CM E
Child Physical Abuse: The Need
for an Objective Assessment
Emalee G. Flaherty, MD; and Amanda K. Fingarson, DO
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EDUCATIONAL OBJECTIVES
1. Identify factors that inhibit physicians from reporting child abuse
when identified in the office setting.
2. Determine indicators that provide
objective support to a diagnosis of
suspected physical abuse.
Emalee G. Flaherty, MD, is an Associate
Professor in Pediatrics–Academic General
Pediatrics and Primary Care, Department
of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine.
Amanda K. Fingarson, DO, is an Instructor in
Pediatrics–Academic General Pediatrics and
Primary Care, Department of Pediatrics, Ann
& Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg
School of Medicine.
Address correspondence to: Emalee G.
Flaherty, MD, Ann & Robert H. Lurie Children’s
Hospital of Chicago, 225 E. Chicago Avenue,
Box 16, Chicago, IL 60611; fax: 312-227-9418;
email: eflaherty@luriechildrens.org.
Disclosure: The authors have no relevant
financial relationships to disclose.
doi: 10.3928/00904481-20121126-12
PEDIATRIC ANNALS 41:12 | DECEMBER 2012
© Shutterstock
3. Develop increased confidence in
reliably identifying and reporting
suspected child physical abuse.
P
hysicians may fail to recognize
child abuse for a number of reasons,1 including a lack of training and experience. Many physicians
received little training during medical
school or residency;2 such training increases pediatric residents’ self-rating
of competency in evaluating child maltreatment.3 Pediatricians and pediatric
residents who received child abuse education expressed more confidence in
their ability to identify and manage child
maltreatment4,5 and were more likely to
diagnose child maltreatment.6
Because the diagnosis of child maltreatment requires a thorough clinical
and historical assessment, the diagnosis can be missed if the physician does
not ask detailed questions about how
an injury occurred, whether witnesses
were present, and whether the child
suffered previous injuries.7,8 A careful
Healio.com/Pediatrics | 1
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physical examination may reveal bruises, the most common injury caused
by child abuse.9 Finally, appropriate
laboratory and imaging studies may
reveal old or occult fractures, intracranial bleeding, or the presence of other
medical conditions, which explain the
observed injuries.
FAILURE TO DIAGNOSE
CHILD ABUSE
Not Enough Data Gathered
If child abuse is not considered a possibility or included in differential diagnoses, the diagnosis may be missed.10
Complete evaluations are often not accomplished; a small study of children
younger than 2 years of age with subdural hematomas demonstrated that only
22 of 33 children had received all basic
laboratory and imaging tests.11 When
physicians do order appropriate imaging studies, the diagnosis of child abuse
may be missed if imaging studies are of
poor quality, incomplete, or incorrectly
interpreted.12
The physician must identify any
child, family, and social factors that
may place a child at risk of abuse,
recognizing that the absence of obvious risk factors does not rule out child
abuse. Children with physical, cognitive, or emotional disabilities are more
vulnerable to abuse.13,14 Parental stress,
poverty, unwanted pregnancies, maternal depression, substance abuse, and
interpersonal violence are associated
with child abuse.15,16 A caregiver’s poor
understanding of appropriate child development and behavior also increases
the risk of abuse.17
Physician Bias
Physicians may fail to identify child
maltreatment if they are not objective
in their assessment because they have
preconceived ideas about who abuses
children. A study by Jenny et al18 examining cases of abusive head trauma
left undiagnosed by physicians, found
2 | Healio.com/Pediatrics
that missed cases were more likely to
involve white, two-parent families.
This confirms other studies with similar findings about race and class.19 Even
after adjusting for socioeconomic differences, minority children older than
1 year with an accidental injury were
three times more likely than a white
child with an accidental injury to receive an unnecessary skeletal survey.20
Physicians may fail to identify
child maltreatment if they
are not objective in their
assessment.
In other studies, race did not influence
physician willingness to consider the
possibility of child abuse, but socioeconomic status did.21,22
Biases can influence clinical reasoning and lead to misdiagnosis. The dual
process model of reasoning divides decision making into two types of reasoning: intuitive reasoning and analytical
reasoning.23 Biases particularly affect
intuitive reasoning because physicians
rely on their previous training and experience. Although intuitive reasoning
is fast and reflexive, errors are common. Analytical reasoning is more deliberate and more rule-based. Physicians may follow guidelines or decision
trees. This type of reasoning is slower,
but much less prone to error. Generally,
physicians use both systems and move
back and forth between the two.
When a physician recognizes a
certain pattern early, then the quicker
intuitive thinking takes over. If a pattern is not recognized, the physician
engages in more analytical thinking.
When abuse is possible, the physician
should take a more analytical approach
and perform a more systematic evaluation to avoid errors in decision making.
FAILURE TO REPORT
SUSPECTED CHILD ABUSE
Physician Uncertainty
Physicians have admitted that they
do not report all cases of suspected
maltreatment.24-26 When physician reporting behavior was examined prospectively, physicians failed to report
27% of children with injuries they suspected were likely or very likely caused
by child abuse.27
Physicians said the main reason
they did not report suspected abuse was
they were not certain that it was child
abuse,24,25 although states mandate
physicians to report if they have “reasonable cause” to suspect child abuse
rather than “certainty” that a child was
abused.
Unfamiliarity with Child Protective
Services
Physicians also cited their previous experience with Child Protective
Services (CPS) and factors related to
CPS, including their own prior reporting experiences such as CPS failing to
protect a child, as reasons for not reporting.25,26,28 The physicians also said
they did not report because they were
concerned that they would lose families
from their practice and that they would
have to appear in court.25,26
As with the diagnosis of abuse, child
and family features influence the likelihood that a physician will make a CPS
report. In one study, physicians were
PEDIATRIC ANNALS 41:12 | DECEMBER 2012
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more likely to report suspected abuse
when they were unfamiliar with the
family, and when the child was black
with private insurance.27,28 Among children without private insurance, reporting rates were the same for black and
white patients. Black patients may not
have been over-reported, but instead
white patients may have been underreported.18
Other studies showed that physicians were more likely to report younger children and children from poor
families.29 Physician biases appear to
influence their reporting decisions just
as biases may influence their diagnosis
or recognition of child abuse.
MANDATE TO REPORT
Although all 50 states mandate that
physicians report suspected child abuse
to CPS, physicians appear confused
about the meaning of these state laws.30
In the Child Abuse Reporting Experience Study, clinicians showed great
variability in reporting injuries at various levels of suspicion. They reported
0.5% of the patients with injuries they
judged “unlikely” to be caused by child
abuse, 24% of the injuries they deemed
“possible,” and 86% of those they
judged “likely caused by abuse.” Only
64% of the injuries judged “very likely” caused by child abuse were reported, suggesting that additional factors
influenced the physicians’ decisions to
report.27
Reasonable Suspicion
Levi and Brown31 have conducted
several studies examining how physicians interpret the concept of reasonable suspicion. He found great variability in how they interpreted “reasonable
suspicion,” when he asked Pennsylvania pediatricians to designate how high
child abuse would need to be on the
differential diagnoses list to be considered reasonable suspicion of child
abuse. While 12% of the pediatricians
PEDIATRIC ANNALS 41:12 | DECEMBER 2012
said it should be ranked first or second
on the differential diagnosis, 41% said
third or fourth, and 47% indicated it
could rank anywhere from fifth to tenth
on the list and be considered reasonable suspicion.
Levi and Brown also asked the pediatricians to estimate the probability
that an injury was caused by abuse to
be considered reasonable suspicion:
their threshold for reporting ranged
from 10% chance that it was abuse to
more than 75% probability.31 When the
two scales were paired, their responses
were inconsistent. The pediatricians
commonly indicated that reasonable
suspicion required a 50% to 60% probability, but could be ranked as low as
fourth or fifth on the differential diagnosis list.
Even child abuse experts show variability in how they assess the likelihood that an injury was caused by child
abuse.32 When these experts were asked
to rate the percentage likelihood of the
injury being caused by abuse, the physicians rarely rated a case as “definite
abuse” when the likelihood was estimated at less than or equal to 95%, and
they were unlikely to report to CPS
if the injury was rated as less than or
equal to 15% likelihood of abuse. They
are more likely to agree about cases that
had the highest concern for abuse. They
also showed some agreement about
which cases needed to be reported.
Recommended Actions
Physicians who treat children are in
a key position to identify child physical abuse and prevent further abuse. In
order to do this effectively, the possibility of abuse should be considered when
evaluating an injury.
Physicians must take a thorough history, determining who was present at
the time of the injury event, when the
injury occurred, and what exactly happened. They need to ask about previous
injuries and screen for factors that may
SIDEBAR 1.
When Suspicions Should
Be Raised for Child
Physical Abuse
• No history to explain an injury in a
nonverbal child.
• History of injury implausible or inconsistent with mechanism of injury.
• Conflicting histories or changing
histories.
• Bruises or fractures in a nonambulatory child.
• Multiple injuries and/or injuries occurring at different times.
• Delay in seeking care for an injury.
Source: Flaherty and Fingarson
place a child at risk of maltreatment.
Physicians also need to examine the
child, including a complete skin exam
for bruises. Appropriate laboratory tests
and imaging studies (see Sidebar 1) are
also needed. Objective assessment and
clear analytical reasoning will reduce
the likelihood of bias, conscious or unconscious, in their decision making.
Flow sheets, checklists, and operationalized criteria may help physicians
recognize and report child maltreatment.33-35 Three questions appear to
increase the identification of physical
abuse: 1) Do findings from the examination conform with the history provided?; 2) Was there a delay in seeking
care?; and 3) Is the history inconsistent
with the injury?35,36 The use of screening guidelines has been shown to decrease the racial disparity between
which infants were screened with skeletal surveys.37
Many of the decisions about whether
a child has been maltreated are complex. Although all physicians should
evaluate for maltreatment and report
their suspicions of maltreatment to
CPS, they should recognize their own
limitations and advocate for a child to
have a more definitive evaluation by a
Healio.com/Pediatrics | 3
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child abuse expert when the findings
are not definitive. Also, when pediatricians are uncertain whether to suspect
and report maltreatment, they can discuss their questions with a child abuse
pediatrician or child abuse team. Most
children’s hospitals and pediatric training hospitals have multidisciplinary
child abuse teams and many are staffed
by board-certified child abuse pediatricians. These physicians and teams are
available for consultation.
IMPROVED TRAINING
All physicians need some education
in child maltreatment, but particularly
physicians who care for children in any
capacity. They need to learn how to take
a complete history, the importance of a
thorough physical examination including a skin examination, and the appropriate imaging and laboratory studies
that may facilitate diagnosis. Training
should include education about counter
transference reactions that may occur
as result of reporting.38 Physicians who
only occasionally encounter child maltreatment particularly need this training.
Physicians need a better understanding of the mandate to report if they have
“reasonable suspicion” of child maltreatment. Perhaps providing a clear
threshold for reporting as part of the
definition of “reasonable suspicion,”
such as whether a physician is a particular percentage certain that maltreatment is present, would improve their
reporting performance.39
Physicians often cite systems issues
as a barrier to evaluating and reporting suspected child maltreatment. For
example, they mention the lack of follow-up by CPS and the perception that
children who were reported to CPS did
not benefit from the intervention.25,40
Their fear of causing harm to a family
may supersede their belief that the child
could suffer further harm without their
intervention, despite the fact that CPS
permanently removes very few chil4 | Healio.com/Pediatrics
dren. Education about what happens
after a report could help to allay these
fears. This education could include information about the child protection
investigation, law enforcement investigation, legal proceedings, as well as the
outcome for children with or without
intervention.41
Physicians should learn about the
likelihood of continuing and escalating
Physicians need a better
understanding of the
mandate to report if they
have “reasonable suspicion”
of child maltreatment.
abuse in households without CPS intervention. Professionals often assume
that caregivers will perceive CPS intervention as punitive, but, in fact, the majority of clients report satisfaction with
the intervention provided.42,43
When physicians were asked what
would help them evaluate children for
maltreatment, they cited informative
articles to read and regional trainings.40
In addition, physicians said they would
find hands-on training with patients in
the physician’s office and hands-on
training in academic centers useful.
Self-instructional programs also have
been shown to increase physicians’
knowledge about child maltreatment.44
Some states require physicians and
other professionals to receive training
in child maltreatment as a prerequisite
for licensure.45 Most of the professionals who participated in such a training in
New York said that they learned something new in the course.46 The majority
of the physicians said that the course
should be repeated at some point.
CONCLUSION
Child maltreatment often goes un-
recognized and unreported to CPS.
Physicians must remain alert to the possibility of maltreatment, systematically
evaluate any child who has findings or
complaints that may have been caused
by maltreatment, consult others when
needed, and report any “reasonable suspicions” of maltreatment to CPS.
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Healio.com/Pediatrics | 5
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
BEATING
THE DEVIL
OUT OF
THEM
Corporal Punishment in
American Families and its
Effects on Children
Murray A. Straus
with Denise A. Donnelly
With a new introduction by the author
Transaction Publishers
New Brunswick (U.S.A.) and London (U.K.)
Preface
ood science tends to be a labor of love. Unfortunately, my love
is mostly unrequited. As of this writing, almost no social scientists have embraced my belief, even as a hypothesis, that spanking, that is, hitting children, is a major psychological and social
problem. A somewhat larger number considers corporal punishment undesirable for both parents and children, but not truly a
major problem. Even among those who disapprove of spanking, it
would be hard to find anyone who puts hitting children in the same
class as hitting wives.
I am a feminist, but my theory that corporal punishment is one
of the causes of wife beating has been denounced by some of my
feminist colleagues as a diversionary tactic that takes away attention from the "real" cause-male dominance (Breines and Gordon,
1983; Pagelow, 1984). I am a scientist, but my theory that corporal
punishment in and of itself causes serious psychological harm typically is regarded as not even worthy of discussion (see McCord,
1988 for an exception) because it does not deal with the "real"
cause-incompetent parenting in general. For these reasons, I want
to add a few words about the view that inadequate parenting is the
"real" cause of the harmful side effects of corporal punishment.
Chapter 1 picks up that theme and attempts to explain why social
scientists have ignored corporal punishment of children, except as
an incidental part of harsh parenting.
G
Hitting Children and Hitting Wives are Equivalent
For more than 20 years I argued that slapping a wife is a unique
type of family violence. Writing this book caused me to reconsider
xviii • Preface
that and come to what will seem like an outrageous conclusion to
most people-that slapping a child deserves equal billing with hitting wives because the problems are equivalent. Consider some of
the ways that hitting children and hitting wives are believed to be
different, but really are similar.
Hitting children is legal and socially approved, but hitting a
spouse is a crime. This is the case now, but hitting a wife was legal
until the 1870s, when courts in the United States stopped recognizing the common-law principle that a husband had the right to
"physically chastise an errant wife" (Calvert, 1974). It is time to
also change the law on hitting children.
Children themselves believe they sometimes need "strong discipline." This is not very different from the fact that many wives think
they "deserved it," as did many slaves who were "disciplined" by
their masters. The battered-women's movement has worked for
years to tell women that no one deserves to be hit and no one
should tolerate it. Now it is time to do the same for children. All
children misbehave, but no child deserv~s to be physically assaulted.
Hitting children is thought to be different from hitting wives because it rarely results in physical injury. The low injury rate is correct, but this also applies to hitting wives. There have been only
two studies of assaults on wives in the general population. One
shows that 97 percent of women who were physically assaulted by
their spouses did not suffer an injury that required medical attention (Stets and Straus, 1990). The other study showed that 99 percent were not physically injured (Brush, 1990). Staff members of
battered-women's shelters do not see this because injury is one of
the reasons women go to a shelter.
When done in moderation, corporal punishment is believed to
be different from hitting wives because it does not cause the psychological injuries that assaulted wives experience. On the contrary, all the chapters in Part II of this book show that children who
have been hit by their parents suffer serious psychological harm,
just as wives suffer serious psychological injury as a result of being
hit by their husbands.
Minor assaults on wives, such as slapping, are thought to be different from minor assaults on children (corporal punishment) because the minor assaults on wives can escalate into severe assaults,
namely, wife beating. Unfortunately, corporal punishment can esca-
late into physical abuse as well
Martin, 1981). While slapping<
late, research shows that "mine
typically escalate into severe as
Usually, minor violence stops tl
1989; Suitor, Pillemer, and Stra
parent because women whose 1
do not seek help from a shelter.
typically stops at the minor le1
lence is acceptable. Minor viole
the violence by parents that goe
punishment must also stop. Sw
all spanking and other forms <
Chapter 11).
Spanking or slapping a child .
a wife is an act of violence. In l
as one man told me, "I didn't h
same thing about slapping their
The campaign to end violen
of shelters for battered wome
women's movement. Ending
should be added to the femini
First, since hitting children is c:
lence is part of the feminist ide
the evidence in Chapter 7 indic:
the root causes of wife beating.
important step toward protectir
The main differences betwee1
es are that hitting children is sti
ize the harmful side effects of '
effects do not show up until la
child, there is no obvious clue
chance that the child will grow
her children, or suffer from me
chological ills.
When I say that hitting child
tally the same, I am referring t<
corporal punishment, and to tl
least once in perhaps two-thir
Preface • xix
late into physical abuse as well (see Chapter 5, and Kadushin and
Martin, 1981). While slapping a child and slapping a wife can escalate, research shows that "minor" violence against wives does not
typically escalate into severe assaults in the form of wife beating.
Usually, minor violence stops there (Fagan, 1988; Feld and Straus,
1989; Suitor, Pillemer, and Straus, 1990). Of course, this is not apparent because women whose partners have stopped hitting them
do not seek help from a shelter. Just because violence against wives
typically stops at the minor level does not mean that minor violence is acceptable. Minor violence against women must stop, and
the violence by parents that goes under the euphemism of physical
punishment must also stop. Sweden has taken the lead by making
all spanking and other forms of corporal punishment illegal (see
Chapter 11).
Spanking or slapping a child is an act of violence, just as slapping
a wife is an act of violence. In both
Purchase answer to see full
attachment