Am Fam Physician. 2000;61(10):2977-2985
Child abuse and neglect are prevalent in American society. In many cases, the abuse is perpetuated generationally.1 Child maltreatment, abuse and victimization refer to the intentional assault of a child by a caretaker. This definition has been expanded to cover any action that undermines a child's development potential and is a significant expansion of the definition associated with the battered-child syndrome.2,3
Although the classic battered child who presents with multiple injuries can be easily identified by the family physician, it is a diagnostic challenge when no physical signs are apparent or the child has a single injury. For example, more than 60 percent of children who are sexually abused will not have physical indicators of abuse, thereby decreasing the value of the physical examination.4 In these situations, having an understanding of normal child development and behavior, along with recognizing the relationship between mechanism of injury and unintentional versus intentional trauma, are critical. Family physicians should also be aware of medical conditions that can be confused with abuse, for the outcome is tragic when a caretaker is falsely accused because of a child's illness.
Alternative medical practices have become increasingly common among children.5,6 This may be especially true within immigrant and muticultural families. Among the more common regimens that have been used and are often confused with abuse are CaoGio, or coining, among Southeast Asians; bahnkes or cupping used among Russians, Koreans and others; and Caida de Mollera or fallen fontanella, among Latinos.7 In the case of coining or cupping practices, which are thought to draw infections from the body, erythematous and ecchymotic rounded lesions or linear streaks are produced on the body from a suction technique. A careful history taken by the family physician will disclose the correct etiology of the bruising and prevent an unnecessary social service investigation.
Fallen fontanella, a practice that involves turning a child upside down to correct a depressed fontanelle, can cause vomiting, diarrhea and dehydration in infants. Retinal hemorrhages can also occur, and sometimes shaken-baby syndrome is erroneously diagnosed.
Being culturally sensitive and alert to the ways parents and children deal with illness is important among diverse patient populations.
In this issue of American Family Physician, the clinical approach to the abused child is well covered in Pressel's article, “Evaluation of Physical Abuse in Children.”8 The article is a good complement to a previous article in AFP by Bethea.9 Risk for serious injury and the prevalence of abuse trauma is highest in infants and young children, with the greatest fatalities occurring during the first several months of life.10 Family physicians must be familiar with development milestones during this period, because the risk of fatalities increases significantly when the diagnosis of child abuse is missed. Statistics reveal that neonaticide accounts for 45 percent of infant deaths within the first 12 months of life, making the newborn nursery evaluation, including parental acceptance of the infant and bonding, a critical component.11
Child abuse in general is underreported, and vigilance on the part of family physicians is paramount. A recent study10 revealed that more than 80 percent of infant homicides are due to severe child abuse, and associated risk factors include young parental age at childbirth, birth of a subsequent child, and no pre-natal care. According to the Third National Incidence Study of Child Abuse and Neglect (NIS-3), the birth order was strongly correlated with risk of physical injury.12
Armed with this information, it is clear that family physicians should inquire about risk factors for infant abuse during the pre-natal period, with interventions initiated throughout pregnancy and the postpartum period. In addition, evidence shows that the risk of partner abuse may be greater during pregnancy and postpartum, especially among adolescent parents.
Screening for partner and infant abuse is therefore an important component of the history for family physicians during pregnancy and well-child visits. Screening for infant abuse is a priority when infant prematurity or disability exists, because of the increased risk of caregiver stress and decreased bonding.
The correlation between child abuse and domestic violence should also be emphasized. Studies have shown that in 45 to 50 percent of cases in which there is intimate partner abuse, there is also child abuse.13 Prevalence studies in a pediatric office and emergency department setting reveal that when mothers are questioned about domestic violence, as many as 30 to 50 percent report a personal history of abuse from their partner.14,15
Child abuse may be a marker for domestic violence, suggesting the need for dual screening and intervention by family physicians. In order for this assessment and advocacy to be effective, family physicians must routinely ask about child abuse along with queries about domestic violence. The American Academy of Pediatrics (AAP) recommends that questions about domestic violence be a part of anticipatory guidance counseling.16 This type of brief, directed counseling has been shown to be effective and, when incorporated as part of the well-baby office visit, serves as a strategy for primary prevention. In addition to discussing age-appropriate safety issues in the home, the physician can facilitate discussion on the effect of conflict and violence on children, and nonviolent discipline techniques, and inform adult victims about abuse dynamics and safety planning. When appropriate, a physician may make referrals.
Violence witnessed by children is also a growing issue; between 3 million and 10 million children witness violence in their homes.17 This has been shown to produce a growing list of psychologic problems. Some of the effects include an increase in violence-related behavior and emotional activities, aggressive and disruptive responses in stressful situations, and an increase in undifferentiated abdominal pain, headaches and soft-tissue musculoskeletal pain.1 Current studies have shown an association between witnessed abuse and health outcomes in children. Researchers reveal that witnessing domestic violence can be just as traumatic as sexual abuse, and children younger than 11 years are at a greater risk for post-traumatic stress disorder than adult witnesses.18,19
A growing number of advocacy programs throughout the country offer treatment to children in this category and their families. Some offer home-based family counseling, while others have cross-trained health care professionals who can intervene and address both victims' needs. Family physicians should be familiar with and support such outreach agencies within their communities. These neighborhood-based programs serve as the best intervention and prevention services for families in crisis.