Child Abuse and Neglect

The topic of child abuse and neglect frustrates many health professionals because they do not know the best way to assess the abuse and/or intercede. There are 15 incidences of abuse and neglect for every 1,000 children under 18 nationwide. This translates into more than one million abuse and neglect victims reported each year.1 An even uglier statistic is that 45 states' Child Protective Services (CPS) reported 996 child deaths from abuse or neglect in 1995.1

• What is the physician's legal responsibility to the abused child?
• What is Child Protective Services and how can it help me intercede in an abusive situation?
• What constitutes child neglect? Physical abuse? Emotional abuse? Sexual abuse?
• How do I recognize the psychological signs of neglect and abuse?
• What are some risk factors of neglect and abuse?

As a medical student, you have several motivations to intervene. The child's immediate health concerns justify it. In addition, as a primary care physician, you may be able to stop injuries and prevent a possible fatality. Minimization of long-term effects of the abuse is a worthy goal as well. Your social concerns also weigh heavily in the interest of mediating an abusive situation. The rate of juvenile delinquency jumps dramatically in an abuse and neglect victim population. Interrupting the family violence cycle is another priority. Abused and neglected children may grow up to be abusive, neglectful parents. Finally, you have a legal responsibility to report suspected abuse or neglect. Your state has statutes outlining your reporting duties. These requirements will vary per jurisdiction, therefore, contact your State Health Department to learn specific terms of the law, such as statutes of limitation and reporting protocol (your State Health Department will also be able to inform you of local abuse and neglect agencies). 2

Primary care physicians have an important role in identifying neglect and abuse victims. Your position of respect, your anatomical expertise, and unique status of being trusted by and yet removed from the family give you special standing. Typically, the generalist physician has two opportunities to assess whether a child has been abused or neglected. The first case is the event of severe maltreatment, when the child comes to you with injuries caused by abuse or neglect. The second opportunity is the well-child checkup, an opportune time to not only look for symptoms of maltreatment, but also to refer families to people or agencies who can help them. The challenge to your medical education is that while medical schools teach the physician's legal obligation to report instances of neglect and abuse, most pediatricians and general practitioners are uneasy with their abuse assessment skills.3

As a primary care physician, you will need to know the physiological and psychological signs of the various types of maltreatment: physical, emotional and sexual abuse as well as physical, medical, educational and psychological neglect. This Project-in-a-Box aims to give you a cursory look at child abuse and neglect, upon which you can build with continuing education courses and specialized training.

Student Organizer's Guide
The purpose of this Project-in-a-Box is to educate future primary care physicians about some of the nuances of neglect and abuse. Because of your role as a medical authority figure, you have a distinctive opportunity to identify and help abused and neglected children. In this Box you will find: the federal law on determining child abuse; information about support services for intervention; definitions of neglect, physical abuse, psychological abuse and sexual abuse; and a case study.

Suggested Activities
Evaluate your school's curriculum on child abuse/neglect assessment and intervention. Based on that evaluation, these activities can supplement your school's program.

Speaker Suggestions:

• Have a panel discussion. Pull from pediatrics and psychiatry departments. Topics include: identifying neglect and abuse, long-term care of victims, and interacting with families of victims.
• Invite a member of the local CPS to explain the agency's policies and procedures for intervention. You could advertise the speech with slogans like, "You have a legal responsibility to report child abuse. What happens after your report?"
• Organize a talk on the social services available for neglected and abused children. A good source for services is the Yellow Pages, under Child Abuse. Agencies like the United Way can give you names of child abuse professionals. If you would like to balance the professional viewpoint with the emotional issues of neglect and abuse, you could request names of adult survivors to speak to your chapter.
• Discuss the case study in this Project-in-a-Box in a student forum.
• Organize a field trip. Check out area hospitals' sexual abuse referral, management or investigative services and ask them to give your medical student group a tour.
• Host a slide show with slides depicting child abuse injuries. There is much criticism that primary care physicians do not recognize the signs of abuse, especially anogenital injuries.

Many physicians acknowledge their conflict in reporting abuse and neglect. Doctors know that statutes mandate them to report all suspected abuse and neglect cases; however, many physicians feel that their reports do not receive proper attention from social services. Some doctors feel that by retaining the maltreated child in their care, they can monitor the abuse, make sure that the child does not get severely maltreated, maintain their friendly standing with the family and discourage the abuse in indirect ways. Therefore, many doctors choose to look the other way because they feel it is the best way to "do no harm." While a desire to minimize the abuse and neglect is understandable, it is not laudable.3 Although CPS is "fragmented, underfunded, overworked, episodic and unable to generate any information that would let us know that children are in fact being protected, it is a system from which we can begin to protect children. Your follow-up and concern can strengthen CPS and help the abusive family interrupt its cycle of violence. Abandoning CPS leaves children at greater risk.3

The Child Abuse Prevention and Treatment Act (Public Law 100-294) defines child abuse and neglect as the physical or mental injury, sexual abuse or exploitation, negligent treatment or maltreatment:

• of a child (a person under the age of 18, unless the law of the State in which the child resides specifies a younger age for cases not involving sexual abuse)
• by a person (including any employee of a residential facility or any staff person providing out-of-home care) who is responsible for the child's welfare.
• under circumstances that the child's health and welfare is harmed or threatened.

The Act defines sexual abuse as:

• the use, employment, persuasion, inducement, enticement or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct (or any simulation of such conduct) for the purpose of producing any visual depiction of such conduct
• rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children.2

Dealing with the Report of Child Abuse
To report a case in which you suspect abuse or neglect, you must first get in touch with the local CPS agency. You can find their number in your local phone book's blue pages or through the local Health Department. CPS, the designated child abuse and neglect social service agency (in most states), receives reports, investigates, and provides rehabilitation services to children and families with abuse or neglect problems. Larger social service agencies, such as Departments of Social or Human Services, often house CPS.4

Proof is not necessary to report that you suspect child abuse or neglect; if you report and follow the letter of the law, you will be immune from liability in civil or criminal courts. When you report, you will need to provide the agencies involved with information about the child, the family and your suspicions.2 It is noteworthy that your right to client-professional confidentiality (as well as privileged communication between husband and wife) is usually waived in the case of reporting child maltreatment.5

State and local agencies bear the greatest burden in responding to reports of child abuse and neglect. The investigation that follows the report is completed by either the police or CPS. Public and private community agencies, volunteer organizations and self-help groups also provide assistance and support to families. Military bases have a child abuse and neglect program called the Family Advocacy Program (FAP), which cooperates with CPS.2

If the initial report suggests a high-risk situation, most states require CPS to respond within 24 hours. In cases of severe physical or sexual abuse, CPS, the police or hospital personnel might choose to remove the child from the home. Such measures will be followed by a custody hearing, usually within 24 or 48 hours.5

CPS's primary goal is to ensure that the children perceived as threatened are safe. Its secondary interest is to maintain the integrity of the home. If CPS determines that the child is not safe, it will, with the help of the civil courts, put the child into foster care. Whether the child is removed or not, if CPS determines that abuse or neglect has occurred or is likely to occur, the agency will provide the family with social services. In the event of severe physical abuse and sexual abuse, CPS may bring suit in the criminal court system.2

As a primary care physician, you will never be wholly responsible for managing a case. Furthermore, you will need to work with the other involved experts. Although there may be a number of interviewers, doctors, prosecuting attorneys, police officers and mental health workers, it is important to only hold one interview with the child. Remember that you will need to collect all of the necessary information at this one interview. You may have access to regional centers that handle abuse reports as a team. Note that at least one study found that when a team handles the case, the victim is significantly more likely to identify the perpetrator and file charges.3

Case Plan--The casework document outlining outcomes and goals necessary to reduce the risk of maltreatment.

Child Protective Services (CPS)--The designated social service agency (in most states) to receive reports, investigate and provide rehabilitation services to children and families with problems of child maltreatment. Frequently, this agency is located within larger, public social service agencies, such as Departments of Social or Human Services.

Family-Focused Intervention--Intervention that includes all family members, rather than focusing on one individual primary care provider. This approach targets the whole family as a dysfunctional unit, not just one individual within that unit.

Primary Prevention--Activities targeting a population sample to prevent child abuse and neglect from occurring.

Secondary Prevention--Activities designed to prevent breakdown and dysfunction among families at risk for child abuse and neglect.

Substantiated/Founded--A CPS determination that credible evidence exists that child abuse has occurred.

Tertiary Prevention--Treatment efforts designed to address situations in which child maltreatment has occurred with the goals of preventing further child maltreatment in the future and avoiding the harmful effects of child maltreatment.4

Abuse and Neglect Affect Society
Although no one set of deviant characteristics describes the influence of abuse, a pervasive presence of socioemotional problems is well recorded. Consequences of maltreatment on children may include behavioral, intellectual and cognitive, personality, neurological and emotional repercussions.6 Other possible negative effects are school learning problems, pseudo-adult behavior, low self-esteem, social withdrawal, hypervigilance to adult cues, oppositional behavior, compulsivity and psychiatric problems.6 These effects depend on several factors: duration and intensity of the abuse, developmental level of the child, and the ensuing domestic environment and degree of community support.6 A child who has been abused may act one of two ways- passive and withdrawn or active and aggressive. Self-destructiveness seems to be a pronounced behavior in physically abused children; they are much more prone to suicide attempts and self-mutilation.6 Likewise, a study of 6,815 delinquent youths found that neglected, delinquent children usually perpetrate nonviolent crimes, for example, drug possession.6

Neglect
Neglect is defined as failure to provide a child with basic needs--minimally adequate food, clothing, shelter, supervision and medical care.7 Of all forms of child abuse, neglect claims the most victims: an estimated 917,200 cases per year. While physical abuse claims 4.9 per 1,000 children and sexual abuse victims occur at an incidence of 2.1 per 1,000 children, the incidence of neglect cases is 14.6 per 1,000 children.7

We characterize neglect as physical, emotional or educational. Physical neglect is the largest category. It includes: inadequate supervision; expulsion from home; abandonment; being disallowed from returning home; being refused or delayed in getting health care; being left with others for long periods of time; inadequate food, clothing or sanitation; lack of supervision around hazards; driving with the child while intoxicated; and leaving a young child unsupervised in a car.7 Emotional neglect occurs when a parent or caregiver gives the child permission to use alcohol or drugs; does not bestow adequate nurturing; when the child is refused or not provided psychological care; when the child witnesses extreme or chronic spouse abuse; or when a child is constantly subjected to expectations unfitting of the child's developmental level. Educational neglect occurs when a child's special educational needs are ignored, when the child is allowed to be a chronic truant or when the child is not enrolled in school.7 While willful neglect may cause CPS to intercede, neglect caused by poverty may be remedied by teaching parents about available social services.8

Neglect Risk Factors
The correlation of child neglect with poverty is a strong one. "The poorest of the poor" have the greatest numbers of neglected children due to a lack of health care, adequate housing and child care.7 Unemployment and its concomitant psychological and economic stresses is a frequent state within a neglectful family. Furthermore, a neglectful family rarely accesses support systems, be it neighbors or psychological and social services.7 In addition, neglectful families typically have only one parent, generally a mother. This lack of a father and his income translates into fewer resources for the family.7 These few available resources are stretched even further because most neglectful families have more than four children.7 Frequently, alcohol and drug abuse is a factor in child abuse; furthermore, reports from CPS agencies note that it is an increasingly present factor in neglect cases. It is notable that the urban, inner-city cocaine addiction epidemic has paralleled the increase of neglect reports.7

There is a clear relationship between the risk of the child and the personalities of the neglectful parents. Neglectful parents cannot determine their children's age-appropriate needs because they lack both the knowledge and empathy necessary for child rearing. As a result, their expectations are unrealistic. Polansky et al studied mothers and determined that childhood emotional deprivation caused their immature personality development.9 In comparison with abusive mothers, Friedrich, Tyler and Clark's study names neglectful mothers as "more dysfunctional than the abusive mothers, less socialized, more angry, more impulsive, more easily aroused (by infant cries) and have greater difficulty habituating to stressful and nonstressful stimuli."10 A lack of social skills and problem-solving abilities also mark neglectful mothers.7 Neglectful parents in a sense still need to grow up and, therefore, need nurturing themselves. Therapy which helps a neglectful parent express their feelings about their abusive or neglectful childhood may be intervention enough to stop the cycle of maltreatment.7

Long-Term Effects of Neglect
The long-term effects of child neglect derive from the fact that the neglected child has not bonded with its mother. The problems from which neglected children may suffer are chronic and severe. The child's unhealthy behavior may begin to manifest itself at one year of age and get worse through his/her preschool years. Neglected two-year-old toddlers had significantly fewer coping skills, were noncompliant, and were more easily angered and frustrated when compared to non-neglected children control groups. Furthermore, neglected preschool children have poorer control over impulses and manifested lower self-esteem as compared to nonmaltreated children. In addition, they were less persistent and less creative problem-solvers and they demonstrated less complex play.7

Manifestations of neglect get worse as the child gets older. Teachers rated some neglected school children as "extremely inattentive, uninvolved, reliant, lacking in creative initiative, and as having much difficulty in comprehending day-to-day schoolwork. . .They were dependent on the teacher- somewhat helpless, passive and withdrawn, and at times angry."7 Empirically, neglected children have acute learning problems. Their standardized test scores, especially in the areas of reading and math, are significantly lower than their peers, even those children with abuse histories. Apparently, a home environment devoid of stimulation of the intellect causes severe language disparities.7 A study comparing developmental repercussions between children from the four groups of maltreatment--neglect, physical abuse, sexual abuse and psychologically unavailable parents--concluded that neglected children suffer the worst consequences.7

A final, surprising statistic is that neglect causes almost as many child fatalities as abuse does. A study of CPS agencies' records showed that neglect was responsible for 44.3 percent of the 556 fatality cases.7

Physical Abuse
Beating, burning, punching, biting, hitting, kicking or causing a child physical injury qualifies as physical abuse. While the perpetrator may not want to injure the child, physical abuse occurs when the injury is not an accident. Injury caused by over-discipline or age-inappropriate physical punishment is also physical abuse.8

A strong indicator of abuse is the parents' history; a parent who was abused as a child may abuse her/his children.8 This correlation between abusers and their abused childhood has been well documented and studied.6

Risk factors for physical abuse fall under the umbrella of "family stress." Domestic violence, poverty, unemployment and social isolation contribute to the likelihood of physical abuse. While the perpetrators are usually the mothers, male caretakers--fathers or mothers' boyfriends--are generally the cause of a child fatality.11 Male children are at higher risk for physical abuse than are female children. Children with disabilities, premature children and children with low birthweights also have an increased risk. Problems in early bonding and a lack of the paternal/child attachment may also cause this increase.11

Treatment of Neglect
While interventions to improve social skills succeeded with abused children, they were much less successful with neglected children.7 The mother's disregard creates a child with either very passive, withdrawn behavior or arbitrary and wild responses.7 One effective prevention strategy is early intervention. Recommendations include visitation to parents identified as high risk (determined by their poverty level, mental retardation, substance abuse, number of children, lack of social support or history of maltreatment) by nurses and other professionals for prenatal and postnatal, in-home interviews for up to two years.7

Physical Abuse Symptoms
Symptoms of physical abuse manifest both physically and psychologically. The best description of abuse's physical effects is in The Battered Child, the seminal work about the physical abuse of young children by pediatricians C.H. Kempe, et al.12 Representative injuries include burn injuries, long bone fractures, subdermal hematomas, and multiple soft tissue injuries. Permanent disability may occur over time. Evidence of the injury may manifest later in neurological and cognitive symptoms. Or, the injury may be very subtle, such as the head or eye injuries resulting from Shaken Baby Syndrome.2 Other child abuse indicators include unrelated injuries and/or injuries of different ages, a delay in seeking care and the caretaker's explanation (an injury unexplained by the explanation given; an inconsistent, changing or evolving history; or the caretaker's inappropriate effect).13

Emergency room studies show that child abuse causes 15 percent to 30 percent of childhood burns. Nonaccidental burns are distinguished from accidental burns in several ways. Accidental burns generally occur when a child pulls a container of hot liquid off a surface. They are "cascading," becoming less severe on the lower part of the trunk or leg; they often have splash marks. Purposeful burns, however, have one of the following characteristics: a stocking or glove distribution on the body; a lack of splash marks indicating a struggle; burns requiring more advanced motor skills than the child possesses; and burns reported as unwitnessed or caused by a sibling.13

Occult fractures in young children raise suspicions of child abuse. X-rays of abused children under two often reveal asymptomatic fractures; the American Academy of Pediatrics suggests a skeletal study in all questionable child abuse cases of children under two. Other fractures commonly found in child abuse victims include posterior rib fractures, metaphyseal fractures of the long bones, and complex or diastatic skull fractures.13

In sum, as a primary care physician, you will see burns, fractures and head traumas in infants and toddlers. In older children, you will observe abrasions, bruises and pattern marks from beatings.11

Psychological Abuse
Psychological abuse is defined as actions of the parent or caretaker that cause or could cause mental, emotional, cognitive or behavioral disorders. Some acts may be adequate proof of emotional abuse to justify the intervention of CPS, such as imprisonment of a child in a closet or torturing the child. Less extreme forms of abuse will require obvious harm to the child before CPS intervenes. Behaviors such as rejection, denigrating and scapegoating must meet the standard "demonstrable harm."2 Psychological abuse is almost always found whenever other forms of abuse are identified.6

Psychological Abuse Symptoms
There are a number of reasons why emotional abuse is the most difficult form of child abuse to identify. First, the manifestations of emotional abuse, learning problems, speech disorders and delays in physical development are also present in children who have not suffered from psychological abuse. In addition, these effects might not become apparent until later in the child's maturation. Finally, the conduct of an emotionally abused child resembles the conduct of an emotionally disturbed child.6

You can differentiate between children who have been emotionally abused and children with emotional disturbances with the help of the following guidelines. Note the demeanor of the parents. Parents with an emotionally disturbed child will acknowledge that their child has a problem. They show anxiety about the child and solicit guidance. Parents of an emotionally abused child, however, will generally ignore the existence of the child or reproach the child for his/her difficulties. When given offers of help, parents of an emotionally abused child generally reject them, seem unconcerned and will even chastise the child.6

Sexual Abuse
Acts falling under the sexual abuse definition include rape, sexual exploitation, exhibitionism, sodomy, fondling a child's genitals, intercourse and incest. For these acts to be considered child abuse, a caretaker (parent, day-care provider, etc.) must have committed them. When a non-caretaker commits these acts, it is considered sexual assault. Sexual assault cases are handled by the police and criminal courts rather than by CPS.2 The reasons why a primary care physician may suspect sexual abuse include: anatomic findings, a parent's concern, a child's own disclosure, a sexually transmitted disease diagnosis, and behavioral and emotional symptoms.3

Physicians have good sources for guidance on sexual abuse. The American Academy of Pediatricians' Committee on Child Abuse and Neglect published its reference guide, Guidelines for the Evaluation of Sexual Abuse of Children; the American Medical Association established similar rules for the primary care physician. The American Professional Society on the Abuse of Children (APSAC) is a group of physicians who have joined forces with therapists, CPS workers, attorneys and law enforcement personnel. The APSAC provides a forum for discussion and training in child abuse, including pediatric anogenital anatomy training, especially normal versus abnormal. Two anatomic atlases developed under these auspices are Chadwick and colleagues' 1989 Color Atlas of Child Sexual Abuse as well as Heger and Emans' 1992 Evaluation of the Sexually Abused Child.3

Sexual Abuse Risk Factors
Children at high risk for sexual abuse are children who fall under one of the following categories: they are growing up in a family with unrelated caretakers; their mother is unavailable or frequently absent; they have family members with sexual abuse histories; the family is socially isolated; or their parents are drug and/or alcohol abusers.11

Symptoms of Sexual Abuse
The physical symptoms of sexual abuse include bleeding or discharge, enuresis, encopresis, and genital and/or anal pain.11 However, sexually abused children may be asymptomatic or show nonspecific signs of stress. These children may regress, show anxiety, be depressed, withdraw from society, perform poorly in school, fear adults, sleep poorly, complain of psychosomatic pain, or show hostile or aggressive behavior.11 Young children who have been sexually abused do not have the maturity--sexual, emotional or intellectual--to handle the sexual behaviors they experience during abuse. Therefore, they are more likely to act out sexually. While all children masturbate, abused children display age-inappropriate sexual behavior that is more explicit than merely "curious."11

Older children who have been sexually abused often use drugs and alcohol to cope with their emotions. Frequently, they will become sexually promiscuous for the same reason. In addition, most teenage runaways have escaped from a sexually or physically abusive home.11

Psychologically, sexually abused children are likely to suffer from feelings of guilt and shame, and they may lack self-esteem.l Their emotional reaction is frequently similar to the symptoms of Post-Traumatic Stress Disorder (PTSD): flashbacks to traumatic experience, obsessive thoughts about it, an exaggerated startle response and depression. Keep in mind that many children will not display these signs at all; it depends on the nature and extent of the abuse.11

History and Physical Exam
One of the weak points in many students' medical training is the sexual abuse physical exam. This Project-in-a-Box highly recommends specialized clinical training but has some communication pointers as well. In taking the child's history and interpreting his/her statements, a pediatrician must be careful not to ask leading questions, instead establishing only that there is reason to believe that abuse might have occurred.3 Non-directive questions you might employ are, "Tell me why your mom brought you to see me today" and "Has anybody ever touched you in a way that made you feel uncomfortable or upset? Tell me about it." Experts suggest three ways to reduce the child's stress during the exam: 1) prepare the child in advance for the exam, 2) give the child greater control during the exam, and 3) debrief the child and parents after the exam.3

Physicians with specialized training will have an easier time dealing with the unique problems arising from the examination and interview of a sexual abuse victim. For example, during the examination, you might discover evidence indispensable for a legal action. Frequently, this information is inadequately documented or documented in a way that keeps this information from being admitted into a legal proceeding. Specialized training can also teach proper interview techniques when using anatomical dolls, diagrams and drawings done by the child.3

It is important to note that sexually abused children often have normal physical exams. The reasons are several fold: complete healing of genital and anal injuries may have occurred; the abuse may be of the sort that does not leave any evidence, for example, fondling, cunnilingus, fellatio, or having adults expose themselves; or many children will not reveal that they have been victimized until many weeks, months or years after the abuse occurs. In addition, as a child's genitals develop, the anatomy will change and may mask indications of the abuse. Pediatricians have a responsibility to know children's normal and abnormal genital and anal anatomy through various stages of maturation.11

For the primary care generalist treating adults victimized by sexual abuse, the most effective way to broach the topic is with an aboveboard manner. Frequently, primary care practitioners find it helpful to routinely interview patients about possible childhood physical or sexual abuse during their first office visit. The subject can be introduced with seemingly innocuous questions like, "In what ways would you like for your children's childhood to be different from yours?" and "Do childhood experiences continue to make things difficult for you today?" or even, "What was your childhood like?" In the event that you suspect abuse, but the patient is unwilling to discuss it, you can set ground rules with that patient that establish the office as an appropriate place to discuss unpleasant topics. The patient may then feel comfortable introducing the subject at a later date.11

Long-term Effects of Sexual Abuse
The long-term effects of sexual abuse vary somewhat from the effects of other types of abuse. They include psychological problems, fear, anxiety, depression, anger, guilt and shame, and an impaired ability to trust. Social problems include school difficulties, running away, delinquency and truancy. Psychiatric problems may include revictimization, aggression and self-destructive behavior.5 In teenagers who have been sexually abused, the incidence of sexually transmitted diseases and unwanted pregnancies is much higher than in the regular population.5 Adult victims of childhood sexual abuse verify the following long-term effects: suicidal tendencies, sexual dysfunction, substance abuse, promiscuity, fear, isolation, low self-esteem, distrust and revictimization.5 Other results of the abuse include obesity, bulimia and poor self image.15 Studies of the trauma that follows sexual abuse divide the effects into four major emotional reactions of the victim: betrayal of trust, stigmatization by one's feelings of guilt and shame, developmentally inappropriate sexualization, and a profound sense of being powerless.11 An effect that commonly manifests itself in adult survivors of sexual abuse is chronic pelvic pain, which may be symbolic of the psychological pain and be a defense against memories of the victimization.11 Long-term effects are not restricted to the victims of the abuse; siblings feel the effects of the abuse too. They experience fear, emotional trauma, anger, guilt and helplessness.5

Factors that influence the severity of the effects are the use of force, the duration of the abuse, and the degree of closeness between the victim and perpetrator.5 In your role as a physician, you should be aware of findings that the severity of the effects from the abuse are directly influenced by support systems available from professionals, parents, relatives and siblings.5

As a primary care provider, you will be responsible for the health and welfare of many children. You must weigh the effects of abuse and neglect to determine how you feel comfortable intervening. Perhaps you will want specialized training, or more contacts with CPS, or to change your approach with abusive and neglectful families. Medicine confers much power; make sure you use yours to protect innocent children.

Case Study
Marissa is a 4 year-old girl whose day care provider has called the children's clinic with some questions about possible sexual abuse. Marissa is frequently angry and often hits the other children at day care. In addition, she touches her genital area regularly. Furthermore, she has tried to open-mouth kiss some of the young boys at the center. She will leave the center easily with her parents (who are both full-time attorneys), but seems intimidated by her sixteen year-old brother when he arrives for her.

• What makes Marissa high risk for sexual abuse?
• Which aspects of Marissa's behavior might indicate sexual abuse?
• How should the day care provider proceed?
• Do you have any reservations about reinforcing the day care provider's suspicions? For what reasons?

National Child Abuse and Neglect Organizations

American Academy of Pediatrics

141 Northwest Point Blvd, PO Box 927
Elk Grove Village, IL 60007

(800) 433-9016

 

American Professional Society on the Abuse of Children (APSAC)

332 South Michigan Ave Suite 1600
Chicago, IL 60604

(312 ) 554-0166

 

C. Henry Kempe Center for Prevention and Treatment of Child Abuse and Neglect

1205 Oneida Street, Denver, CO 80220

(303) 321-3963

 

Child Welfare League of America

440 First Street, N.W. Suite 310
Washington, D.C. 20001

(202) 638-2952

 

Childhelp USA

6463 Independence Ave
Woodland Hills, CA 91367

(800) 4-A-CHILD

 

National Center on Child Abuse and Neglect (NCCAN)

P.O. Box 1182, Washington, D.C. 20013

For publications, call (800) FYI-3366

 

National Child Abuse Coalition

733 15th Street NW Suite 938
Washington, D.C. 20005

(202) 347-3666

 

National Committee for Prevention of Child Abuse

332 South Michigan Ave Suite 1600
Chicago, IL 60604-4357

(312) 663-3520

 

National Council on Child Abuse and Family Violence

1155 Connecticut Ave, NW Suite 400
Washington, DC 20036

(800) 222-2000

A Final Word On What Can You Do To Become More Involved

• Get AMSA's Prevention of Child Abuse Prevention Project (Call 703-620-6600, ext. 217), a module for teaching school children about sexual abuse.
• Begin a support group for abused adolescents.
• Consider lobbying state and federal legislatures to include anogenital exams in well-child checkups.
• Organize an April is National Child Abuse Prevention Month. Contact one of the above organizations to get publicity ideas and posters to promote it.
• Have a fundraiser to stock local clinics and Emergency Department waiting rooms with pamphlets advocating children's health. Call (800) 628-7733 to order the following low-cost publications:

Pamphlets:
Child Neglect 16774A (in Spanish 48074A)

About Child Sexual Abuse 16667K-2-96

Sexual Abuse of Children 16667A (in Spanish16832A)

Sexual Victimization of Children 48553A

Putting a Stop to Child Abuse 42887A

Child Abuse and Child Neglect 14001A

Emotional Abuse and Neglect of Children 48850A

Keeping Your Cool When Your Baby Cries Preventing Shaken Baby Syndrome 8919A

Coloring Books:

You're in Charge 54619A (in Spanish 56341A)

Physical Abuse is Never OK 56523A

What Every Kid Should Know About Sex Abuse 54627B

Words That Hurt 56812A

Stay Safe Around People You Don't Know Well 54585A4

References

1. U.S. Department of Health and Human Services, Child Maltreatment 1995: Reports From the States to the Nat'l Child Abuse and Neglect Data System (Washington, DC: U.S. Government Printing Office, 1997), p.ix, p.2-10- 2-11.
2. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, National Center on Child Abuse and Neglect. Child Abuse and Neglect: A Shared Community Concern .Washington D.C.: U.S. Government Printing Office; Revised 1992. p.1-11.
3. Kerns, David; Terman, Donna; Larson, Carol, "The Role of Physicians in Reporting and Evaluating Child Sexual Abuse Cases" The Future of Children, Sexual Abuse of Children, Vol. 4, No. 2- Summer/Fall 1994, p.121-131.
4. U.S. Dept of Health and Human Services, Child Maltreatment 1995: Reports From the States to the National Child Abuse and Neglect Data System (Washington DC: U.S. Government Printing Office, 1993), p. vii-59.
5. Pence DM, Wilson CA, "Reporting and Investigating Child Sexual Abuse" The Future of Children, Sexual Abuse of Children, vol. 4, No. 2- Summer/Fall 1994, p.72.
6. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, National Center on Child Abuse and Neglect. A Coordinated Response to Child Abuse and Neglect: A Basic Manual. McLean, VA: The Circle, Inc.; 1992, p.12-15.
7. U.S. Department of Health and Human Services, Admin. for Children and Families, Administration on Children, Youth and Families, National Center on Child Abuse and Neglect. Child Neglect: A Guide for Intervention. Washington D.C.: Westover Consulting, Inc., 1993, p.1-50.
8. U.S Dept. Health and Human Services,The Third National Incidence Study of Child Abuse and Neglect (Washington, DC: U.S. Government Printing Office, 1996). p.5-17.
9. Polansky NA, et al. Damaged Parents. Chicago: University of Chicago Press, 1987, 109.
10. Friedrich WN, Tyler JD, and Clark JA "Personality and Psychophysiological Variables in Abusive, Neglectful and Low-Income Control Mothers," Journal of Nervous and Mental Disease vol. 173, 1985 p. 449-460.
11. U.S. Department of Health and Human Services, Public Health Service. National Health Service Corps Educational Program for Clinical and Community Issues in Primary Care. Reston, VA: American Medical Student Association/Foundation, 1994, p. 5-31.
12. Kempe, C., and Helfer, R., eds. The battered child. 3rd ed. Chicago: University of Chicago Press, 1980.
13. National Health Service Corps Educational Program for Clinical and Community Issues in Primary Care: Child Abuse, Neglect and Domestic Violence Module, p. 18-24.
14. Briere JN, Elliott D "Immediate and Long-Term Impacts of Child Sexual Abuse" The Future of Children, Sexual Abuse of Children, vol. 4, No. 2- Summer/Fall 1994, p.58.
15. Medical Technology and Practice Patterns Institute, Diagnostic Imaging and Child Abuse: Technologies, Practices, and Guidelines (Washington DC: MTPPI Press, 1996), p. vii-59.
16. Maternal and Child Health Bureau, Public Health Service. Responding to Child Abuse and Neglect: A Continuing Challenge. Washington, D.C.: U.S. Government Printing Office; 1994, p.13-15.
17. Finkelhor D, "Current Information on the scope and Nature of Child Sexual Abuse" The Future of Children, Sexual Abuse of Children, vol. 4, No. 2, 1994, p.37-48.

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