PEDIATRICS, June 1963
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VOLUME 31 JUNE 1963 NUMBER 6
COMMENTARY
THE
PHYSICALLY
ABUSED
CHILD
T
HE SYMPOSIUM, “The Battered ChildSyndrome,” held at the American
Acad-emy of Pediatrics meeting in Chicago in
October, 1961, brought into focus the
in-creasing professional recognition of a new
significance to an old problem. The phrase
“the battered child” was, of course,
arrest-ing and accounted in part for the large
audience. The interest shown, however,
was not simply a response to the
sensa-tional but rather an expression of the need to clarify a vague and ill-defined area that
had long troubled many physicians. The
presentation recalled to the memories of
many of the participants cases never fully
solved to their satisfaction, and defined an
entity into which many of these would fit.
Typical skeletal lesions consisting of
mul-tple fractures of the long hones
accom-panying subdural hematoma were
de-scribed by Caffev1 in 1946. In 1953
vn2 in reporting additional cases
ascribed such lesions to trauma,
unrecog-nized or unadmitted. \Voolley in 1955
seems to have been the first to point to
in-flicted injurY as the etiologic factor in many of these cases.
\Vithin the last 5 ‘ears, and more
espe-cially within the last 2, the subject of the
physically al)used child has appeared in
the medical literature and in the 1a-’ press with increasing frequency.
From one or two papers per year on the
abused child complex, the volume increased
to about 15 papers in 1961-62.
Simultaiie-oush’ articles have appeared in popular
magazines-a reversal of the attitude
ex-pressed. by one editor several years ago
that “this isn’t the sort of thing the Ameri-can family wants to read about at break-fast.”
\Vhether the true incidence of child
abuse is actually rising is not clear, though the increasing number of cases reported in
newspapers would seem to indicate this.
No valid incidence figures are available, nor are they likely to become so. The entity
has only recently been described for phsi-cians and is still unknown to many of them.
Hospitals have no diagnostic symbol
through which they can retrieve records
of cases on which a diagnosis of 1iy’sica1 abuse may have been made or sllSpecte(l.
Some indication of the magnitude of the
problem can he obtained from surveys such as that of Kempe and his associates,5 who
reported 302 cases in one year from 71
hospitals and 447 cases from 77 district at-torneys, and from reports of series of cases
from individual institutions, such as the
article in this issue by McHenry, Cirdany, and Elmer. Such reports can indicate only a small fraction of the cases. Undoubtedly
the great majority, including those which
do not result in broken bones or gross
dis-ability, never come to the attention of
physicians.
896 PHYSICALLY ABUSED CHILD
referred to the Massachusetts Society for
the Prevention of Cruelty to Children in
1960 for child abuse, a significant fact for
the medical profession emerges. Only 9% of
the cases were referred by hospitals or
physicians, though they had been involved
in over 30% of them. Case histories from
many hospitals substantiate the fact of
re-peated medical contacts without action to
prevent recurrences. This failure on the
part of physicians probably has several
causes. The first is missed diagnosis. The
syndrome of multiple skeletal injuries
oc-curring over a period of time has only
re-cently been the subject of scientific papers.
Since few doctors are yet aware of this
fairly definite complex, it is understandable that isolated or first injuries are missed.
Even when strong evidence of this
con-fronts the physician, he may find the idea
that parents could abuse their children so
abhorrent that he denies the facts. Often
young physicians, interns, or residents espe-cially, finding such behavior too bizarre for
belief, try to explain the physical signs as
manifestations of some rare disease.
A further reason for the physicians’
fail-ure to act in behalf of the child is the
absence in some, fortunately only a few,
of a social conscience. Just as there are
abusing parents, there are neglectful
doc-tors. Some take the attitude expressed by a
resident, “I am here to treat the child. I
am doing everything I can for him
medi-cally and that is all you can expect of me.”
Others hide behind exaggerated fears of
court procedures or adverse publicity, or
even of suit for false accusation.
Probably many physicians have failed to
act because they did not know what to do.
Though they may have suspicions, they
usually have no proof. A good medical
so-cial worker is, of course, their best ally.
She has interviewing skills through which
she can get valuable information from the
family and she knows the community
re-sources which can be used to protect the
child. But often resources are meager or
agencies are slow, the family removes the
child and disappears, and the physician is
left with the uneasy feeling of having gone too far or not far enough.
The experience of the group at the
Chil-dren’s Hospital of Los Angeles in using
the requirement in California law for
re-porting by doctors and hospitals of inflicted injuries provides evidence that this method of starting action can be effective. Aroused
over the fate of children who after
dis-charge from the hospital died or were
se-verely injured as the result of additional attacks, they explored what legal machinery
was available to them. When their
di-agnostic skills were reinforced by the recog-nition of definitive radiologic findings, the
doctors and social workers found in their
existing law, which requires such reporting, a way of developing a working relationship
with law enforcement officials and the
juvenile court that resulted in protective
procedures for the children. This
experi-ence led a group of consultants meeting
with the Children’s Bureau in January,
1962, to recommend the development of a
Model State Law. Subsequently the
Chil-dren’s Bureau called together a group of
experts, largely from the legal profession,
to lay down the principles on which
legis-lative language could be drafted.
Else-where in this issue is a discussion of the
proposal for such legislation and its
inter-pretation by Professor Fowler Harper of
Yale (see pp. 897-902).
Obviously arguments can he raised for
and against requiring physicians to report
cases of suspected physical abuse of
chil-dren. The rationale of reporting is that a
case of suspected child abuse constitutes
a medical and social emergency. The
pat-tern in these cases is for abuse to he
repeti-tive, and prompt preventive action must he
taken. Reporting, though based on the
premise that a crime has been committed,
and though it may result in action against
the parents, is primarily for the purpose of
protecting the child.
For the physician, reporting is to some
report-ing of gunshot wounds, when reporting of
evidence of inflicted injuries to a child is
required, this relieves the physician of the
burden of choice. This requirement also
may relieve him of feelings of guilt toward the parents.
No one believes that requiring doctors or hospitals to report cases of suspected I)l.Ysical abuse will end, or even lessen, such abuse. Such a law, and the process of
enacting it and implementing it, would
focus on the problem, alert the medical
profession to its existence and its serious-ness, and perhaps set in motion community
action to provide better protective social
services for children. Even though abused children are identified, either by voluntary
or required reporting, unless adequate
pro-vision is made for their subsequent care
and for the rehabilitation of their parents, nothing will have been accomplished.
Gross physical abuse is only one
seg-ment of a much wider problem of parental
neglect. The unloved child, the emotionally traumatized child, the socially and
emotion-ally deprived child, become part of our
pool of neurotic, disturbed, retarded, or
delinquent adults. Out of this morass of
social breakdown, current interest is being focused on one specific malady which can be identified and for which the physician has a primary responsibility for diagnosis.
Any physician seeing children should
de-velop a high level of suspicion for possible inflicted injury. Any case in any social class where the injuries are not fully explained
by the history should be tagged and
ex-plored. At present, the only solution in many
cases is to remove the child from the home
by court order. Many of the parents are
themselves so psychologically damaged that
they are beyond the reach of our present
therapeutic measures. \Ve need studies of the
kinds of parents who abuse their children
and of criteria that will identify those
par-ents that can be helped. Some beginnings
along these lines are recorded by the Chil-dren’s Bureau’s Clearinghouse for Research in Child Life.’
For many years some communities have
provided help for these families and their
children through the public child welfare
program or through private agencies such
as the Society for the Prevention of Cruelty to Children. Getting the child identified before it is physically or emotionally ruined
has been difficult. Obviously the role of
the physician is of crucial importance.
KATHERINE BAIN, M.D.
Deputy Chief, Children’s Bureau Department of Health, Education,
and Welfare
Washington 25, D.C.
REFERENCES
1.Caffey, J.: Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Amer. J. Roentgenol., 56:163,
1946.
2. Silverman, F. N.: The roentgen manifestations of unrecognized skeletal trauma in infants. Amer. J. Roentgenol., 69:413, 1953. 3. \Voolley, P. V., Jr., and Evans, W. A., Jr.:
Sig-nificance of skeletal lesions in infants resem-bling those of traumatic origin. J.A.M.A.,
158:539, 1955.
4. Bibliography on The Battered Child, Clearing-house for Research in Child Life, Children’s
Bureau, Department of Health, Education,
and Welfare, March, 1963 (Revised). 5. Kempe, C. H., et al: The battered-child
syn-drome. J.A.M.A., 181:17, 1962.
6. Merrill, E. J.: Physical abuse of children-an
agency study; in Protecting the Battered Child, Children’s Division, The American
Hu-mane Association, Denver, Colorado, 1962.
7. Boardman, 11. E.: A project to rescue children from inflicted injuries. Social Work, 7:43,
1962.
Suggested Language for State Legislation
on Reporting of the Physically Abused Child
EmToR’s Nol’E:
The proposed legislative language, still in draft form, was prepared by the Children’s Bureau in consultation with a number of interested persons from the medical, legal, and social work
profes-sions. The present draft represents a consensus of opinions and suggestions from many reviewers.
Incorporated in a more comprehensive statement
entitled “Principles and Suggested Language for
898 PHYSICALLY ABUSED CHILD
l)y the Children’s Bureau as the fourth in a series d)f guides for State legislation Ofl child welfare.
An Act for the Mandatory Reporting by
Physicians and Institutions of Certain
Physical Abuse of Children
1. Purpose.
The purpose of this Act is to provide for
the protection of children who have had
physical injury inflicted upon them and
who are further threatened by the
con-duct of those responsible for their care
and protection. Physicians who become
aware of such cases should report them to
appropriate police authority, thereby
causing the protective services of the
state to he brought to bear in an effort to
protect the health and welfare of these
children and to prevent further abuses. 2. Reports by Physicians and Institutions.
Any physician, including any licensed
doctor of medicine, licensed osteopathic physician, intern, and resident, having reasonable cause to suspect that a child under the age of --#{176} brought to him or coming before him for examination, care, or treatment has had serious physical in-jury or injuries inflicted upon him other
than by accidental means, by a parent or
other person responsible for his care, shall report or cause reports to be made in accordance with the provisions of this Act; provided that when the attendance of a physician with respect to a child is pursuant to the performance of services as a member of the staff of a hospital or similar institution he shall notify the
per-son in charge of the institution or his
* It is recommended that the maximum age of JIlvenile Court jurisdiction in the State he usedl.
designated delegate who shall report or
cause reports to be made in accordance with the provisions of this Act.
3. Nature aiul Content of Report; to ‘%Vhom
Ma(le.
An oral report shall be made immediately by telephone or otherwise, and followed as soon thereafter as possible by a report in writing, to an appropriate police
au-thority. Such reports shall contain the
names and addresses of the child and his
parents or other persons responsible for
his care, if known, the child’s age, the na-ture and extent of the child’s injuries
(in-cluding any evidence of previous
in-juries), and any other information that the physician believes might he helpful in establishing the cause of the injuries and the identity of the perpetrator.
4. lmniunitij From Liability.
Anyone participating in good faith in the making of a report pursuant to this Act shall have immunity from any liability, civil or criminal, that might otherwise be incurred or imposed. Any such partici-pint shall have the same immunity with respect to participation in any judicial proceeding resulting from such report.
5. Evidence Not Privileged.
Neither the physician-patient privilege
nor the husband-wife privilege shall be a
ground for excluding evidence regarding a child’s injuries or the cause thereof, in any judicial proceeding resulting from a report pursuant to this Act.
6. Penalty For Violation.
