Chapter 3
Child Abuse

Child Abuse

An estimated 896,000 children were determined to be victims of child abuse or neglect in 2002. The rate of victimization per 1,000 children in the national population has dropped from 13.4 children in 1990 to 12.3 children in 2002.

More than 60 percent of child victims experienced neglect. Almost 20 percent were physically abused; 10 percent were sexually abused; and 7 percent were emotionally maltreated. In addition, almost 20 percent were associated with "other" types of maltreatment based on specific State laws and policies.

Children ages birth to 3 years had the highest rates of victimization at 16.0 per 1,000 children. Girls were slightly more likely to be victims than boys.

American Indian or Alaska Native and African-American children had the highest rates of victimization when compared to their national population. While the rate of White victims of child abuse or neglect was 10.7 per 1,000 children of the same race, the rate for American Indian or Alaska Natives was 21.7 per 1,000 children and for African-Americans 20.2 per 1,000 children. (http://nccanch.acf.hhs.gov/pubs/factsheets/canstats.cfm)

Definition

The Child Abuse Prevention and Treatment Act (CAPTA) identifies four major types of maltreatment: physical abuse, child neglect, sexual abuse, and emotional abuse. Although state definitions may vary, operational definitions include the following:

Physical abuse: The inflicting of physical injury upon a child. This may include, burning, hitting, punching, shaking, kicking, beating, or otherwise harming a child.

Neglect: The failure to provide for the child's basic needs. Neglect can be physical, educational, or emotional. Physical neglect can include not providing adequate food or clothing, appropriate medical care, supervision, or proper weather protection (heat or coats). It may include abandonment.

Sexual abuse: The inappropriate sexual behavior with a child. It includes fondling a child's genitals, making the child fondle the adult's genitals, intercourse, incest, rape, sodomy, exhibitionism and sexual exploitation and commercial exploitation through prostitution or the production of pornographic materials.

Emotional abuse: (psychological/verbal abuse, mental injury) involves acts or failures to act by parents or other caregivers that have caused or could cause serious behavioral, cognitive, emotional, or mental disorders.

There has been much effort expended to identify and typify child abuse perpetrators. Unfortunately, the number who regularly use psychologically abusive, controlling violence (i.e., who fit the pattern of "perpetrators") is much smaller -- perhaps 5% of partnered men. Perpetrators are often young, troubled, unemployed, and of low self-esteem; they have often experienced abuse (of various types) themselves. However, these factors do not justify their abusive behavior (The Perpetrators of Domestic Violence, Romans, S.E. & Martin, J.L.;www.mja.com.au).

Physician Intervention in Cases of Child Abuse

If a physician believes a child has been abused, the first step to intervention is to protect him or her from further abuse. A crying baby with a minor inflicted injury may be sent home only to return the next day with a more severe injury. If a child protection service exists and has an on-call worker, usually a place in an emergency foster home can be arranged if hospitalization is not required.

Bringing up the subject of abuse to families and parents may be difficult. Perhaps the best way is with the statement that the physician has a legal obligation to report certain patterns of injury, which does not make an assumption of innocence or guilt. The State of Florida requires that any person who has knowledge of or suspects that an elderly person or child has been abused, neglected or exploited must report this immediately to the abuse hotline at 1-800-962-2873. Any person willfully failing to report such treatment is guilty of a class A misdemeanor, punishable as provided in Florida Statute 775.082 or 775.083.

Histories in Child Abuse

There are several injury histories that should raise considerable suspicion on the part of the caretaker. Any child who reports that a person has hurt them should be assumed truthful. Any child who has an unexplained injury should be examined. Parents in a healthy household relationship are inclined to know of any injury the moment the child hurts him/herself and are willing to elaborate in detail on the circumstances of the injury. Discrepancies that can point to abuse are two parents providing conflicting histories, explanation of a minor incident for a major injury, or a discrepancy in time and actual dating of bruises.

Information to place in Medical Record

In addition to noting superficial marks including bruises, strap, and grab marks, particular attention should be paid to the oral cavity, eardrums, and genitals. Sites most suggestive of inflicted rather than accidental wounds, including upper arms, trunk, upper anterior legs, sides of face, ears and neck, genitalia, and buttocks. More common sites of accidental injury are shins, hips, lower arms, prominence of spine, forehead, and under chin--all areas that tend to prominently hit objects on the way to the ground or while running.

Pinpointing sexual abuse during the physical examination

The possibility of sexual abuse deserves particular attention. This may include vaginal intercourse, anal intercourse, oral genital contact or molestation including fondling, masturbation or exposure. The hymeneal ring should be inspected for any abnormalities, particularly in the posterior half. If the throat is inflamed, a test for gonococcus should be performed. For most children, the Child Protection Team is most appropriate for evaluation of abuse.

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