The community in which I practice, though not small by population standards (100,000), is relatively isolated. It is located 150 miles from a newly developing medical school and 350 miles from an established teaching facility. Because of its relative isolation, the area lacks many of the medical and paramedical personnel who could be helpful to the practitioner in working with the problem of child abuse. Psychiatric and psychologic services are extremely limited, and children's protective services have until recently been understaffed and overworked. No social services exist in either of the two local hospitals.
Like so many others, 1 learned about child abuse the hard way. Case 1. Some years ago, a couple brought their one-month-old boy to my office because of his "inability to move his arms." The story was related to me by the mother, who was 20 years younger than her husband. She appeared quite upset and distraught. She said she had put the infant down for his nap a couple of hours earlier, following his feeding, when he had seemed quite normal. She returned later to find that he was unable to move his arms and immediately brought him to the office. On examination the infant was normal in every respect except for crepitation of both arms. X-rays confirmed the clinical impression of bilateral fractures of the humeri.
The infant was hospitalized for six weeks. The fractures gradually healed. During this time numerous attempts were made by those concerned with the case to obtain an accurate history and establish rapport with the parents. These attempts were unsuccessful; mutual feelings of hostility and anger quickly developed and persisted throughout the hospital stay.
Finally, the case came to trial (which, in retrospect, should not have happened), and after a long and discouraging afternoon in court 1 saw the infant returned to his parents, possibly to be abused again.
After my initial experience, 1 began to notice articles in the medical literature describing child abuse, its pathogenesis, clinical course, and treatment. 1 read them, however, with only cursory interest. Cases of child abuse were occasionally seen in the pediatric ward, and I would see them as referrals from the emergency room or in consultation. I would render an opinion, work with the primary physician or specialist, but leave most of the psychosocial workup of the case to the protective-services social worker. There was little if any follow-up of the child. The child would be discharged home and, in all probability, the abuse would be repeated at another time and in another place.
It was not until some years later, when I became a member of the American Academy of Pediatrics Committee on the Infant and Preschool Child, that my attitude changed, and I was challenged to become involved with the problem of child abuse. It was during discussions at the meetings of the committee that I learned what the pediatrician's role in the community should be as a leader in the development of child advocacy programs.
Stimulated by the participants at these sessions, I embarked on an educational program that included the ever-growing bibliography on the subject of child abuse as well as the self-instructional materials developed by the American Academy of Pediatrics and Dr. Ray Heifer. Gradually, I developed a better understanding and became more comfortable working with the families of abused children.
The only other persons I could find who were interested in the subject of child abuse were those in child protective services, and I immediately began to share with them the materials I had gathered.
The child protective-services workers were initially my only allies. Their orientation was somewhat different from mine. By having joint discussions about and with the parents of abused children, we established a firm basis for follow-up care and support. During these sessions, varied opinions were expressed that were helpful to the parents and provided learning experiences for us. The floor nurses were then included in the discussions because of the unique nature of their contact with the hospitalized child and family. They contributed a great deal of information that would otherwise have been lacking. The clinical psychologist with the mental health association was the next addition to these sessions, and our joint participation benefited all. I found these persons extremely helpful in the areas of history taking, therapy, and follow-up. Cooperation among us led to the formation of what is essentially a self-educated therapeutic, interdisciplinary team that has had a very positive effect on the outcome of our cases of abuse. The problems encountered are too complex and time consuming for most physicians in private practice to handle effectively by themselves. For this reason, the interdisciplinary team was organized horizontally rather than vertically, with shared leadership responsibility. Case 2. I will long remember being told by a very excited and angry ward clerk that I had better hurry to the pediatric floor because "some young mother has broken her baby's leg and needs to be locked up."
The case was a fracture of the fibula in a one-month-old black boy. The mother, 16 years old, had brought the infant to the emergency room and, after he was admitted, had promptly left. When finally located, she was withdrawn and uncommunicative, at least during my initial attempts to interview her. She gave a vague, contradictory history. It soon became apparent that I alone was not going to be of help to this mother or infant. At my request, a young female protective-services social worker began to see the mother while her infant was still in the hospital. In time, the social worker was able to establish a good working relationship with the mother, and we felt confident in discharging the infant to the mother's care. The social worker, along with the public health nurse, visited the home regularly, and all visited my office on a routine basis for follow-up and general care. The mother now seems able to fulfill her parental role quite successfully. The infant is developing normally, and there has been no recurrence of abuse to date.
Occasionally, a classic textbook case comes along that is both stimulating and rewarding, making one feel that perhaps those who write the books really do know something about what they write. This is particularly true in their descriptions of the psychosocial disease process. Case 3. An eight-month-old white boy was admitted to the hospital because of failure to thrive. The infant had been seen in the office for wellbaby checkups and had been noted to have gradually fallen below the third percentile for both height and weight, as well as showing signs of developmental lag. There were no overt signs of physical abuse. The infant seemed withdrawn, showing little response when handled. All laboratory and x-ray studies gave normal results. The infant slowly began to respond to "tender, loving care" on the ward and went home in 10 days showing substantial improvement in both his physical and emotional development.
During his hospitalization, the following social history was obtained from the mother: She had become pregnant and married at the age of 16 "to get out of the house and far away from home." She had dropped out of school, had her baby, and divorced her first husband. She had then gone to Uve with her mother, who was also divorced. As a child, she herself had been abused by her father on numerous occasions and had received little support or encouragement from her mother. Her second marriage, at the age of 18, was to a 22-year-old army private who was stationed in Germany. They had met and married while he was home on furlough. She became pregnant immediately, and he returned overseas. He was later discharged and came home during her last month of pregnancy.
This man was a rather passive, ineffectual person. He was the youngest son of an older couple who had opposed the marriage from the beginning. Conflicts developed between the woman and her in-laws concerning the care given to the baby. Her husband was unsupportive, and she felt unable to cope with the rearing of the children and the criticism of her in-laws. Financial problems aggravated the situation, as the husband was unable to find steady work. The woman became withdrawn and preoccupied with her problems, and was "too upset and busy" to pay much attention to the baby.
During the infant's hospitalization, these parents were seen by several members of our developing team, including a social worker and an interested nurse. The visits seemed helpful and supportive to the family, and with follow-up by the social worker and nurse the family seems to have stabilized. Both parents now bring their children to the office on a regular basis. Their problems are openly discussed, and the infant is thriving vigorously.
This case of maternal deprivation illustrates many of the psychosocial factors frequently encountered in child abuse - an abused teenage girl who becomes pregnant, an unsupportive spouse, and a series of crises - all of which lead to a breakdown in parenting and subsequent neglect, deprivation, and/or physical abuse. Case 4. The 23-year-old mother of an 18-month-old boy called the office on a busy afternoon and asked to speak to me. She was crying and told the nurse that she knew of my interest in child abuse and desperately needed to talk to me. I took the call, and the mother told me she felt that if she did not get help soon she was going to hurt her child. The precipitating event was trying to get her child to take a nap. The child had resisted all the mother's attempts to put him to bed. She felt that she was going to lose control and "hit him - and hit him hard." I spent a good hour talking to her over the phone, listening and reassuring her. At the end of the call, she seemed better able to understand and cope with the situation. 1 asked a protective-services worker to visit her at home later that day to counsel her concerning her feelings and frustrations. This mother gave a history of being physically and sexually abused by her father during his frequent drinking bouts when she was a child. She felt uneasy in her role as a parent, was 15 years younger than her husband, and had little or no knowledge of children and child-rearing principles.
This mother was seen at regular intervals with her husband in the office. They were encouraged to discuss their problems openly without fear of disapproval or recrimination. Most helpful, however, were a young student nurse and her roommate who have been working with the mother in a supportive and educational manner, functioning as parent aides. The mother is still having some difficulties, and she calls from time to time; but she has not abused her child.
The pediatrician who shows an interest in the problem of child abuse and neglect will find himself participating in many activities and programs of mutual interest and benefit to his community and himself. Community interest in this subject in my area was almost contagious. I had opportunities to participate in many varied activities. Some ways in which I found the pediatrician to be effective were as follows:
1. He can educate, inform, and work with paramedical and ancillary personnel dealing with this problem. Lectures and panel discussions with audience participation can be made part of the nursing and paramedical teaching programs both in and out of the hospital. I found the "brown bag" lunch to be an effective way of talking with interested but busy social workers, teachers, and school nurses.
2. He can help develop an awareness of the problem among his fellow practitioners by talks and discussions at medical society, hospital staff, and sectional meetings. He can alert other specialists - such as neurosurgeons, orthopedists, general surgeons, and other primary-care physicians - to the seriousness and frequency of this syndrome.
3. He can make sure that the subject of child abuse and neglect is made part of the curriculum of the nursing and nursing-aide programs in the local colleges and universities.
4. The physician is usually well respected by lawyers and judges in his community. They may be especially receptive to educational programs and discussions encouraged by the physician advocate. Local bar associations frequently seek speakers in other disciplines for their meetings. This affords an excellent opportunity to address many of the local legal personalities on the subject of child abuse. I have asked lawyers to participate in panel discussions on public-information programs concerning child abuse. Those who did participate lent their expertise and added another dimension to the discussion.
5. Because of his status in the community, the physician can play an important role in the education of the general public. Public education alone in our area resulted in a threefold increase in reported cases. This may be accomplished by use of audiovisual materials as well as of the local news media. I assisted the child protective services in developing their own public-information program. AU cases of child abuse should be documented by photographs for possible use in court proceedings. Using these pictures, it is not difficult to develop your own set of "horror" slides for use in these presentations. Slides such as these, along with those depicting the poor home conditions and inadequate sanitation and safety conditions, can be used as effective background material. This program proved to be as effective as the one developed by the Department of Public Welfare for use throughout the state. The local news media - television, radio, and the newspapers - are usually eager to obtain material on the subject of child abuse and neglect because of its highly emotional impact. In general, the media are very interested in local problems and how they are being met. They will often ask the physician for help with articles and programming.
6. Teacher involvement is necessary if a child-abuse awareness program is to succeed. Teachers must be made aware of the problem, as they are frequently the ones who first encounter the child who has been beaten or neglected. The physician must encourage them to report suspected cases and reassure them that they can do so without fear of reprisal. Inservice educational meetings afford a good opportunity for these discussions.
7. Interested student nurses, have been of great value, working as parent aides as well as functioning as support persons in times of crisis. A student nurse was instrumental in inviting "Jolly K"* and other Parents Anonymous leaders to present their programs to a large group of interested citizens.
As can be seen from the above, the isolated practicing pediatrician can find his place in any and all of these activities if he will show an interest and make himself available. In my experience, one thing has led to another; though at times things have seemed to get out of hand, I have had little time over the past few years to be bored with the general practice of pediatrics. Boredom and the questioning of the practicing pediatrician's role have been the subject of much soul searching in recent years. 1 would challenge those who find such to be the case to become involved with the child-abuse problems of their community. D