that have been sexually assaulted usually appear normal during exams.

So what do the new recommendations mean?

Well, they don't mean we should stop evaluating children, thinking about abuse in our differential, asking the tough questions when indicated and doing a thorough exam. A child or teen who starts wetting the bed, who is fighting an eating disorder or who is pregnant may be a victim of forms of abuse. We must do our best to prevent and stop abuse. We must educate ourselves about trauma survivorship and its clinical presentations and advocate for healthy homes and communities for our children.

And it means that more research is needed to tell us what interventions make a difference. Can we change the trajectory of an abused child? I know that I have made a difference by asking questions, even when the abuse was long ago but the scars still linger. Letting a patient know that you will believe -- using active listening and referring for effective counseling, when needed -- can go a long way to helping a patient find the path to true health in the fullest sense of the word.

Sadly, many cases of abuse go unnoticed. That makes it so important that family physicians be aware of the long-lasting effects that childhood abuse can have on our adult patients. Abuse and neglect can haunt people for years after they have stopped, and they can have profound effects on an individual's health.

Every day in a typical family medicine practice, I see these patients, You likely see them as well. Do you know who they are? Do you know how to inquire and what to do with a positive response? Is it your coworkers? Is it you? Do you know which community resources are trauma informed and provide effective help?

The Adverse Childhood Experience(www.cdc.gov) (ACE) study, an ongoing collaboration between the CDC and Kaiser Permanente, follows more than 17,000 patients who underwent comprehensive physical examinations and provided detailed information about their childhood experiences. The original research was published in 1998, but more than 60 scientific articles(www.cdc.gov) have been published based on the research.

Patients derive their ACE scores by assigning one point to each of the 10 following adverse experiences: abuse (emotional, physical or sexual); neglect (emotional or physical); or dysfunctional household (a household member who had mental illness, substance abuse problems and/or was incarnated; parental separation or divorce; and a mother who was treated violently).

Sixty-four percent of patients experienced at least one adverse experience, 16 percent experienced two, 10 percent experienced three and 12.5 percent experienced four or more.

Researchers found that as ACE scores (and childhood stress) increase, so do patients' risks for a number of health problems, including

  • adolescent pregnancy,
  • alcohol abuse,
  • chronic obstructive pulmonary disease,
  • depression,
  • early initiation of smoking,
  • early initiation of sexual activity,
  • illicit drug use,
  • intimate partner violence,
  • ischemic heart disease,
  • liver disease,
  • sexually transmitted diseases,
  • suicide attempts and
  • unintended pregnancies.

Researchers estimate these long-term health effects can shorten a person's life by nearly 20 years.

The good news is that we can help. If we know what to look for and ask the right questions, we can help our patients unburden themselves from the old secrets they have kept and help them start to heal.

We've all been exasperated by patients who are noncompliant with their medications and others who don't follow up with our referrals. Why don't they take our advice? Maybe they never learned that they are valuable human beings.

Unfortunately, some patients do not realize that they are worthy of care because of the way others, often those who were supposed to love them, mistreated them in the past. And certain exams and procedures -- going to the dentist, colonoscopy, pelvic and rectal exams, etc. -- can cause people who have been violated and traumatized to relive that trauma.

I've presented ACE at medical conferences, and every time, at least one person from the audience has approached me afterwards and told me that they counted their own ACE score, and they don't know how they made it through. Often, they confide that even their own wife or husband doesn't know what they endured.

Too often, victims of abuse never tell anyone.

Will they talk to us? Are you prepared to listen and respond?

Family physicians can make a difference because we treat entire families. We can build relationships with young parents; steer them to parenting classes; and give them good advice about supporting each other, being resilient and providing a nurturing environment.

And because we take care of both the parents and the children, we also are more likely than our subspecialty colleagues to know when something isn't right. It is our obligation to the child to report abuse and neglect.

We also can make a difference for our adult patients who still are dealing with old scars and current health challenges related to the past.

See the big picture. Educate yourself and advocate for children and families in your community.

Take action when it's needed.

We can help. This is family and community medicine at its finest.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Posted at 01:24PM Jul 03, 2013 by Wanda Filer, M.D.

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