Non-accidental Injury and Child Maltreatment
Phillip S. Ebrall
Neil J. Davies
Non-accidental injury and child maltreatment are serious concerns for all primary health care professionals, especially those who regularly deal with infants, children, and adolescents. Over the last 20 years, the clinical flags of such trauma have become well established (1). Given the estimate that some 100,000 children suffering from abuse or neglect annually pass through the doors of chiropractors’ offices in the United States (2), it is not surprising that the chiropractic literature has started to address the issue (2,3,4,5).
The issues surrounding non-accidental injury and child maltreatment, however, are not as simplistic as the general term “child abuse” might imply. Children suffer more victimizations than do adults, including more conventional crimes, more family violence, and some forms virtually unique to children, such as family abduction. Victimizations have been grouped into three categories: the pandemic, such as sibling assault, which affects most children (6); the acute, including physical abuse, which affects a small but significant percentage of children; and the extraordinary, such as homicide, which affects a very small number (7). The latter notwithstanding, one out of five teenage and young adult deaths in the United States was gun related in 1988, and firearm death rates for both black and white teenagers exceed the total for all natural causes of death combined (8).
This chapter deals with acute victimization and will demonstrate the nature of the non-accidental injury and the other manifestations of maltreatment that can be expected to be seen in chiropractic practice.
THE NATURE OF THE PROBLEM
In Western societies the highest rates of substantiated abuse and neglect occur among children age 13 and 14 years (5.1 and 5.2 children per 1,000, respectively), followed by children younger than 1 year (4.6 per 1,000) and those aged 3 years (4.5 per 1,000) (9). Ninety percent of fatal child abuse and neglect occurs among children younger than 5 years, and 41% occurs among infants (10). In the United States, the highest rates of abusive violence toward children were found among families located in the East; families whose annual income was below the poverty line; families in which the father was unemployed: families in which the caretakers held blue collar jobs; families with four or more children; caretakers who used drugs at least once; families with male children; and children aged 3 to 6 years (11).
Rates of substantiated sexual abuse increase with age up to 14 and 15 years, whereas rates of substantiated emotional abuse and neglect were highest for those age 1 and younger (9). Girls are the subjects in the majority (75%) of sexual abuse cases; both sexes were the subjects in a nearly equal number of cases of neglect, physical abuse, and emotional abuse (9). In The Netherlands, where voluntary notification exists, an “extraordinary increase” was found in cases of emotional maltreatment during the 10-year period of 1974 to 1983, and sexual abuse was more recognized during that period, accounting for 7.2% of detected cases of maltreatment in 1983 (12).
Reports of child abuse and neglect come mainly from friends or neighbors (17% of finalized cases) or parents (14%); however, the reports of friends and neighbors have one of the lowest rates of substantiation. Importantly, although the child is one of the sources reporting least often, it provides one of the highest rates of substantiation (9).
The long-term effects of child maltreatment are becoming evident. A history of abuse among adolescent boys is predictive of serious drinking problems (13). Identifying high-risk youths and their families can effectively address the youth’s problems and troubled behavior before drug use and delinquent careers
become firmly established (14). Early detection and reduction of some forms of abuse can produce long-term cost benefits within the public health system. Female patients older than age 15 who experienced childhood sexual abuse reported more problems with respiratory, gastrointestinal, musculoskeletal, neurological, and gynecological functions than a control group (15). Furthermore, 65% of women outpatients with chronic mental illness reported a history of some type of abuse or neglect as a child (16).
become firmly established (14). Early detection and reduction of some forms of abuse can produce long-term cost benefits within the public health system. Female patients older than age 15 who experienced childhood sexual abuse reported more problems with respiratory, gastrointestinal, musculoskeletal, neurological, and gynecological functions than a control group (15). Furthermore, 65% of women outpatients with chronic mental illness reported a history of some type of abuse or neglect as a child (16).
Exposure to physical or sexual abuse has been associated with a significantly increased risk of suicide attempts for chemically dependent male adolescents but not for female adolescents (17). Among the general Australian population, men between the ages of 15 and 24 are more likely to take their own lives, and in Tasmania, the Australian state with the highest suicide rate (20.7 per 100,000), just <11% of telephone calls to a “Kids Help Line” involved physical or sexual abuse (18,19). Although we do not yet know how many of the suicides among a normative population are preceded by a history of maltreatment, abused children are at specific risk of developing depression, suicidal tendencies (20), and borderline personality disorder (21). There is also an increased risk of subsequent substance abuse in maltreated children. A study of psychiatrically hospitalized, dually diagnosed, adolescent substance abusers found that 61% had a history that warranted suspicion of past or current maltreatment, most commonly physical abuse, followed by sexual abuse and neglect (22).
TYPES OF MALTREATMENT
In broad terms, the abuse of children may be physical, sexual, or deprivational, or may take the form of neglect (23). In specific terms, child abuse may take a variety of forms, ranging from extreme physical violence to nutritional deprivation. Furthermore, abuse is rarely a single incident but rather a pattern of behavior that is repeated over time. The longer it continues, the more serious the effects on the child, the family, and the community.
On the surface, that which constitutes child abuse may seem obvious, but, in fact, the diversity of opinion as to definition at the “lesser end of the scale” contributes to a significant diagnostic dilemma. The definition of what constitutes abuse varies widely from culture to culture, making a “standard international” approach to the problem enigmatic. Nevertheless, an excellent broad definition has been formulated by the South Australian Police Department for use by their Victims of Crime Section (24). The definition states:
“Child abuse is any non-accidental act of omission or commission that endangers or impairs a child’s physical or emotional health and development.”
Although this definition incorporates the widest possible characteristics of child abuse, greater specificity is required for each category of abuse for there to be useful guidelines for health care providers who are faced with the invidious task of deciding whether to initiate the intervention process.
Physical Abuse
Physical abuse is any non-accidental physical injury inflicted on a child by a parent or caregiver. Non-accidental injuries may include beatings, burns, scalds, ruptured spleens, hematomas, retinal hemorrhages, fractures, poisoning, bruises, welts, brain damage, and suffocation.
Emotional Abuse
This form of abuse may be defined as the continual rejection or scapegoating of a child through humiliation, name-calling, coldness, or open hostility. Emotional abuse may range from ignoring the child to the induction of psychopathology through verbal threats and psychologic terrorism.
Psychological maltreatment has been defined by Garbarino in terms of caregiver behavior that thwarts the meeting of the needs of the child. Garbarino (25) demonstrates that psychological maltreatment can be evident in five forms: rejecting by sending messages of rejection to the child; ignoring by being psychologically unavailable to the child; terrorizing by using intense fear as a weapon against the child; isolating by removing the child from normal social relationships; and corrupting by socializing the child into self-destructive and antisocial patterns of behavior.
High anxiety has become a common problem among children, more so than previously determined. Recent studies have shown that, on average, one in just eight children suffer from anxiety disorders (26). These may be attributed to the rise in the number of fractured families, feelings of failure, and school or internet bullying.
Affecting a third of all students, bullying has become a major source of stress for school-age children. Reportedly more than 160,000 children will miss at least one day of school because of emotional abuse. When asked, most children admitted to being afraid to tell an adult out of fear of repercussions, in effect enabling the abuse to continue and not breaking the stress cycle (27).
“Hyper-parenting” is a phrase that has been coined to describe a dangerous trend in child rearing in middleand upper middle-class homes. In these families, parents become overly involved in every detail of their children’s academic, athletic, and social lives, unnecessarily augmenting their environment and over-scheduling them. In a vain attempt to raise the perfect child, they
add unnecessary stress by not allowing these children needed down-time.
add unnecessary stress by not allowing these children needed down-time.
The subliminal message being sent is that these children are inadequate in their current state. They convince themselves that if they were acceptable just as they are, then they wouldn’t need all of this extra enrichment. They begin to feel inadequate or inferior and begin to disassociate from the family unit, which adds to their emotional distress (28).
Recent studies have determined that depression among children is on the rise; about 20% of all teens experience some form of clinical depression. Unfortunately, fewer than 33% of this number will seek help and 30% will later develop a substance abuse problem (29).
Sexual Abuse
Child sexual abuse happens when an adult or someone bigger and/or older than a child involves a child in sexual activity by using his or her power over a child or taking advantage of the child’s trust. Often tricks, bribes, threats, coercion, and sometimes physical force are used to make a child participate in the activity.
Child sexual abuse includes a range of sexual activity, such as exhibitionism; fondling genitals; oral sex; vaginal or anal penetration by a finger, penis, or other objects; and even coercion into prostitution.
Neglect
Neglect is a failure on behalf of the caregiver to provide a child with adequate nutrition, medical care, clothing, shelter, or supervision to such an extent that the child’s health and development are impaired or placed at serious risk. A child may further be defined as neglected if left uncared for or unsupervised for long periods, either inside or outside the home. Neglect is usually a “sin of omission” rather than an overt act of commission, but this depends on jurisdiction.
Physical neglect, compared with the other types of abuse, is the most predictable and distinguishable (30). Although the general rule of thumb is that non-accidental injury and child maltreatment know no social, economic, or racial boundaries, recent studies using exploratory logistic regression models suggest that physical neglect is most clearly related to economic factors such as low-income and Aid to Families with Dependent Children status, regardless of race (30).
Other Abuse
Unusual and bizarre forms of child abuse have been reported, including the extraction by parents of their children’s permanent incisors as a punishment for misdemeanors (31). Also, sadistic ritual abuse, including satanic cult abuse, is now emerging as a syndrome among people with severe dissociative disorders, including multiple personality disorder. Sadistic ritual abuse remains highly controversial but should not be dismissed as a possible clinical differential in cases of adolescent and child victimization (32).
Non-accidental injury and maltreatment are accepted as being inflicted within the family situation; however, as recent evidence from Romania demonstrates, devastating victimization of children can occur within government-operated institutions. A health team working in an institution for intellectually challenged children in Romania diagnosed many children with undernourishment, retarded growth, skin infections, injuries, and untreated physical deformities. Some of these children were in urgent need of medical attention and, sadly, children with cerebral palsy and motor, auditive, and visual challenges were not given attention (33). This type of maltreatment is social neglect and it results in children who display signs of deprivation, anxiety, and behavioral maladjustment. Further tragic cases of social neglect will be uncovered as more chiropractors commit their professional services to Third World countries.
It can also be a mistake to think the “out-of-home” placement system in Western societies is always safe for children and adolescents. Cases of physical abuse, sexual abuse, and neglect in foster homes, group homes, residential treatment centers, and institutions have been reported (34). In these environments, physical abuse is the most frequent cause of injury, and reports of sexual abuse are most likely to be confirmed. Prior allegations of abuse or neglect regarding the perpetrator were indicated in 27% of reports (34).
Third World countries have unique types of abuse; however, the literature tends to be based on studies of Western societies, and reliable, peer-reviewed, and indexed reports of problems in other societies are only now becoming available. For example, a study of child abuse and neglect in northern Nigeria, a Third World state, has shown that some children are exploited by poor families through street begging, perhaps because the laws that exist to protect minors and prevent street begging by children are seldom enforced (35).
Self-inflicted intentional injury (such as assault or suicide attempts) is also a form of abuse that must be considered in clinical practice, particularly with adolescent patients. The average annual incidence of intentional injuries treated in the hospital was 76.2 per 10,000 person years, and 11.4% of these were self-inflicted (36). The chiropractor needs to be aware that self-inflicted injury does not always result in hospital attendance; for example, a 16-year-old girl in the practice of one of the authors presented with multiple small, circular lesions
on her forearms. A directed history revealed these were the result of her burning herself with a cigarette in an attempt to balance out the pain her behavior during early adolescence had caused her mother, a history that was confirmed by her older sister. This type of adolescent behavior is usually transient; however, a small percentage will repeatedly inflict injury on themselves. Recent statistics have shown that more 10% of all teenagers self-mutilate; of this number, 64% “cut.” Contrary to popular opinion, self-mutilation is not an attempt at suicide and generally those attempting suicide will not use their preferred method of self-harm.
on her forearms. A directed history revealed these were the result of her burning herself with a cigarette in an attempt to balance out the pain her behavior during early adolescence had caused her mother, a history that was confirmed by her older sister. This type of adolescent behavior is usually transient; however, a small percentage will repeatedly inflict injury on themselves. Recent statistics have shown that more 10% of all teenagers self-mutilate; of this number, 64% “cut.” Contrary to popular opinion, self-mutilation is not an attempt at suicide and generally those attempting suicide will not use their preferred method of self-harm.
Self-mutilation reportedly is a coping mechanism used by teenagers to help them deal with feelings of anger or anxiety; statistically, it is as common among teenagers as eating disorders, with four out of five selfinjurers being young women (37).
CHARACTERISTICS OF NON-ACCIDENTAL INJURY AND MALTREATMENT
Child maltreatment is the outcome of many interacting factors that affect parental capabilities, including stress (6). However, given the continuum along which maltreatment ranges—from mild sibling violence to child murder—it is challenging to try to determine what degree of physical injury is necessary before an act is determined to be abusive (38). In some jurisdictions, if abuse is suspected, it is to be reported.
Some sociological indicators may be of assistance. For example, in Finland, severe violence was perpetrated more frequently by fathers, and the highest incidence of severe violence was found among youth living in families with a stepfather (39). Unemployment within a family tended to increase both mild and severe violence. However, besides studies that suggest a higher incidence of abuse among certain populations, the astute clinician will realize that non-accidental injury and maltreatment can affect a child regardless of his or her age, sex, socioeconomic class, or geographic location (40).
Although maltreatment crosses all social boundaries, there are some risk factors (41). These include young maternal age, an unwanted pregnancy, a history of family disturbance, foster care, and poverty (41). Some knowledge of stressors within the family environment of the child patient may assist the clinician who suspects maltreatment. Three stress indicators, namely “trouble with teenagers,” “violence and separation,” and “public assistance,” were identified in a study of 151 parents of abused children (42).
Notwithstanding the frank effects of physical abuse on the musculoskeletal system, which are discussed in this chapter, the chiropractor is also likely to detect the sometimes subtle neurological signs that attend abuse by nutritional deprivation. Vitamin B12 deficiency has been related to maltreatment by abnormal eating habits. Of two reported cases from The Netherlands, one was a 2-year-old girl with neurodevelopmental regression and macrocytic anemia as a result of the combination of maternal deficiency and inadequate feeding after birth. The other was a 14-year-old obese girl with severe polyneuropathy and mild macrocytic anemia as a result of a bizarre feeding pattern adopted subsequent to her being the victim of child abuse (43).
The injuries associated with physical abuse may involve any anatomic focus and organ system, although most of these injuries cannot serve as definitive evidence of maltreatment. It is vital to retain a high index of suspicion and an awareness of the patterns of injury commonly observed in abused infants and children. The less familiar intracranial and abdominal injuries must be thoroughly evaluated for possible abuse when circumstances suggest maltreatment or when no plausible explanation is given for the radiologic findings (44).
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