Child Abuse: The Conflict of Underdetection and Overreporting

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COMMENTARIES

441

5. Expert Scientific Working Group: Assessment of the Iron

Nutrition Status of the U.S. Population Based on Data Collected in the Second National Health and Nutrition Ex-amination Survey, 1976-1980, Life Sciences Research Of-fice. Bethesda, MD, Federation of American Societies for Experimental Biology, 1984

6. Ten-State Nutrition Survey 1968-70: IV. Biochemical, US Department of Health, Education, and Welfare publication No. (HSM) 72-8132. Atlanta, Centers for Disease Control, 1972

7. Committee on Iron Deficiency: Iron deficiency in the United States. JAMA 1968;203:407-412

8. Florentino RF, Guirriec RM: Prevalence of nutritional ane-mia in infancy and childhood with emphasis on developing countries, in Stekel A (ed): Iron Nutrition in Infancy and Childhood. New York, Raven Press, 1984, pp 61-72 9. The Centers for Disease Control: Declining anemia

preva-lence among children enrolled in public nutrition and health programs, selected states, CDC Pediatric Nutrition Surveil-lance System, 1975-85. MMWR 1986;35:565-566

10. Yip R, Walsh KM, Goldfarb MG, et al: Declining childhood anemia prevalence in a middle-class setting: A pediatric success story? Pediatrics 1987;80:330-334

1 1. Reeves JD, Yip R, Kiley V, et al: Iron deficiency in infants: The influence of antecedent infection. J Pediatr

1984;105:874-879

12. Jansson LT, Kling 5, Dallman PR: Anemia in children with acute infections seen in a primary care pediatric outpatient clinic. Pediatr Infec Dis 1986;5:424-427

13. Sadowitz DP, Oski FA: Iron status and infant feeding prac-tices in an urban ambulatory center. Pediatrics 1983;72:33-36

14. Thomas WJ, Collins TM: Comparison ofvenipuncture blood counts with microcapillary measurements in screening for anemia in one-year-old infants. J Pediatr 1982;101:32-35 15. Yip R, Mohandas N, Clark MR, et a!: Red cell membrane

stiffness in iron deficiency. BloOd 1983;62:99-106

16. Martinez GA, Krieger FW: 1984 Milk-feeding patterns in the United States. Pediatrics 1985;76:1004-1008

17. Rees J, Monsen E, Merrill J: Iron fortification of infant foods. Clin Pediatr 1985;24:707-710

18. American Academy of Pediatrics, Committee on Nutrition: Pediatric Nutrition Handbook. Elk Grove Village, IL, Amer-ican Academy of Pediatrics, 1985, pp 212-220

19. Dailman PR: Biochemical basis for manifestations of iron deficiency. Annu Rev Nutr 1986;6:13-40

Child

Abuse:

The Conflict

of

Underdetection

and

Overreporting

In 1946, Caffey’ reported the association of mul-tiple bone fractures and subdural hematomas in children and set the stage for the identification of what subsequently became known as the battered child syndrome. For the next 15 years, radiologists involved in the care of children added support to

his observations and demonstrated that the lesions

he described had a specificity that indicated physi-cal trauma when a history of injury was lacking or

even denied. These reports met with little response until Kempe and associates2 indicated, in a sym-posium at a meeting of the American Academy of Pediatrics in October 1961, the serious nature of the observations in relation to pediatric morbidity

and mortality. The title for the symposium was

“The Battered Child”, a term coined by Kempe for its shock value, and the substance of the presenta-tion appeared in June 1962 under the same title.

Kempe’s assessment of the effect of the term he chose was immediately confirmed by numerous

ar-tides in newspapers and magazines including a

rapidly increasing number of professional publica-tions. Equally responsive was the action of the Children’s Bureau in January 1962 when it sup-ported a meeting of medical, paramedical, and legal consultants to address the problem of child abuse and how to contain it. Impressed by results reported by participants from California where mandatory reporting by physicians and hospitals was already in place, the group suggested that similar action in other states could indicate the magnitude of the problem as well as play a role in its control. To accomplish this, it was further suggested that the Children’s Bureau might support the development of a “model law” that other states could use as a

basis for their individual approach to the issue. A second meeting was undertaken to which additional

members of the legal profession were invited, and

using this group’s conclusions as a basis, the Chil-then’s Bureau provided principles and suggested language for the states to use in the generation of their own legislation.3 Physicians and hospitals or similar institutions were to be required to report to an appropriate police authority the occurrence of physical injuries to a child when there was reason-able cause to suspect that they had been inflicted by other than accidental means. Anyone participat-ing in good faith in making a report was to have immunity from legal liability as a consequence of reporting, and knowing and willful failure to report was subject to legal penalty. The principles stated

that the proposed legislation was not intended to

prevent or discourage voluntary reporting by others than those mandated to report.

Within a few years, all of the states had a child abuse law enacted that conformed more or less closely to the “model law.” Further legislation in the form of the federal Child Abuse Prevention and Treatment Act of 1974 required states to expand laws on reporting child abuse to all forms of ma!-treatment, including neglect and sexual abuse, and provided federal grants to states meeting the ex-panded standards. Child protection services were

strengthened and child abuse discovery became a

more important function of social service agencies.

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

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442 PEDIATRICS

Vol. 80 No. 3 September 1987

In the past decade, changes in social mores illu-minated sexual activities previously concealed from public view and largely excluded from public dis-cussion. Among them was sexual abuse of children. One of the reactions was a surge in media accounts of incidents followed by an aroused public interest, probably enhanced by the breaking of social taboos that were involved. With increasing exposure of the public to the concept of sexual abuse of children, a marked increase in reports of child abuse occurred.

This was favored by the mandatory and permissive

language related to reporting that had been retained

from the initial legislation. The phenomenon has

been described as a “move from underreporting of

the problem to hypervigilance and frequent overre-porting.”4 Almost simultaneously, agencies became aware that many reports were not reliable. Accord-ing to a report of the House Select Committee on Children, Youth, and Families, nearly 1.9 million children were reported as victims of child abuse and neglect in 1985; three fifths of the cases in-volved neglect (Washington Post, March 3, 1987, p AS). The American Humane Society noted, in 1984, that more than 58% of all reports were unsubstan-tiated, a figure that had remained fairly constant throughout the previous few years.4 “Unsubstan-tiated” may mean anything from no basis found on careful investigation, through inadequate investi-gation or a successful cover-up by the perpetrators, to a lack of investigation.

In addition, unjustified and even deliberately false reports made their appearance.58 The number of reports of sexual abuse, according to the Child Welfare League,9 increased 59% from 1983 to 1984. Some of the most visible instances of malicious false reporting have been related to child custody or visitation litigation in which one parent accuses the other of sexual abuse of children.7”#{176} But others were generated by emotionally or mentally dis-turbed individuals exploiting the permissive report-ing aspects of the child abuse legislation. Equally suspect may be anonymous reports, in one study of which during a period of 2 years, 87.6% were

un-founded.5 These false reports tend to obscure the

bona fide, but subsequently unsubstantiated,

re-ports made by responsible individuals honestly

con-cerned about possible child abuse because of

mi-tially unexplained injuries and place a significant burden on agencies responsible for investigation of reports.

Increased reporting leads to increased investiga-tion by police and/or child protective personnel and consequently confrontations with families who can-not help but resent what they consider intrusions by government into their personal and family life.” As a result, an understandable backlash against child abuse laws has come into being. The move-ment appears to be fueled by reactions to

proce-dures intended to protect the child that are initiated by reports proved to be unsubstantiated only after lengthy and painful investigations and/or legal ac-tions. An organization of persons (mainly parents) who have been exposed to the trauma of false accusation of child abuse has been formed under the acronym of V.O.C.A.L.-victims of child abuse laws’2”3-and is seeking support for changes in the current legislation and especially its

implementa-tion. Among the complaints against the present

system are (1) aggressive actions of investigating personnel, whether from child protective agencies,

from police, or from prosecuting attorney offices;

(2) admissibility of anonymous accusations; (3) in-ability to confront accusers; and (4) immunity of

identifiable initiators of malicious false reports

from legal action. The belief is that “the falsely accused not only face the ‘law,’ they face a powerful social attitude that casts them as ‘guilty’ before the facts are even known.”#{176}

It is unfortunate that an adversarial attitude that seems to be a carry-over from painful court expe-riences is developing in relation to child protective activities. No system is perfect, and one oriented toward protection of children has to be biased in their favor. A false report of abuse has to be re-sponded to just as a false report of a fire; the hazard

of not responding, or an inadequate response, is too great to be allowed and the report is not identified

as false until after the response. If the report is

deliberately false, at least in the case of a fire, penalties are invoked. Some recommend the estab-lishment of civil or legal liability for malicious reports and requiring the recipient agency to

ques-tion the nonmandated reporter with particular care

during the investigation. Others have suggested

that anonymous reports should be rigorously

screened to determine the reporter’s identity which

can be maintained as confidential. Still others

in-dicate that anonymous reports be made unaccept-able, as they generally involve low-risk situations.5 It is worth noting that allegations by nonprofes-sional reporters are more likely to be incorrect than those by professionals. In one study, 35% of those by the former group were true compared with 47% by the latter, and the lower figure decreased to 31% when combined with anonymous reports.6

Substan-tiated cases were more common in two-parent homes, in minority children, and in younger

mar-ned women than in their opposites.’4

There is deep personal involvement in the

cir-cumstances surrounding an accusation of child

abuse-by the individuals responsible for providing

protection, by those with various degrees of

culpa-bility, and by those who are victims of a false accusation. Those who find fault with the manner in which child protection activities are carried out deserve to be heard. Constructive criticism should

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COMMENTARIES 443

be welcome from any source as a means to improve the detection of child abuse and its prevention. It would seem that open discussions of the various

points of view could permit accommodations to

justified complaints such that the positive aspects

of child abuse legislation are not in danger of being compromised. The members of V.O.C.A.L. are not victims of child abuse laws; their problem is with

the implementation of the laws.

At the time that Caffey’ introduced us to the objective radiographic features that accompanied

physical child abuse, he told us that he had been reluctant to state his belief that the injuries were

inflicted because he was fearful of legal

repercus-sions. His concern was with legal action against a

physician who stated that injuries were nonacciden-tal and also with the possibility of incorrect

accu-sations for whatever reasons. This did not prevent

him from subsequently supporting the strength of the radiographic evidence and even pointing out that intracranial damage could occur from shaking an infant without radiographic or external signs of

injury.15 What his reaction would be to the extent and nature of the legal ramifications today is un-certain, but I do not believe he would be pleased. He might even believe that his contribution had been abused.

FREDERIC N. SILVERMAN, MD Department of Radiology

Stanford University Medical Center Stanford, CA

REFERENCES

1. Caffey J: Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR

1946;56:163-173

2. Kempe CH, Silverman FN, Steele BF, et a!: The battered child syndrome. JAMA 1961;181:17-24

3. The Abused Child: Principles and Suggested Language for Legislation on Reporting of the Physically Abused Child. US Department of Health, Education, and Welfare. Welfare Administration. Children’s Bureau. Government Printing Office, 1963

4. Schetky DH: Emerging issues in child sexual abuse, edito-na!. J Am Acad Child Psychiatry 1986;25:490-492

5. Adams W, Barone N, Tooman P: The dilemma of anony-mous reporting in child protective services. Child Welfare

1982;61:3-14

6. Fa!ler KC: Unanticipated problems in the United States child protection system. Child Abuse Neglect 1985;9:63-89 7. Green AH: True and false allegations of sexual abuse in

child custody disputes. J Am Acad Child Psychiatry

1986;25:449-456

8. Jones DPH, McGraw JM: Reliable and fictitious accounts of sexual abuse in children. J Interpersonal Violence

1987;2:27-45

9. Too Young To Run. The Status of Child Abuse in America.

Washington, DC, Child Welfare League of America. 1986 10. Spiegel LD: A Question of Innocence. A True Story of False

Accusation. Parsippany, NJ, The Unicorn Publishing House, 1986

11. Duquette DN: Liberty and lawyers in child protection, in Kempe CH, Helfer RE (eds): The Battered Child, ed 3. Chicago, University of Chicago Press, 1980, pp 316 12. Pride M: The Child Abuse Industry. Westchester, IL,

Cross-way Books, 1986

13. Eberle P, Eberle 5: The Politics of Child Abuse. Secaucus, NJ, Lyle Stewart Inc, 1986

14. Hawkins WE, Duncan DF: Perpetrator and family charac-teristics related to child abuse and neglect: Comparison of substantiated and unsubstantiated reports. Psychol Rep

1985;56:407-410

15. Caffey J: On the theory and practice of shaking infants: Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child 1972;124:161-169

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1987;80;441

Pediatrics

FREDERIC N. SILVERMAN