Earlier this year, I observed a murder trial for a young child who had died of abuse. As I listened to the pediatrician on the stand get grilled on the accuracy of his diagnosis and every imaginable aspect of his medical knowledge and credibility, my thoughts kept turning to the photographs of the child with the telltale bruises and scars of recurring intentional injury. I stared at the back of the alleged perpetrator's head and tried to imagine the terrible interaction that must have taken place between the parent and the child just before the fatal injuries occurred. My mind shied away from the heart-wrenching scene. What could possibly have led this man to such violence against a defenseless child?
What drives anyone to injure a child? For all the time that we, as pediatric residents, spend thinking about the consequences of child abuse and the management of nonaccidentally injured children, it seems that we give remarkably little time to the underlying etiology of the condition. Of course, we know about the comorbidities of parental drug and alcohol use and stressed families with little social support. We say that child abusers come in all shapes and sizes or that they may have been abused themselves as children. Even so, we end up doing a poor job of predicting when a child is in danger of abuse. Clearly, there is something missing from this multifactorial model.
It caught my attention, therefore, when in preparing a recent talk on child abuse I came across the following statement:
"Many parents who abuse their children lack basic information about normal child development and parenting. One significant characteristic of child abusers is that they have unrealistic expectations of their child's ability to do certain tasks or to respond emotionally."1
In other words, some parents don't understand what children are capable of, or what children are not capable of, so their expectations of children are too high. It makes sense that a person stressed with poor coping mechanisms to begin with, already facing the many challenges of daily life as well as those inherent in caring for a child, becomes so frustrated when that child repeatedly fails to live up to their expectations that they resort to physical violence. The adult lacks insight into the child's normal abilities and motivations. The expectations are too high because the understanding is poor; violence is a response to frustration.
Some parents interpret irritating behaviors in young children as deliberate attempts to provoke them. Imagine a toddler has just emptied your briefcase onto the floor and damaged some of its contents. Anyone would become frustrated in this scenario, but, because you are aware of the importance of a child's natural curiosity and spirit of exploration, and because you recognize that the child "doesn't know any better," you probably would tolerate the behavior with little more than a reprimand, or, better, with redirection of the child's energies. Now imagine a coherent adult behaving in the same fashion, emptying your briefcase's contents onto the floor and scribbling on an important manuscript. Your reaction would probably be quite different.
A caretaker who does not understand a toddler's level of cognitive and social development and imagines the child to have an adult-type respect for property and privacy might interpret a behavior like the one described above as a deliberate intrusion. Such a person easily could become repeatedly frustrated and angry with the toddler as the child naturally continues with similar normal toddler behaviors. In the presence of other predisposing conditions, this caretaker, frustrated beyond his or her capacity, might react with violence.
The good news is that there is room here for pediatricians to effect change. Anticipatory guidance is an important part of what we do as pediatricians, and child development is ultimately at the heart of it. While well-child visits can't fill the course requirements for "Child Development 101," we recognize that helping parents anticipate certain milestones is a valuable task. Is it possible that, by expanding our routine guidance in the right ways, we could help prevent the frustration that may often lead to child abuse?
For example, we know that toddlers learn through repetition. Where adults find the constant repetition of a phrase, activity, song, or joke to be irritating, this repetition is stimulating for young children. Perhaps an understanding of the importance of repetition for learning in children could help parents deal with annoying, but normal, behaviors like incessant questions or knock-knock jokes in a supportive way. Positively incorporating the concept of repetition into other parenting techniques also may make attempts to teach things like household chores or potty training more effective and less frustrating. It is giving parents an important tool for understanding their child and dealing with otherwise difficult behaviors.
Perhaps if all new parents knew that some young infants cry loudly and inconsolably for apparently no reason, and were routinely given active, positive tools for dealing with crying, we would see a smaller number of shaken babies. Maybe if caregivers didn't expect toddlers to eat without a fuss or a mess, and thought of meals as a chance for children to explore the tastes and textures of their world, fewer toddlers would be battered. Could it be possible that a preemptive discussion of temper-tantrums and techniques for their management at a well-child check could prevent disciplinary efforts that land children in the pediatric intensive care unit?
As with everything else in parenting, parents may not know what interpersonal skills to expect from a developing child. As pediatricians, we study child development and know that children are different from adults in fundamental ways. It seems to me that we could do parents, and ultimately their children, a service attempting to convey certain of these expectations to parents.
I once overheard a woman in the lobby of our hospital yelling loudly at her young son for removing his eye patch. Angrily, she told him he might go blind because their insurance had lapsed as a result of problems with paperwork and his condition had worsened such that eye drops were no longer an option, so now he now had to wear the patch. The child's fidgeting only worsened as her explanation increased in complexity, as well as in volume. She was clearly frightened and her stress level was high; she was also vastly overestimating the child's ability to understand and react appropriately to her fears. As a result, the situation escalated. I don't know if that mother was inclined toward violence; I certainly did not witness any in the brief time that I was in earshot. Another parent in a similar situation, however, might have reached a breaking point.
What sort of anticipatory education could have helped this mother deal with her son's restlessness in a more productive fashion and helped prevent the escalation in behavior? An understanding of the concept of concrete thinking in childhood may have helped her communicate more effectively but is too much to convey during a well-child visit; obviously, the amount of time we have to discuss these concepts with parents is limited. Even so, the idea could have been included in a larger conversation about discipline; perhaps she would have benefited from anticipating the ineffectiveness of abstract, logic-based explanations in tired, irritable children.
One of the depressing things about child abuse is that, despite our best efforts, there never will be a vaccine or an antibiotic to prevent this affliction. By the time a child's life becomes the subject of a murder trial, it is far too late for any intervention to protect them. Therefore, for the sake of children, we must work continually towards prevention. As a resident, I am always pressed for time in the examination room, and I know that as a practicing pediatrician I will have to become even more time-conscious and efficient. Every office visit, and particularly every well-child checkup, is an exercise in prioritization. How much time can we spare in educating parents to understand their children with the goal of preventing abuse? It seems to me that there are few things in pediatrics more important than keeping kids safe where they live, learn, and play.
1. Recognizing and Reporting Child Abuse and Neglect: An Explanation of Oregon's Mandatory Reporting Law. Oregon Department of Human Services. March 2004 Available at: http:// www. oregon.gov/DHS/abuse/publications/ children/mandrptlaw04.pdf. Accessed April 20, 2005.