I am sure that a great many of us in the private practice of pediatrics have encountered cases of child abuse, and I am just as sure that most of these have gone misdiagnosed as simple accidents or the mishaps of an accident-prone child.
If a parent brings the child to us with a history of a minor auto accident, a fall down the stairs, or a collision with the sharp corner of a table, do we investigate further? We usually take the word of the parent, and we hesitate to express doubts as to the origin of the trauma or to give the parent reason to feel that he or she is suspected. In my own experience, questioning a child has proved of little help - so fearful are they of their parents' anger.
If the trauma is so severe that the child must be hospitalized or if the child is a clinic patient, the investigation, diagnosis, and treatment are greatly simplified. There are facilities for x-raying the whole body to find evidence of old fractures. There is a social-service department, and there are visiting nurses. There are psychologists and psychiatrists.
It is quite evident, then, why so many more cases of child abuse are reported by clinics than by practicing pediatricians. This, of course, has led to the erroneous conclusion that child abuse is a syndrome associated with families of lower economic groups.
There is evidence that many maltreated children have parents who themselves were maltreated during childhood. Furthermore, recent sociologie studies have shown that at the present time a very common factor among families of abused children is the loss of jobs - a situation that affects a great many middle-class families as well as those of lower economic status.
It is well recognized that the pediatrician is the pivot on which depends the recognition of children suffering from child abuse. But this recognition is only the beginning of a problem with numerous ramifications.
If the child is not hospitalized, who will report the case and investigate the family relations? ïf a child is suspected of being beaten frequently, have we the legal right to invade the privacy of a home to investigate? If a child has been badly beaten, should he or she be returned to the family? Has the hospital or community a multidisciplinary team to investigate the situation and treat the child as well as the family? Are there adequate funds to cover the full care of all cases reported? And, most important, can we detect the potentially violent parent ahead of time?
These are only a few of the important questions that must be answered.
The Guest Editor of this important issue of Pediatric Annals is Dr. Rowland L. Mindlin. Dr. Mindlin has had a wealth of experience not only as a practicing pediatrician but also by his later work in child care in the Departments of Health in New York City and Boston, and as the chairman of the Committee on the Infant and Preschool Child of the American Academy of Pediatrics.
Under his editorship, the subject is covered from all angles - historical, diagnostic, statistical, preventive, legal, and ethical. Treatment and prevention are also considered.
Dr. Mindlin opens the symposium with a review of the historical aspects of child abuse and the outlooks for a future approach.
This is followed by an article by Drs. Eli H. Newberger and Jessica H. Daniel on the magnitude of the condition as well as its epidemiology.
The diagnosis and immediate treatment are next considered with photographic illustrations of the common types of injury. The author, Dr. George W. Starbuck, in discussing the early diagnosis, warns the physician against openly accusing the parent or caretaker suspected of maltreating the child.
It has been estimated that more deaths of children in the United States are caused by child abuse than by all diseases combined. Many of these pass undetected. The article by Dt. Milton Helpern, former Chief Medical Examiner of New York City, deals with the importance of a careful postmortem study in every case of sudden or unexpected death in an infant or child. Dr. Helpern emphasizes not only the errors that can be made in accepting the words of parents or of unsuspecting physicians but also the difficulties often faced by the medical examiner or coroner in arriving at the actual cause of death.
Generally the treatment of child and family is of long duration, and a superb multidisciplinary approach to the whole problem is provided in the article by Dr. Barton D. Schmitt and Patricia J. Beezley, M.S. W., of the National Center for the Prevention and Treatment of Child Abuse and Neglect and the University of Colorado Medical Center. Next is an interesting article describing the experience of a practicing pediatrician who ran head on into a case of child abuse without previous experience or the facilities for the proper care of the child and family. Dr. William D. Fürst emphasizes the important part a pediatrician can play in organizing an interdisciplinary team to deal with the problem, as well as in alerting the public.
Probably the most difficult problem is in the early identification of families prone to child abuse. Dr. Ray E. Heifer, an international authority on the subject, discusses this problem in his article. What legal and moral rights have we to intrude ourselves into family lives in an effort to prevent potential maltreatment of children? However, Dr. Heifer mentions definite periods when parents are accessible for mass screening, and he suggests some basic training in parenthood for children in elementary school and high school.
Because of the ethical issues raised in Dr. Heifer's article, he asked the medical ethics group at the Michigan State University to comment. Their opinion follows his article. Howard Brody and Sister Betty Gaiss carefully review the problems, noting how jealously society guards "how one chooses to raise one's children as part of one's personal life." Also, they discuss whether concern over the rights of parents is overridden by the need to protect the essential rights of children.
The final contribution is an excellent and complete review of the legal issues involved in the management of child abuse and neglect. Gordon David Fisher discusses the laws by which the government holds jurisdiction over the children within its boundaries. The criminal laws, child abuse and neglect reporting laws, and the adoption laws permitting permanent separation from abusive parents are all considered. Mr. Fisher notes that physicians, particularly those in private practice, are the chief obstacle to the effective reporting of child abuse and neglect.