The Physician's Role in Alleviating Child Abuse
Family Physicians Play a Central Part in Reporting Child Abuse
Sep 19, 2009
Family physicians who are involved in the care of children are likely to encounter child abuse and should be able to recognize its common presentations. A history that is inconsistent with the patient's injuries is the hallmark of physical abuse. A pattern of physical findings, including bruises and fractures in areas unlikely to be accidentally injured, patterned bruises from objects, and circumferential burns or bruises in children not yet mobile, should be viewed as suspicious for child abuse. (American Academy of Pediatrics fact sheet, 2000)
In a 1998 American Academy of Pediatrics study entitled “The role of the pediatrician in recognizing and intervening on behalf of abused children,” it was reported that in a group of asymptomatic but high-risk children less than 2 years of age who were admitted to hospital for investigation of abuse, results of imaging studies revealed that 37% had head injuries, despite normal results of neurological examinations. The article also noted that 55% of physicians do not have sufficient knowledge of child abuse.
Although the classic battered child who presents with multiple injuries can be easily identified by the family physician, it becomes a 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 (American Family Physician).
In a 2003 American Family Physician article entitled "Evaluation of Physical Abuse in Children," it was reported 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 prenatal care. In addition, the birth order was strongly correlated with risk of physical injury.
Evaluation of Physical Abuse in Children
The physician evaluating children who may have been abused is faced with special challenges. In addition to providing the diagnosis and treatment, the physician plays a new role when providing care for victims of physical abuse. In these cases, the physician must also ensure the child's safety and assist in the collection of evidence for possible litigation.
Hostile families may challenge physicians when the possibility of physical abuse is broached. Preconceived ideas regarding racial, cultural or economic norms as well as the strong feelings elicited when children may have been intentionally injured are confounding factors complicating the evaluation of suspected child abuse.
Typical features of the history, physical examination and focused laboratory and radiologic studies help physicians in diagnosing physical abuse in children. In addition, physicians caring for children must remain cognizant of the many medical conditions whose presentation can mimic signs of physical abuse.
Medical History
The most important information leading to a diagnosis of physical abuse is obtained through the medical history. While perpetrators of child abuse and their victims come from all socioeconomic classes, certain factors place children at increased risk of physical abuse. Adults who have been abused as children may become perpetrators of abuse as adults, although this is generally not the case.
Even for physicians, physical injury from abuse can be difficult to recognize. In a retrospective study of abusive head trauma in children less than 3 years of age, the diagnosis was missed by physicians in 31% of patientsat the time of initial presentation (American Family Physician). It is clear that family physicians should inquire about risk factors associated with child abuse.
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