Sooner or later, you will have to decide. Are you going to protect our children or not?" With these words, an attending physician who until that moment seemed both unapproachable and intimidating accepted my invitation to testily on behalf of a patient I was responsible for during my internship, a child who had been physically abused by his father. Since my residency more than 20 years ago, I have witnessed the disappearance of once common debilitating, if not fatal, diseases. Yet child abuse is still with us, sometimes unrecognized, its incidence and prevalence virtually unchanged.
Dr. Shulman's invitation to guest edit an issue devoted to child abuse gives me the chance, as a general pediatrician, to choose articles for physicians and other health care personnel who have first contact with an abused child in primary care. While I cannot address all aspects of child abuse, I chose authors who touch on several prominent issues I see concerning the prevention, detection, and reporting of abuse, as well as the evolution of new threats of abuse to children.
IN THIS ISSUE
Not all cases of child abuse are reported, which seems contrary to our mission as primary care practitioners to promote the health and welfare of children. The reasons reports are not made are complex, and Drs. Emalee Flaherty and Robert Sege provide an excellent review of research exploring the many reasons physicians do not report cases of suspected child abuse in their article "Barriers to Physician Identification and Reporting of Child Abuse." They also suggest possible ways to improve physician reporting of suspected child abuse.
Most cases of physical abuse involve head trauma. In their article "Diagnosing Pediatric Head Trauma," Drs. Kent Hymel and Caitlin Hall discuss the clinical presentation and diagnosis of this most common form of physical child abuse. This article also serves as a primer on the recognition and reporting of physical child abuse in general and how to testify in court if necessary - a good review for all of us.
Other major forms of physical abuse include skeletal fractures, burns, and abdominal trauma. Dr. Sara Thompson provides a concise review of the presentation and clues to the recognition of these forms of child abuse. Her article, together with that of Drs. Hymel and Hall, cover the majority of physical child abuse the general practitioner is sure to encounter sooner or later.
The incidence and prevalence of sexual abuse also are virtually unchanged, yet how we diagnose this crime has evolved considerably. Drs. Angelo Giardino and Martin Finkel discuss the importance of history despite the infrequent findings on physical examination when faced with a child disclosing sexual abuse or possibly displaying signs and symptoms of sexual abuse. Their article describes how best to put a child at ease for the all-important first-time history and physical examination after sexual abuse disclosure or discovery. The authors also provide a glimpse into the investigative process by the police and child protective services.
Without question, we should be preventing child abuse in the first place. As the adage states, "Violence begets violence." For some time now, Dr. Carol Berkowitz has championed the recognition and prevention of domestic violence. Her article, "Recognizing and Responding to Domestic Violence," points out that most perpetrators come from a violent home environment. Efforts to change that environment may help stop the cycle of abused children growing into abusive adults.
In addition, new forms of child abuse are always appearing. Drs. Maria McColgan and Angelo Giardino explore the effects of the Internet on children and the potentially harmful risks children may take when they "surf the web." Some readers may believe that using the computer is not a threat for children, but the authors make some observations and comments that are concerning. In a sense, the Internet can serve as a unique tool for abuse: children can both abuse others and be abused by others.
Finally, in the Resident's Viewpoint, Dr. Kerry McGee, a secondyear resident in pediatrics, observes how a simple change in our well-child encounters could make a significant change in how a child is raised.
Over the years, I have formed several general opinions about child abuse. Child abuse does exist, yet judges, juries, and people in general find it hard to believe because they cannot conceive that parents would purposely hurt their children. However, most abuse is not planned; it occurs as a result of unchecked anger or rage.
Further, our duty is to report suspicion of abuse, not proven abuse. It is the legal authorities' responsibility to decide if abuse truly occurred. In addition, even if we are certain abuse occurred, we should make every effort to consider other diagnoses in order to maintain professional credibility and objectivity. One must always be aware that the perpetrator may not be the person you suspect.
Finally, sooner or later, every doctor must decide whether to protect our children.