Child abuse or maltreatment includes physical abuse, sexual abuse, psychologic abuse, and general, medical and educational neglect. The National Center on Child Abuse and Neglect¹ has established a set of working definitions of the various types of abuse; however, the specific acts that constitute the various forms of abuse are defined under state law and, thus, vary from one jurisdiction to another. For this reason, child abuse is a legal finding, not a diagnosis.

Primary prevention is defined as both the prevention of disease before it occurs and the reduction of its incidence. In the context of child abuse, primary prevention is defined as any intervention designed for the purpose of preventing child abuse before it occurs. This definition encompasses what some authorities have defined as secondary prevention.^2–4

Family physicians should be aware of the risk factors for child abuse and possible interventions that could prevent it. This article reviews possible causes of child abuse and current intervention strategies.

Epidemiology

Between 1985 and 1993, the number of cases of child abuse in the United States increased by 50 percent. In 1993, three million children in the United States were reported to have been abused. Thirty-five percent of these cases of child abuse were confirmed.

Data from various reporting sources, however, indicate that improved reporting could lead to a significant increase in the number of cases of child abuse substantiated by child protection agencies. The lack of substantiation does not indicate that maltreatment did not occur, only that it could not be substantiated. The fact remains that each year, 160,000 children suffer severe or life-threatening injury and 1,000 to 2,000 children die as a result of abuse. Of these deaths, 80 percent involve children younger than five years of age, and 40 percent involve children younger than one year of age.^1,5 One out of every 20 homicide victims is a child. Homicide is the fourth leading cause of death in children from one to four years of age and the third leading cause of death in children from five to 14 years of age.⁶ Neonaticide (i.e., the murder of a baby during the first 24 hours of life) accounts for 45 percent of children killed during the first year of life.⁷

It is generally accepted that deaths from maltreatment are underreported and that some deaths classified as the result of accident and sudden infant death syndrome might be reclassified as the result of child abuse if comprehensive investigations were more routinely conducted.¹ Most child abuse takes place in the home and is instituted by persons known to and trusted by the child. Although widely publicized, abuse in day-care and foster-care settings accounts for only a minority of confirmed cases of child abuse.⁸ In 1996, only 2 percent of all confirmed cases of child abuse occurred in these settings.⁹

Child abuse is 15 times more likely to occur in families where spousal abuse occurs. Children are three times more likely to be abused by their fathers than by their mothers.¹⁰ No differences have been found in the incidence of child abuse in rural versus urban settings.¹¹ The incidence and types of reported cases of child abuse are listed in Table 1.⁹

Consequences

Not only do children suffer acutely from the physical and mental cruelty of child abuse, they endure many long-term consequences, including delays in reaching developmental milestones, refusal to attend school and separation anxiety disorders. Other consequences include an increased likelihood of future substance abuse, aggressive behaviors, high-risk health behaviors, criminal activity, somatization, depressive and affective disorders, personality disorders, post-traumatic stress disorder, panic attacks, schizophrenia and abuse of their own children and spouse.^12,13 Recent research has shown that a loving, caring and stimulating environment during the first three years of a child's life is important for proper brain development. This finding implies that children who receive maltreatment in these early years may actually have suboptimal brain development.¹⁴

Causes of Child Abuse

Research regarding the causes of child abuse has recently undergone a paradigm shift. The results of research initiated by the National Research Council's Panel on Research on Child Abuse and Neglect⁸ signal the first important step away from simple cause-and-effect models. As was recognized by researchers for the National Research Council's panel, the simple cause-and-effect models have certain limitations, mainly related to their narrow focus on the parents. These models limit themselves by asking only about the isolated set of personal characteristics that might cause parents to abuse or neglect their children. Moreover, these models also fail to account for the occurrence of different forms of abuse in one child. At the same time, these models had very little explanatory power in weighing the value of various risk factors involved in child abuse. As a result, they were not very accurate in predicting future cases of child abuse.

To replace the old static model, the panel has substituted what it calls an “ecologic” model. This model considers the origin of all forms of child abuse to be a complex interactive process. This ecologic model views child abuse within a system of risk and protective factors interacting across four levels: (1) the individual, (2) the family, (3) the community and (4) the society.^8,15,16 However, some factors are more closely linked with some forms of abuse than others.⁸ The factors thought to contribute to the development of physical and emotional abuse and neglect of children are listed in Table 2 and are discussed below.

SOCIETAL FACTORS

Many would argue that our society does not really value its children. This assertion is highlighted by the fact that one in four children in the United States lives in poverty, and many children do not have any form of health insurance. The presence of high levels of violence in our society is also thought to contribute to child abuse. Deadly violence is more common in the United States than in 17 other developed countries. Seventy-five percent of violence occurring in this country is domestic violence. The United States leads developed countries in homicide rates for females older than 14 years and for children from five to 14 years of age.¹⁶ Other factors that may contribute to high rates of violence include exposure to television violence and reliance on corporal punishment.¹⁶

Poverty is the most frequently and persistently noted risk factor for child abuse. Physical abuse and neglect are more common among the people who are the poorest. Whether this association is precipated by the stress of poverty-related conditions or results from greater scrutiny by public agencies, resulting in over-reporting, is debated. Nevertheless, this association is well documented.^8,16,17 Other societal factors that have been cited include inaccessible and unaffordable health care, fragmented social services and lack of support from extended families and communities.^8,16

PERSONAL FACTORS

Parents who were abused as children are more likely than other parents to abuse their own children. However, the retrospective methodology of research in this area has been criticized.⁸ Lack of parenting skills, unrealistic expectations about a child's capabilities, ignorance of ways to manage a child's behavior and of normal child development may further contribute to child abuse.^8,18 It is estimated that 40 percent of confirmed cases of child abuse are related to substance abuse.¹⁹ It is also estimated that 11 percent of pregnant women are substance abusers, and that 300,000 infants are born each year to mothers who abuse crack cocaine.²⁰ Domestic violence also increases the risk of child abuse.²¹

Other factors that increase the risk of child abuse include emotional immaturity of the parents, which is often highly correlated to actual age (as in the case of teenage parents),²² poor coping skills, often related to age but also occurring in older parents,^8,15,22 poor self-esteem and other psychologic problems experienced by either one or both parents,^8,15 single parenthood and the many burdens and hardships of parenting that must be borne without the help of a partner,⁸ social isolation of the parent or parents from family and friends and the resulting lack of support that their absence implies,^8,23 any situation involving a handicapped child or one that is born prematurely or at a low birth weight, any situation where a sibling younger than 18 months of age is already present in the home,^8,24 any situation in which the child is the result of an unwanted pregnancy or a pregnancy that the mother denies,^25–27 any situation where one sibling has been reported to child protective services for suspected abuse²⁸ and, finally, the general inherent stress of parenting which, when combined with the pressure of any one or a combination of the factors previously mentioned, may exacerbate any difficult situtation^8,15,16 (Figure 1).

Primary Prevention Strategies

The U.S. Advisory Board on Child Abuse and Neglect has stated that only a universal system of early intervention, grounded in the creation of caring communities, could provide an effective foundation for confronting the child abuse crisis. It is generally held that successful strategies for preventing child abuse require intervention at all levels of society.^8,16,18 However, no consensus has formed regarding which programs or services should be offered to prevent child abuse. In part, this is because research on the prevention of child abuse is limited by the complexity of the problem, the difficulty in measuring and interpreting the outcomes, and the lack of attention to the interaction among variables in determining risk status for subsequent abuse. Although a broad range of programs has been developed and implemented by public and private agencies at many levels, little evidence supports the effectiveness of these programs.

A 1994 retrospective review of 1,526 studies on the primary prevention of child abuse found that only 30 studies were methodologically sound.² Of the 11 studies dealing primarily with physical abuse and neglect, only two showed a decrease in child abuse as measured by a reduction in hospital admissions, emergency department visits or reports to child protective services.² Although there is a need for better designed research to evaluate the effectiveness of prevention strategies, recommendations for preventive interventions are based on what we currently know about the causes of child abuse.

SOCIAL INTERVENTIONS

Primary prevention strategies based on risk factors that have a low predictive value are not as likely to be effective as more broadly based social programs. In addition, programs focused on a societal level rather than on the individual level prevent the stigmatization of a group or an individual.⁸

Social strategies for preventing child abuse that are proposed but unproven include increasing the value society places on children, increasing the economic self-sufficiency of families, enhancing communities and their resources, discouraging excessive use of corporal punishment and other forms of violence, making health care more accessible and affordable, expanding and improving coordination of social services,¹⁶ improving treatment for alcohol and drug abuse,²⁰ improving the identification and treatment of mental health problems,^7,15 increasing the availability of affordable child care⁸ and preventing the births of unwanted children through sex education, family planning, abortion, anonymous delivery²⁵ and adoption.^7,25–27

FAMILIES

Strategies targeted at the individual can also be considered strategies for helping the family. Common features of successful child abuse prevention programs are described in Table 3.^29,30

The recommendations in this table embody the concept of supporting parents in their role of parenting. Until parents' basic needs are met, they may find it difficult to meet the needs of their children. The first thing parents need is assistance in meeting their basic requirements for food, shelter, clothing, safety and medical care. Only when these needs are met can higher needs be addressed.

The next step should be to identify and treat parents who abuse alcohol or drugs, and identify and counsel parents who suffer from spousal abuse. Identifying and treating parents with psychologic problems is also important. Other issues that need attention include financial concerns, and employment and legal problems. Providing an empathetic ear and being a source of referral for help with these issues may take physicians a long way toward nurturing needy parents.

The next higher level of need includes education about time management and budgeting skills, stress management, coping and parenting skills such as appropriate discipline, knowledge of child development, nutrition and feeding problems, and safety issues.

DELIVERY OF SERVICES

In the United States, some of the specific methods of delivering services to families include long-term home visitation, short-term home visitation, early and extended postpartum mother/child contact, rooming in, intensive physician contact, drop-in centers, child classroom education, parent training and free access to health care.²

Of these methods, only long-term home visitation (up to two years) has been found to be effective in reducing the incidence of child abuse as measured by hospital admissions, emergency department visits and reports to child protective services.² Indeed, many organizations are now embracing the concept of home visitation as a method of preventing child abuse by identifying family needs and providing the appropriate services.^30–32 Results of one study on home visitation showed benefits or improvements in several areas: parents' attitudes toward their children, interactions between parents and children, and reduction in the incidence of child abuse.³³ However, without an infrastructure of support services such as health care, social services and child care, home visitors will be unable to deliver needed services.³²

What Can Physicians Do?

TREAT THE PARENTS FIRST

It is clear that many of the causes of child abuse center on the needs and problems of the parents. Therefore, in order to prevent child abuse, we must first help and support the parents.^3,4,34 Parents with multiple emotional, medical, financial and social needs find it difficult to meet the needs of their children. It is imperative that physicians develop a supportive attitude toward parents to ultimately help the children.

Effective prevention of child abuse and neglect can best be achieved using strategies designed to help parents protect and nurture their children. These strategies include giving parents the necessary support, resources and skills (Table 4). The physician should obtain help from social workers, home health agencies, financial counselors, psychologists, local mental health facilities, alcohol and drug treatment centers and parenting centers, as appropriate. To that end, physicians should become familiar with the resources available in their community. It is useful to keep a list of such agencies with telephone numbers and addresses readily available in patient education files to distribute to patients. Physicians should be aware of the many public and private agencies already available for information and referral. The National Committee to Prevent Child Abuse has a nationwide network of 52 chapters that provide leadership in the prevention of child abuse³⁵ (Table 5).

Studies have shown that busy physicians may spend as little as one minute discussing anticipatory guidance with parents.³⁶ One proposed strategy for improvement in this area is to provide group parenting classes to discuss such issues.³⁷ Topics for discussion include safety issues, nutrition and feeding concerns, discipline and normal child development. Classes should be divided into two groups: one for the parents of infants and one for the parents of toddlers, since these two groups will require a different focus. Providing child care during these classes may be necessary to ensure attendance.

Many practical strategies can help the busy physician try to prevent child abuse.^3,34 Spending less time examining an obviously well child and more time discussing psychosocial issues with that child's parent is one recommendation. Questions to ask parents that might help physicians assess the risk of child abuse are listed in Table 6. If psychosocial problems are uncovered, the physician might schedule more frequent visits to allow for further discussions. Other strategies include inviting fathers for an office visit and encouraging the parents to rely on the support of families and friends.

It is important to address issues that are of concern to the parents. It is also important to try to give very specific and concrete suggestions to parents instead of talking in broad generalities. For example, physicians could suggest that parents use an egg timer to help children anticipate and be more compliant with bedtime or use time-out as an alternative to spanking a child for bad behavior.^3,34 Parents should be reminded of and taught to distinguish between childish behavior and willful disobedience, and to discipline only those actions that are in the child's control according to his or her stage of development.

ADVOCACY FOR CHILDREN

It is clear that we as physicians cannot hope to solve the problem of child abuse by ourselves. Many things need to happen at international, national, state and community levels to prevent child abuse. The physician who is concerned for the welfare of children should be an advocate for more accessible, affordable and high-quality child and health care in the local community. Studies have shown that countries with the most generous social services have the lowest rate of child homicide.¹⁶ Physicians should lobby for greater availability of drug and alcohol treatment programs, more shelters for the homeless, more accessible mental health care and more shelters for abused women and children. These programs and those that provide parenting skills, support groups and respite care for parents and care-givers should be available in every community.

Final Comment

Although child abuse is a pervasive and complex problem with many causes, we should not take a defeatist attitude toward its prevention. Despite the absence of strong evidence to guide our preventive efforts, physicians can do many things to try to prevent abuse. At the very least, showing increased concern for the parents or caregivers and increasing our attempts to enhance their skills as parents or caregivers may help save our most vulnerable patients from the nightmare of abuse and neglect.