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Child maltreatment: Seeing the problem is only step one

Why do abuse victims finally disclose what’s happened to them? For one simple reason: Someone asked the right questions in an environment that felt safe to the child.

David Paulk, EdD, PA-C

David Paulk is associate professor/academic coordinator, Department of Medical Science and Community Health, Arcadia University, Glenside, Pennsylvania. He has indicated no relationships to disclose relating to the content of this article. The author dedicates this article to his children, who have a voice, and to all the children who do not.

The statistics are shocking: in fiscal year 2005, 3.6 million children were investigated by child protective services (CPS) as victims of maltreatment; abuse or neglect was substantiated in approximately 899,000 children; and 1,460 children died (76.6% of them were younger than 4 years).¹ Clinicians see the impact of abuse but usually not until it has progressed to a significant level. The practitioner must understand the scope of the problem, as well as the types of abuse that exist. Most well-trained clinicians may understand reporting laws and recognize such overt signs of abuse as burns, bruising, or other pathognomonic injuries. However, a major problem exists in how clinicians convince a child to disclose abuse when it is suspected in the first place.

SCOPE OF THE PROBLEM

The federal Child Abuse Prevention and Treatment Act, as amended and reauthorized in June 2003, defines child abuse and neglect as, at a minimum, any recent act or failure to act “resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child … by a parent or caretaker (including any employee of a residential facility or any staff person providing out-of-home care) who is responsible for the child’s welfare.”² More recent definitions also take into account the impact of abuse on a child’s development and expand the categories of abuse and neglect to include other actions deemed harmful to children, such as emotional abuse and educational or medical neglect.³

Costs of child abuse Putting a monetary value to what child abuse costs yearly is difficult; however, some costs can be calculated. The National Clearinghouse on Child Abuse and Neglect Information estimates the annual costs to be in excess of $94 billion.¹ These data were culled from various sources, including the Departments of Health and Human Services, Justice, the Census Bureau, and others.¹

There are nonmonetary costs as well. In school, abused children receive more disciplinary referrals and suspensions and are more likely to repeat grades. Maltreated children in grades K through 12 perform significantly below their nonmaltreated peers on standardized tests and have lower grades; 30% have some language or cognitive impairment, more than 50% have social and emotional problems; 14% engage in self-mutilation or other self-destructive behavior; and more than 22% of abused children have a learning disorder.^4,5 Perry found that abused and/or neglected children tend to have 20% to 30% smaller limbic and cortical areas of the brain (these areas regulate emotional response and attachment, which in turn permit the expression of empathy toward others).⁶ Strauss found that children who see and experience recurrent violence are more likely to use violence in their own families and more likely to abuse their own children.⁷

The Adverse Childhood Experiences Study This study originated as a weight loss study in California and examined the long-term effects of adverse childhood experiences, notably child abuse.⁸ Many of the participants who dropped out of the weight loss program were discovered to have been abused as children. This led to a large-scale epidemiologic study of the influence of stressful and traumatic childhood experiences on behaviors underlying the leading causes of disability, social problems, health problems, and death in the United States. The Adverse Childhood Experiences Study was expanded to include more than 17,000 participants, with a median age of 50 years. It assessed childhood exposure to multiple types of abuse, neglect, domestic violence, and other dysfunctional behaviors such as substance abuse. The study examined behaviors from adolescence to adulthood in the research subjects. It concluded that a significant number of adults who went for comprehensive medical screening had experienced household abuse or dysfunction during their childhoods. Compared to those who suffered no adverse childhood experiences, those with significant adverse experiences were twice as likely to become smokers, 12 times more likely to have attempted suicide, 7 times more likely to become alcoholic, and 10 times more likely to have injected street drugs. Clinicians can reduce some of this country’s most profound health problems by recognizing and helping abused children disclose their maltreatment.

CHILD ABUSE CLASSIFICATION

Four types of child abuse are generally reported. They are (with national incident percentages in parentheses) neglect (62.8%), physical abuse (16.6%), emotional abuse (7.1%), and sexual abuse (9.3%). Abuse classified as “other” (18.9%) includes acts such as abandonment and threats of harm to the child, as well as congenital drug addiction. Subsets of each type of abuse exist in various states, and states may code any maltreatment type that does not fall into one of the four main categories as “other.” The percentages total more than 100% because many children were victims of more than one type of maltreatment and were coded more than once.¹

Neglect is the failure to provide for a child’s basic needs and is subject to many factors. Cultural values, the standards of care in the community, and/or poverty may contribute. A neglectful family may be in need of information or assistance, but when a family fails to use information and resources, either deliberately or through ignorance, and the child’s health or safety is at risk, then CPS intervention may be required.

Physical abuse is simply physical injury. Such injury is considered abuse regardless of whether the caretaker intended to hurt the child. It has been this author’s experience that many abusers are genuinely shocked as to the magnitude of their own physically abusive behavior.

Sexual abuse includes activities by a parent or caretaker, such as fondling a child’s genitals, penetration, incest, rape, sodomy, indecent exposure, indecent or suggestive sexual innuendo, exploitation through prostitution, or the production of pornographic materials (either printed or via electronic means).

Emotional abuse is a pattern of behavior that impairs a child’s emotional development or sense of self-worth. This may include constant criticism, threats, or rejection, as well as withholding love, support, or guidance. Emotional abuse is often difficult to prove, and CPS therefore may not be able to intervene without evidence of harm to the child. Emotional abuse is almost always present when other forms are identified. Additionally, emotional abuse is probably the most devastating to experience and replete with long-term consequences for the child.

Other abuse includes types of maltreatment that do not fit neatly into the categories above.

CHARACTERISTICS OF ABUSERS AND VICTIMS

Although certain risk factors may help to identify the person who has abused or who is likely to abuse, PAs should remember that people do not always fit statistical models. For example, those living in lower socioeconomic conditions are statistically more likely to abuse, but those living in higher conditions are not immune from it either. Child maltreatment transcends all situations and all socioeconomic levels.

Certain factors have historically been linked with the likelihood of child maltreatment (see Table 1). Most perpetrators of abuse are female (57.8%), with a median age of 31 years.¹ Substance abuse is also a common factor in child maltreatment; estimates from US studies of the prevalence of chemical dependence among families in the child welfare system have ranged from 50% to 80%, with a strong correlation of reported recurrent maltreatment.⁹ The perpetrator is likely to be a parent (79.4%).¹ Another factor that is consistently correlated with higher incidences of child maltreatment is poverty; studies demonstrate the likelihood that those in dire economic straits abuse their children at a higher rate than do those in less difficult financial circumstances.¹⁰ Early identification of persons who are statistically likely to abuse can go far in helping to prevent a potentially tragic event.

Most victims of child abuse are white (49.7%) or African-American (23.1%).¹ However, the clinician should be on the alert for signs of abuse in all children.

THE EVALUATION

There is no gold standard approach to identifying child maltreatment. Typically, the process begins when the clinician has a feeling that something is not altogether what it seems to be, or should be. Abuse of a physical, sexual, or neglectful type may manifest with physical signs. Emotional abuse is difficult to ascertain if physical components are absent. The clinician should investigate any serious behavioral, cognitive, emotional, or other mental disorders, and Table 2 lists some questions for the PA to consider.¹¹

General questions that the health practitioner should ask when investigating the physical aspects of child abuse and neglect are listed in Table 3. Specific signs may exist for each type of child maltreatment, some of which are listed below. The clinician is urged to remember that combinations of these signs may be present and that additional signs not listed here may be present as well.

Soft tissue injuries (contusions and welts) may form regular patterns, resemble the shape of the article used to inflict the injury (for example, a hand, teeth, belt buckle, electric cord, etc), or be in various stages of healing.
Soft tissue injuries (lacerations/abrasions) may include rope burns, particularly on the wrists, ankles, neck, or torso; and injuries to the palate, mouth, gums, lips, eyes, or ears.
Burns may include cigar or cigarette burns, especially on the soles, palms, back, or buttocks, and immersion burns (stockinglike or glovelike without splash burns on extremities, or doughnut-shaped on genitals or buttocks).
Abdominal injuries may include bruises of the abdominal wall, internal injuries to organs, or intestinal perforation.
CNS injuries include subdural hematoma (often reflective of blunt trauma or violent shaking), retinal hemorrhage, cerebral infarction (secondary to cerebral edema), or subarachnoid hemorrhage (often reflective of shaking).

Radiologic findings indicative of abuse may include metaphyseal chip, or “bucket handle,” fractures; spiral fractures of long bones in nonambulatory infants; multiple fractures of the ribs or long bones in various states of healing (especially rib fractures in children younger than 2 years); and unexplained skull fractures.

Physical signs of sexual abuse include pain, itching, bruises, or bleeding around the genitals; stained or bloody underclothing; soft tissue tears to the external genitalia, vagina, or anus; difficulty in walking or sitting; sexually transmitted disease or pregnancy; and behavior or knowledge that is bizarre, sophisticated, or unusual relative to the child’s age. Many victims of sexual abuse may not have overt signs of physical abuse.

Signs of emotional abuse include an impaired sense of self-worth; withdrawal; extremes in behavior, such as excessive aggressiveness or passivity; delayed physical, emotional, or intellectual development; failure to thrive; speech disorders; and an empty facial appearance.

Physical signs of neglect include constant hunger (begging for or hoarding food); fatigue or listlessness; poor hygiene (matted hair, dirty skin); inappropriate dress; unattended physical or dental problems; and evidence of alcohol or drug use.

DISCLOSURE

The abused child wrongly perceives the abuse as shameful. Getting a child to talk about something that he or she perceives as shameful is difficult, to say the least, and requires remarkable communication skills and patience. In addition, children tend to keep quiet for numerous reasons other than feeling shame: they frequently blame themselves for the abuse; they may fear for themselves or for the perpetrator; or their family communication style may work against disclosure.^12-15 Jensen and colleagues report that children have trouble initiating conversations about “… secret, confusing, and distress[ing events] where there are few conversational routines in a family for talking about such themes.”¹² Furthermore, they note, “… children are sensitive to the needs of their caregivers and fear consequences for their family and offender.”¹² Goodman-Brown and colleagues note that children abused within a family setting take longer to disclose than do those who suffered abuse outside the family.¹⁶ For example, even when family members are aware of intrafamily sexual abuse, it is rarely talked about or shared with others, and many adults report never disclosing their abuse during childhood.¹³

Children suffering from posttraumatic stress disorder may enter an “avoidance” phase in which they will deny that maltreatment occurred or recant any previous disclosure because of the anxiety generated by traumatic memories.¹⁶ One problem with these denials or recantations is that they compromise the child’s credibility and may make prosecution difficult. Legally, immediate disclosure and follow-up are best. However, disclosure often occurs long after the abuse occurred.

Getting children to talk The reactions of adults, including clinicians, frequently determine what children will or will not talk about. Therefore, the clinician must create the environment for disclosure, and this requires creating trust and a sense of connection. The process becomes less difficult if children perceive an opportunity and a reason to speak.

The clinician should engage the child and ask direct questions. Open-ended or “free-recall questions allow children considerable flexibility in choosing the information to report, and thus, promote inconsistency.”¹⁷ Instead, asking a child directly why he or she behaves a certain way, or where a bruise comes from, may be helpful. The practitioner may be confrontational but in an appropriate manner. For example, if a child denies an injury in the presence of physical evidence, then gentle (and nonintrusive) confrontation, such as pointing out obvious discrepancies, can also help the child to talk. If it is difficult to find an appropriate time or place to engage the child, the clinician must use his or her skills to create the appropriate situation, just as in any other medical situation. The skills that enable any patient to trust a clinician—skills such as credibility, support, advocacy, strength, and protectiveness—must be employed. There is no “smoking gun” that constitutes clear proof of child abuse, and no directed algorithm for how to uncover it, when abuse is not overtly present. There is also no sure way to get children to talk. When dealing with a subject as emotionally painful as child maltreatment, all the experience and skill a clinician can muster must come to bear.

Why victims of abuse talk The reason is simple. Someone asked the right questions, in a safe environment, after a dialogue had been initiated. Research is never completely objective because the data are always seen through the eyes of the researcher. Readers should therefore know that the author of this article is a survivor of physical and sexual abuse in childhood. The author suffered repeated rapes and remained silent. This silence grew, just as cancer grows, until it manifested as a lifetime of poor choices and a sense of unworthiness. Other child abuse victims feel this, and when their experiences are left unchecked, many of the same problems ensue. The author disclosed as an adult in response to someone asking. Practitioners should recognize abuse as they are trained to do, and then they should ask. Simply ask. JAAPA

REFERENCES

	1.	US Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2005. Washington, DC: US Government Printing Office; 2007. http://www.acf.hhs.gov/programs/cb/pubs/cm05/cm05.pdf. Accessed April 4, 2008.
	2.	US Department of Health and Human Services; Administration for Children and Families; Administration on Children, Youth and Families; Children’s Bureau; Office on Child Abuse and Neglect. The Child Abuse Prevention and Treatment Act as amended by The Keeping Children and Families Safe Act of 2003. Published June 25, 2003. http://www.acf.hhs.gov/programs/cb/laws_policies/cblaws/capta03/capta_manual.pdf. Accessed April 4, 2008.
	3.	US Department of Health and Human Services; Administration for Children and Families. National Child Abuse and Neglect Data System. Child Maltreatment, 1999. http://www.acf.hhs.gov/programs/cb/pubs/cm99/table2d.htm. Accessed April 4, 2008.
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