Doctors have a key role in detecting the signs of child abuse and neglect, and in ensuring such cases are well documented and reported to the appropriate public agency to protect the children involved. The issues are discussed in a Seminar published in this week's edition of The Lancet.
Professor Howard Dubowitz, Chief of Division of Child Protection, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, USA, and Dr Susan Bennett, University of Ottawa, Canada reviewed data from various medical databases to compile the Seminar. They investigated definitions of maltreatment, its prevalence, risk factors, protective factors, prevention, assessment and diagnosis, outcomes, reporting and treatment.
The authors say: "The abuse and neglect (or maltreatment) of children is a worldwide problem, although its manifestations and extent vary. It is far more prevalent than is generally recognised."
They add: "Measurement of child maltreatment is inherently difficult, since it is rarely seen directly by people outside the immediate family, and is often unreported."
Many risk factors usually interact to place a child more at risk of abuse or neglect - examples include a child's disability and a parent's depression. Violence between parents also increases the risk to their child. But there are also protective factors which decrease the risk of abuse - such as supportive grandparents or accessible mental health care.
Usually medical responses to child maltreatment occur after the event; but the Seminar advocates prevention where possible. Strong doctor-family relationships, parental education about disorders their children may have, screening for risk factors or even home visits by nurses can all improve family functioning and decrease the risk of maltreatment.
Diagnosis of child abuse frequently involves detecting injuries which cannot be explained through the child's medical history or other circumstances. Bruises are the most common manifestation of abuse. Whereas accidental bruises are characteristically anterior and over bony areas such as the shins and forehead due to falls, well padded areas are less likely to be bruised accidentally. Thus bruises of the buttocks, cheeks, and thighs suggest abuse.
Fractures - in various possible areas - are the second most common sign of abuse, including depressed or common fractures to both sides of the skull. The nature of the fracture gives strong clues, for example the so called bucket handle fracture is usually a sign of abuse. Burns are also frequently due to abuse, whether from deliberate intent from the parent or neglect which has allowed the child to burn itself.
When severe head trauma is suspected, an examination of the eye can reveal probable abuse - since the pattern of haemorrhaging may be characteristic in an infant who has been violently shaken. Multiple haemorrhages which extend through multiple layers in the retina usually indicate abuse.
Child abuse has many medical consequences. Children in hospital who have been abused or neglected have more severe injuries, longer hospital stays, worse medical outcomes, and are more likely to die in hospital than children admitted for reasons not connected to abuse.
Many countries have laws which force doctors to report suspected abuse. The Seminar acknowledges the difficulties reporting abuse can involve, such as anger from the parents. The authors say: "Reporting of child maltreatment is not easy. But ensuring the child's safety is the priority, and reporting could be life saving."
The interventions needed to protect a child suffering abuse depend on the individual circumstances, but doctors should know the law, regulations and programmes in place for maltreatment in their area. Working with colleagues in other areas such as mental health and government departments can also help address all forms of child maltreatment.
The Seminar concludes: "Physician advocacy fits well with a vision of improved child health in the 21st century."
In an accompanying comment, Dr Harvey Marcovitch, paediatrician and associate editor, BMJ Journals, London, UK and Dr David Jones, Park Hospital for Children, Oxford, UK says: "It is essential that clinicians are enabled to work competently even within systems that will sometimes fail for vulnerable children and themselves."
They conclude: "Individual training and local support networks for people involved in child protection are essential, whether they are specialists in the field or simply those who might encounter an occasional case. Failure to set up and use such resources indicates professional weakness. No clinician can opt out of recognising and responding to abuse."