The Challenges of Recognizing Child Abuse: Title and subTitle BreakSeeing Is Believing

Almost 4 decades have passed since Kempe and colleagues¹ published in THE JOURNAL their landmark description of the battered child syndrome. There were 2 major findings in that study. The first was a clinical description of children who had been physically abused by their parents. Although the abuse and misuse of children had been recognized for centuries² (pp3-28) and radiographic findings in children thought to be caused by deliberate injuries had been described,^{3 - 4} publication of the article by Kempe et al¹ in JAMA made it clear that injuries caused by physical abuse were clinical problems that required the attention of physicians. The second finding was the result of an epidemiological survey in which 749 abused children—many of whom either had been killed or had sustained permanent brain damage—were identified by 71 hospitals and 77 district attorneys in the United States. This large number of cases suggested that serious child abuse was unlikely to occur infrequently. However, no one in 1962 would have predicted that in the United States in 1997, almost 3.2 million reports of child maltreatment would be made to child protective service agencies. Of these reports, approximately 1 million were confirmed, including neglect (54%), physical abuse (22%), sexual abuse (8%), emotional abuse (4%), and other (12%).⁵

That parents could physically hurt their children was a frightening notion for clinicians concerned with the health and welfare of children, yet the astute observations and clinical descriptions of Kempe et al and the research that followed² changed the way injuries in children were viewed. Clinicians no longer would readily accept certain histories provided by parents as truthful and, instead, would consider the possibility of child abuse.

There have been numerous challenges for the field of child abuse since 1962, including gaining an understanding of the extent of the problem and how abuse occurs in families, the development of statewide systems of protective services to evaluate suspected maltreatment and help ensure the safety of maltreated children, the development of treatment programs for children and families and for adults who were maltreated as children, and the development of prevention programs to help children and families before maltreatment occurs. A cornerstone for all these activities is the appropriate recognition of the abused child and, concomitantly, the appropriate recognition of injuries that are truly unintentional. Although recent media attention⁶ and court cases⁷ have suggested that physicians are overdiagnosing child abuse, the true problem continues to be one of underrecognition. For example, since the early 1970s, repeated unexplained deaths of infants in a family usually were believed to be due to recurrent sudden infant death syndrome (SIDS); however, recent evidence has indicated that some cases of recurrent SIDS are, in fact, homicides.^{8 - 9}

Although the recognition of abuse can be relatively straightforward (eg, a young child with fresh bruises, healing fractures, and no history that explains the injuries), there are many times when recognition is difficult. Why is it so difficult to recognize an abused child? The first problem is the false or misleading history that is often provided. In the usual clinical encounter, the physician is accustomed to a truthful (if sometimes minimized or exaggerated) history. Because diagnostic reasoning is often shaped by the history provided, a misleading history can misdirect the diagnostic process and result in an incorrect diagnosis. In a study of fractures in children younger than 3 years,¹⁰ examination of the initial histories in 52 abused children revealed that in only 1 instance did a parent indicate that the child had been hurt by an adult. Instead, the most common presenting histories were a report by a caretaker of an abnormality (eg, a seizure or decreased movement of a limb) in 52% of cases, a fall in 27%, being hit by an older child in 10%, and a self-inflicted injury in 6%. Of course, young children cannot speak for themselves, but even older children often learn very early the importance of keeping family secrets and telling physicians, teachers, social workers, and others a false story (eg, they tripped and fell) to explain an injury to the face that was caused by abuse.

A second set of factors that influence the likelihood of recognition of abuse are personal biases related to the physician's education, experience, attitudes, and beliefs. Unfortunately, most medical students receive little education—often only 1 or 2 lectures—about abuse or family violence. Physicians who provide care to children may have had little formal education about child abuse and limited clinical experience during their residencies in evaluating suspected abuse. Attitudes and beliefs also can interfere with making a correct diagnosis. Physicians often have difficulty believing that abuse can occur in families in which the parents appear to be caring and interact well with the physicians. In fact, some of the most difficult cases to diagnose can be those in which parents have characteristics much like the physicians who are conducting the evaluations. For instance, instead of considering possible child abuse to explain fresh bruises on the arms of a 6-month-old infant, the physician asks only about a family history of bleeding disorders. Sometimes, physicians do not ask about abuse because they do not want to offend or falsely accuse the family or because they want to be certain about the diagnosis before discussing it. And sometimes, physicians do not want to get involved, although in every state, laws mandate that physicians report suspected (not necessarily confirmed) child maltreatment.

Progress has been made in helping physicians recognize injuries that may indicate abuse. For example, studies on the biomechanics of injuries^{11 - 12} and characteristics that distinguish abusive injuries from those that are unintentional have been helplful.^{10 ,13 - 14} Also helpful has been the increasing number of physicians who have pursued careers focusing on the problem of abuse despite the limited opportunities for funding and fellowship training, both of which fall far short of what is needed, based on the extent of the problem.

Although learning from errors in diagnosis is always difficult, physicians are accustomed to such an approach. In this issue of THE JOURNAL, Jenny et al¹⁵ present an important study on the failure of physicians to recognize head injuries that were due to child abuse. During a 6-year period, 31% of 173 children younger than 3 years with the final diagnosis of a head injury due to abuse had made at least 1 prior visit to a physician at which the diagnosis of child abuse had been missed. The authors note substantial consequences to missing the diagnosis: 28% of the children were reinjured because of a delay in diagnosis and 4 deaths might have been prevented by earlier diagnosis.

The diagnoses made at these initial visits to physicians included the range of possibilities in young children who present with a false or misleading history and symptoms of central nervous system disease, including gastroenteritis, unintentional head injury, colic, or otitis media. Errors in the interpretation of computed tomographic scans of the head (ie, failure to identify subdural hematomas) and radiographs of bones (ie, failure to identify metaphyseal fractures) contributed to missing the correct diagnosis and are an important reminder that the correct diagnosis of child abuse often relies on collaboration with specialists, such as radiologists, orthopedic surgeons, and neurosurgeons.

Not surprisingly, at the initial presentation to the physician, children who had milder symptoms (no seizures, normal respiratory status, and no facial or scalp injury) were more likely to have the diagnosis missed. Also, children whose parents were living together were more likely to have the correct diagnosis missed, which suggests that in the absence of a truthful history, physicians' attitudes and beliefs influenced the likelihood of a correct diagnosis.

This study does not address a related and important type of missed diagnosis, namely, labeling a child's unintentional injury as abuse. Such an incorrect diagnosis can cause substantial harm to the child and family, especially if the child is removed from the home.

Can physicians do better at recognizing injuries caused by abuse and thereby reduce the frequency of delayed diagnoses? Jenny et al¹⁵ provide sound, specific recommendations to improve the likelihood of making a correct diagnosis, such as performing a complete examination on young children with nonspecific symptoms (ie, vomiting or irritability) and being suspicious of bruises or abrasions on the face or head of infants. As part of the evaluation of an infant with such nonspecific symptoms and facial marks, the physician should ask the parent directly about how the facial injuries occurred and about the possibility that someone may have hurt the child and should consider obtaining a computed tomography scan of the head and a skeletal survey.

To make the correct diagnosis of abuse, physicians need to be suspicious for its possible occurrence. Injuries in young children (except those that occur from normal activities, such as bruises on the shins of toddlers, or those that occur from common unintentional events, such as a short, linear, parietal skull fracture from a fall off a bed) need careful evaluation. When a clinician is concerned about the mechanism of how the injury occurred, the extent of the injury, or the timing, child abuse should be considered. It is helpful to review the history with the person(s) who actually witnessed the event; if concerns persist, the clinician should report the case to protective services and obtain the appropriate diagnostic tests (eg, skeletal survey, computed tomography scan of the head, or ophthalmologic evaluation). It may be necessary for the physician to get help obtaining a more detailed social and family history and hospitalize the child to complete the evaluation.

Two general recommendations deserve mention. First, all physicians who see children, not just those in primary care, should receive education about child abuse. This education should begin in medical school, be incorporated into residency training programs, and be extended through continuing medical education courses. Second, collaboration among physicians and other professionals, including protective service workers, should be improved because it is necessary to solve the diagnostic puzzle of child abuse. For instance, the radiologist who is made aware of the child's bruises and the pediatrician's suspicions would certainly be more alert to signs of abuse on the radiographs. Although making the correct diagnosis of child abuse will continue to be a challenge and reducing missed or delayed diagnoses to zero is unlikely, physicians can do better. The key, of course, is "seeing" clearly. When that happens, seeing will become believing, even if what is seen correctly is painful to all—that sometimes adults can hurt children in serious and deadly ways.