Physical abuse and neglect of children

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Physical abuse and neglect of children Howard Dubowitz, Susan Bennett

Child maltreatment includes physical abuse and neglect, and happens in all countries and cultures. Child maltreatment usually results from interactions between several risk factors (such as parental depression, stress, and social isolation). Physicians can incorporate methods to screen for risk factors into their usual appointments with the family. Detection of physical abuse is dependent on the doctor’s ability to recognise suspicious injuries, such as bruising, bite marks, burns, bone fractures, or trauma to the head or abdomen. Neglect is the most common form of child maltreatment in the USA. It can be caused by insufficient parental knowledge; intentional negligence is rare. Suspected cases of child abuse should be well documented and reported to the appropriate public agency which should assess the situation and help to protect the child.

Definitions of maltreatment

Risk factors

The abuse and neglect (or maltreatment) of children is a worldwide problem, although its manifestations and extent vary. It is far more prevalent than is generally recognised. Child maltreatment has short-term and long-term physical, psychological, and social consequences.1–3 Professionals concerned about children’s health and safety have an important part to play to address this problem;4,5 many physicians see their main responsibilities as identification and reporting of child maltreatment, although they could also have a role in prevention, treatment, and advocacy.6 Physical abuse by parents or caregivers includes beatings, shaking, scalding, and biting. Although some forms of corporal punishment are widely accepted,7 many people think of any injury beyond immediate redness as abuse. However, harm might not be immediately evident, thus concerns about potential harm justify consideration as possible maltreatment.8,9 Child neglect is omission of care, such as health care, education, supervision, protection from environmental hazards, meeting physical needs (eg, clothing or food), and emotional support, resulting in actual or potential harm.10 Alternatively, neglect from a child’s perspective is not adequately meeting a child’s basic needs, regardless of the reasons.8,11 Several factors can contribute to neglect, such as parental depression, a child’s disability, family violence, or an absence of community resources. Full comprehension of the problems underpinning neglect helps interventions to be tailored to the specific needs of the child and family.10,12

Child maltreatment seldom results from one cause; rather, many risk factors usually interact.14–16 Factors such as child’s disability17 or a parent with depression18 predispose children to maltreatment. Within a family, intimate partner violence19 increases children’s risk of abuse. In communities, factors such as dangerous neighbourhoods or poor recreational facilities increase risk.20 Societal factors, such as poverty and associated burdens contribute substantially to risk of maltreatment.21 However, children in all social classes can be maltreated, and physicians need to guard against biases toward low-income families.22

Prevalence of child maltreatment Measurement of child maltreatment is inherently difficult, since it is rarely seen directly by people outside the immediate family, and is often unreported. However, data show that child abuse and neglect are not rare.13 Child maltreatment happens in all countries and in families of all racial and religious groups. Different laws and child welfare systems, however, preclude comparisons across countries. Physicians and others can be reluctant to become involved. Thus, cases reported to child welfare agencies probably represent the tip of the iceberg.

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Lancet 2007; 369: 1891–99 See Comment page 1844 Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD 21201, USA (Prof H Dubowitz MD); and Department of Pediatrics and Psychiatry, University of Ottawa, Ottawa, Canada (S Bennett FRCP) Correspondence to: Prof Howard Dubowitz [email protected]. edu

Protective factors. By contrast, some resources buffer the effect of risk factors and protect children from maltreatment. Clinical experience suggests that protective factors include parental recognition of problems seeking help, a supportive grandparent, and accessible mental-health care. Child maltreatment generally results from a complex interplay between risk and protective factors. For example, a single mother with a colicky baby who has recently lost her job is at risk of maltreating the child, but presence of a loving grandmother might prevent abuse or neglect. Full understanding of factors contributing to maltreatment, and of a family’s strengths, is key to effective intervention.

Search strategy and selection criteria We searched Medline from 1966 to October, 2005, Embase from 1980 to November, 2005, and the Evidence Based Medicine Reviews Multifile (EBMZ) to the end of 2005. We searched for “child abuse” in conjunction with ”physical” and ”neglect”. We filtered our results to exclude reports published before 1995, those not relating to people, and material not published in English. We subdivided the articles identified in our search into the categories skin trauma, neurotrauma, burns, and abdominal trauma. Articles about neurotrauma were sought with the terms “shaken baby syndrome”, “brain injury”, and “craniocerebral trauma.” Additionally, we reviewed the Child Abuse Quarterly reviews of research on child maltreatment and searched the journal Child abuse and neglect from Jan 1, 2000, to Dec 31, 2005.

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Prevention

See Online for webappendix

Generally, medical responses to child maltreatment happen after maltreatment has taken place; prevention is preferable. Physicians can help in several ways.23,24 A continuing relationship with a family offers opportunities to develop trust and knowledge of their circumstances. Astute observation of parent-child interactions can reveal useful information. For example, does the relationship seem warm and comfortable or tense and hostile? Parent education about medical disorders helps to ensure implementation of treatment;25 barriers to treatment should be addressed. Simple strategies such as writing down the treatment plan can help. Additionally, parenting advice might help with child rearing, thus diminishing the risk of maltreatment. Hospital-based programmes for parents of newborn babies educating about infant crying and risks of shaking seem to prevent abusive head trauma.26 Screening for risk factors and tackling known problems (often via referral to social or mental-health services) can strengthen families and reduce maltreatment. This role for the physician fits well with a broad view of health, and a professional mandate to help to ensure children’s health and safety.27 Check-ups (preventive care) offer opportunities to screen for psychosocial disorders. The review of systems is standard in such visits. Its traditional focus on organ systems can be expanded to subjects such as feelings about the child, the parent’s own functioning, possible depression, substance abuse, intimate partner violence, disciplinary approaches, and stressors and supports. One approach is to systematically ask parents to complete a brief questionnaire about psychosocial issues while they are in the consulting room (webappendix). This request should be phrased constructively with an empathic tone, and build on longstanding concern for children’s safety. By starting a dialogue with topics familiar to physicians and parents, such as the presence of smoke detectors, the physician might be able to steer the conversation towards sensitive topics, such as drug use. Any concerns raised by such screens need at least brief assessment and initial management. This management could include a referral for further assessment and treatment. Frequent surgery visits can be scheduled for support and counselling, and to monitor the situation. Physicians can advocate for promising interventions in the community. In some studies,28,29 programmes that arrange home visits by nurses improved parental and family functioning and diminished the risk of child maltreatment, although evidence for their effectiveness has been mixed. Efforts and resources to help to ensure adequate nutrition and health care, and to address important risk factors such as parental depression or substance abuse are needed to strengthen families and enhance the health, development, and safety of children.

Assessment and diagnosis Detection of physical abuse is dependent on the clinician’s ability to recognise suspicious injuries, do a 1892

careful and complete physical examination with the judicious use of ancillary tests, and to consider whether the history reasonably explains the physical findings. Absence of explanation for the injury, changing explanations, or one that is inconsistent with the child’s developmental capabilities raises concern about abuse, as does delay in seeking medical care. A detailed medical history should include previous trauma, admissions to hospital, chronic illness, and adherence to treatment. A family history of easy bruising or fractures is important to elicit. Questions about substance or alcohol abuse, mental illness, intimate partner violence, discipline practices, stressors, or previous involvement of child protection services can be difficult to ask, but provide valuable insight into a family’s functioning. Careful documentation, ideally with photographs, is necessary. An interdisciplinary approach is the best way to assess all possible risk factors; many hospitals have developed interdisciplinary teams for this purpose. Bruises are the most common manifestation of physical abuse.30–32 Maguire and colleagues.33 reviewed what patterns of bruising are diagnostic or suggestive of abuse. They identified differences between bruises that were not inflicted (accidental bruising) and those due to abuse. The frequency, number, and location of some bruises are linked to motor development. Bruises in infants younger than 9 months and who have not started walking should lead the physician to consider abuse or illness as likely causes.34–36 Accidental bruises are characteristically anterior and over bony prominences, such as shins and forehead,34–36 usually due to falls.37 Well padded areas are unlikely to be bruised in the course of most childhood activities. Thus, bruises of buttocks, cheeks, and thighs suggest abuse.38 Some sites seldom get bruised in the course of children’s activities (ie, neck, ear, and genitalia). If an implement was used, bruises can carry an imprint. Many factors affect the colour of a bruise, including the depth of the injury, location, force of impact, vascularity of tissues, time since injury, skin colour, and ambient lighting. Physicians might be asked to estimate the age of a bruise to identify possible perpetrators, to corroborate explanations for injuries, or to confirm that injuries happened at different times. However, to precisely date bruises is difficult.39 Occasionally an underlying medical explanation for bruises exists—for example, idiopathic thrombocytopenic purpura, leukaemia, coagulation disorders, or connective tissue disorders such as Ehlers-Danlos syndrome or osteogenesis imperfecta.40,41 Clues to suggest such a disorder should lie in the child’s history and examination. Henoch Schönlein purpura, the most common vasculitis in young children, could be confused with abusive injury. Physicians should realise that the presence of a medical disorder does not preclude abuse. Cultural practices need to be considered in the differential diagnosis. Cao Gio,42 commonly known as “coining,” is a southeast Asian dermabrasion therapy and causes linear petechiae. Birthmarks and Mongolian spots can be www.thelancet.com Vol 369 June 2, 2007

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confused with bruises.40,41,43,44 These marks are not tender and do not rapidly change colour or size. Bite marks have a characteristic pattern of one or two opposing arches with multiple bruises. They can be inflicted by an adult, another child, an animal, or by the patient. Bites by animals vary, but they usually have narrower arches than human bites, and are often deep. Self-inflicted bites are limited to accessible areas, especially the hands. Adult bites generally have more than an inch between the canines, and often cause the most prominent bruises. Many bites by another child suggest inadequate supervision and neglect. Distinction between adult and child bites is often difficult, and consultation with a forensic dentist can be helpful to identify the source of the bite.45 Photographs with a size standard are essential, and swabbing with sterile water or saline might recover genetic markers in saliva.44,45 Childhood burns are frequently due to abuse.46 Many other burns happen because of inadequate supervision or neglect. The pattern or distribution of the burn can reveal the probable mechanism. Immersion burns, when a child is forcibly held in hot water, have clear delineation between the burned and the healthy skin, uniform depth, and might look like a sock or glove. There are often no splash marks since the extremity is held in the hot water.47 Symmetrical burns are especially suspicious,48 as are burns of the buttocks and perineum.49 Burns from hot objects such as curling irons, radiators, steam irons, metal grids, hot knives, and cigarettes have shapes that mirror those of the object. There are some unusual causes of abusive burns such as hair dryers, microwave ovens,50 and stun guns.51 Neglect frequently contributes to childhood burns.52 Children, left at home alone, can be burned in house fires. A parent who has taken illegal drugs could cause a fire and be unable to protect a child. Children might pull hot liquids on to themselves while they are exploring their environment.53,54 Because spilt liquids cool quickly, such a burn is usually most severe and broad around the point of contact. Children might insert objects into an electrical outlet, usually resulting in no external burn, unless the child touched the electrical source. Burns from electric water heaters sometimes happen.55 Several circumstances mimic abusive burns, such as brushing against a hot radiator, car seat burns, enuresis blanket marks, impetigo, and folk remedies such as moxibustion.46,56 Impetigo can resemble cigarette burns, but cigarette burns are usually 7–10 mm across;57 impetigo has lesions of varying size. Accidental cigarette burns are usually oval and superficial. Establishing whether a burn was inflicted is dependent on the history, burn pattern, and the child’s capabilities. A delay in seeking health care could be because the burn initially seemed minor, before blistering or becoming infected. Outside agencies should be consulted to corroborate the history and investigate the scene (eg, testing the water temperature). Severe burns can lead to lifelong scarring and serious psychosocial sequelae.58 Prevention is key, such as setting hot water cylinders under 125°C.59,60 www.thelancet.com Vol 369 June 2, 2007

Bone fractures are the second most common presentation of physical abuse after soft tissue injuries.31 No one lesion is absolutely a characteristic of abuse; however, some strongly suggest abuse (panel 1).61 Although fractures in a child aged less than 1 year are highly suspicious of abuse,62–66 spiral or oblique fractures of the lower limb have been described in infants playing in static activity centres,67 and hairline fractures can take place in the tibia of newly walking toddlers.68–75 The classic metaphyseal lesion (bucket handle fracture) usually suggests abuse, although it has been identified in children treated for equinovarus deformity76 and after a difficult delivery or caesarean section.77 Rib fractures are unusual in accidental trauma, even in motor vehicle crashes and falls from heights of more than 1·8 m.78–80 Rib fractures in children without mineral deficiencies are very rare after cardiopulmonary resuscitation.79,81–86 Chest physiotherapy rarely results in rib fractures.87 Rib fractures are unusual in healthy full-term infants as birth injuries, and usually occur in large babies (weighing more than 3300 g) and in difficult deliveries.79,88–90 Skull fractures happen in only 1–3% of children after falls from heights of less than 1·8 m and are usually linear, narrow, and uncomplicated. Many or complex fractures of both sides of the skull and depressed or growing fractures (leptomeningeal cysts) are typical of abuse.91–93 Skull fractures with intracranial injury in infants are usually due to abuse,94 although simple skull fractures could have a thin adjacent subdural haematoma. Subperiosteal new bone could suggest trauma, but also occurs in several disorders.61,95–97 Physiological periosteal reaction is normally seen in children aged between 6 weeks and 6 months, and is generally symmetrical.98,99 Panel 1: Types of fracture by specificity for diagnosis of abuse61 High Classic metaphyseal lesion Rib (especially posterior) Scapula Spinous process Sternum Moderate Several fractures, especially if bilateral Fractures of different ages Epiphyseal separations Vertebral body fractures Digital fractures Complex skull fractures Low Subperiosteal new bone formation Clavicular fractures Long-bone shaft fractures Simple skull fractures

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The differential diagnosis of fractures due to abuse includes non-inflicted injury, trauma during delivery,100–102 osteogenesis imperfecta, rickets, copper deficiency, Caffey’s disease, congenital syphilis, osteopenia of infancy, osteomyelitis, and normal variant.103–107 Osteogenesis imperfecta is usually a clinical diagnosis, but skin biopsy for collagen analysis might be needed if examination is not definitive.103 If any question about the correct diagnosis remains, the child should be placed in a protected environment while awaiting test results. Temporary brittle bone disease remains unproven and is not accepted as an explanation for fractures by most child abuse experts.108 The American Academy of Pediatrics109 recommends a mandatory skeletal survey in all cases of suspected physical abuse in children aged under 2 years. Follow-up skeletal surveys 10 or more days later can help to detect occult fractures that might not have been apparent on first images.110,111 Similarly, a bone scan might detect occult fractures early on.112 Dating of fractures is an inexact science and clinicians should bear this in mind when offering time frames of injuries to investigating agencies or courts. However, radiologists can clearly differentiate recent fractures from old ones. Such differentiation remains invaluable in identification of children who have been subjected to repeated abuse, or whose injuries are shown to be inconsistent with given explanations.113 Abusive head injuries result from mechanisms including shaking, direct impact, penetration, and asphyxiation or hypoxia, alone or in combination. Hence, the term abusive head trauma is recommended. Although abusive head trauma is usually seen in infants, it is also seen in older children and adults.114–116 Results of studies strongly accord with the contention that adults do shake infants, and that shaking alone can cause widespread brain injury.117 Abusive head trauma can result from frustration associated with a baby’s crying or irritability.118 The adult usually holds the infant by the chest so they face each other, compressing the chest while violently shaking the infant to and fro. In some instances, the infant’s head is also slammed against a hard surface. The exact force needed to cause shaking injuries is difficult to quantify. However, the American Academy of Pediatrics stated that such shaking is so violent that individuals observing it would recognise it as dangerous and likely to kill the child.119–123

Panel 2: Differential diagnosis of subdural haemorrhage in infants and children129 • • • • • • • •

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Accidental or abusive trauma Birth trauma130,131 Congenital malformations (eg, arteriovenous malformation) Coagulopathies (eg, vitamin K deficiency in newborn babies, disseminated intravascular coagulation, haemophilia) Infection (eg, septicaemia, meningitis, and necrotising encephalitis) Metabolic disorders (eg, glutaric aciduria type 1,132 osteogenesis imperfecta) Tumour Vasculitis (eg, Kawasaki disease)

The characteristic findings of abusive head trauma, include subdural haemorrhage, retinal haemorrhages, and brain injury, particularly diffuse axonal injury, but these might not all be present. External signs of head trauma such as swelling, bruises, and skull fractures are sometimes present. Signs of trauma elsewhere, such as bruises, and rib or long bone fractures might be present.122–124 Signs and symptoms of abusive head trauma vary from none to mild and non-specific, and to severe and life-threatening. Poor feeding, emesis, lethargy, and changes in neurological status (including limpness, irritability, seizures, and coma) and respiratory changes (including apnoea) have been reported.125,126 Consequently, the diagnosis of abusive head trauma could be missed and physicians need to be mindful of subtle manifestations.127 Publications about this subject generally suggest that severe abusive head trauma almost always results in the rapid onset of clinically significant signs or symptoms.128 Panel 2 shows the differential diagnosis of subdural haemorrhages.133 A detailed medical history, laboratory tests, and imaging will exclude many of the rare or obvious disorders. Eye examination by an ophthalmologist with indirect ophthalmoscopy and dilated pupils (using eye drops unless pupils are fixed and dilated because of neurological state) is essential to properly assess the retina. Retinal haemorrhage is seen in about 85% of abusive head trauma cases,134 and can be unilateral or bilateral. The detailed characteristics of retinal haemorrhage are important for elucidation of the cause. Multiple retinal haemorrhages that extend to the peripheral retinal edge, and that affect several layers of the retina strongly suggest abusive head trauma. Traumatic retinoschisis can take place, with or without perimacular retinal folds. Such folds are usually confirmation of abusive head trauma from shaking, although a case report described crush injury of the head as a potential alternative mechanism.135 However, other studies of crush injury have not accorded with this finding.136 Retinal haemorrhages are reported occasionally in patients with non-inflicted head injury.137 Less common causes of such haemorrhage include meningitis, HenochSchönlein purpura and other vasculitides, glutaric aciduria, thrombocytopenia, and profound anaemia. However, in such situations the haemorrhages are few and confined to the posterior pole. Substantial retinal haemorrhages are not caused by cardiopulmonary resuscitation. These bleeds are seen in 40% of newborn babies after vaginal delivery, but superficial retinal haemorrhages at birth resolve in less than 2 weeks and deeper intraretinal haemorrhages resolve within 6 weeks.134 CT remains the initial imaging modality for the child with possible abusive head trauma. It is better suited for detecting cerebral oedema and subarachnoid haemorrhage than is MRI. MRI is a useful adjunct to CT, although it might not be possible in unstable patients, and is less sensitive in detection of subarachnoid blood and skull fractures than is CT. MRI can detect intraparenchymal lesions such as shearing injury and subdural haematomas www.thelancet.com Vol 369 June 2, 2007

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better than CT, and therefore should be considered several days after initial CT scans. Caution should be exercised in dating of subdural haematomas with either CT or MRI.61 In 2005, the Court of Appeal of England and Wales, after hearings about convictions for child abuse featuring infants and toddlers with head injuries, concluded that the triad of injuries (subdural haematomas, retinal haemorrhages, and encephalopathy) can be seen in cases of abusive head trauma, but are not necessarily diagnostic of abuse.138 The cases were reviewed because of reports published in medical journals including the work of Geddes and colleagues.139–141 In these reports, investigators postulated that hypoxia and increased intracranial pressure could account for retinal and subdural haemorrhages, even in the absence of impact or substantial force. This work was refuted by Geddes during the trial, in which she acknowledged that the investigators discussed unproven, hypothetical causes of subdural and retinal haemorrhages. The Court of Appeal stated that in their opinion, the Geddes hypothesis could no longer be regarded as a credible or alternative cause of the triad of injuries. Abdominal trauma accounts for substantial morbidity and mortality in abused children.142 Young children are especially vulnerable because they have large abdomens and lax abdominal musculature. Hollow organs can be ruptured by a blow or kick, and solid organs such as the pancreas can be injured, especially over the spine. Bleeding could result from trauma to an organ or from shearing of the vascular supply. Children can present with cardiovascular failure, often after a delay in care or diagnosis.142 Bilious vomiting in a young child without fever or peritoneal irritation suggests a duodenal haematoma, often due to abuse. Indeed, any of the abdominal organs can be injured as a result of abuse.143 The manifestations of abdominal trauma are often subtle, even with severe injuries. Bruising of the abdominal wall is unusual. Damage can evolve slowly; there can be delayed perforation days after the injury, or bowel strictures, or a pancreatic pseudocyst weeks or months later. Timing of an abdominal injury is especially difficult. Subtle presentations call for suspicion of abdominal trauma if other evidence of physical abuse is present. Physicians should screen urine and stool samples for blood, and check liver144 and pancreatic enzymes.145 A screening abdominal ultrasound should also be considered,145 although CT is preferable for detection of trauma to solid organs.142 Possible accidental mechanisms of injury, such as trauma in a bicycle handlebar injury should be considered. But, caution is needed in acceptance of unlikely explanations. Huntmer and colleagues147 noted no evidence that a fall down stairs led to small bowel perforation. Minor falls are also an unlikely explanation.148 Neglect is the most prevalent form of child maltreatment in the USA,21 with potentially severe and longlasting sequelae.149 Neglect has several manifestations that physicians might encounter. Initial questions a physician should consider are: Is this neglect? Have the circumstances www.thelancet.com Vol 369 June 2, 2007

Panel 3: Manifestations of possible health-related neglect • • • • • • • •

Non-adherence to treatment, jeopardising the child’s health Delay or failure in obtaining health care—medical, mental, or dental Non-organic failure to thrive or severe obesity that is not being addressed Recurring injuries or ingestions suggesting inadequate supervision Drug-exposed newborn babies and children Exposure to environmental hazards—in and out of the home Poor hygiene or sanitation Inadequate attention to children’s emotional and cognitive needs

harmed the child, or jeopardised the child’s health or safety?150 For example, adherence to a treatment plan might be less than ideal, without clearly impairing a child’s health. Inadequacies in the care children receive naturally fall along a continuum, so a range of responses should be tailored to the individual situation. Legal or public agency guidelines could discourage physicians from labelling many circumstances as neglect. They can still intervene to help to ensure that children’s needs are adequately met.151 There are usually many interacting factors that contribute to neglect (panel 3). This situation demands a comprehensive assessment of possible underpinning problems—with child, parent, family, and community.151 The system of health care should also be examined. Are there barriers to health care? Does a difficult or antagonistic relationship exist between the physician and the parent or the child, or both? For example, poor adherence to treatment for asthma could be due to the parent not understanding the treatment plan; the physician might not have communicated the plan clearly. Care is needed to avoid the assumption that the parent is responsible. For example, a complicated medical course does not mean poor adherence to treatment. In addition to probing for risk factors, strengths and resources (protective factors) should also be assessed; these are often crucial for effective intervention. A parent’s interest to keep a child out of hospital, for example, can motivate adherence to treatment. Physicians can notice other forms of neglect. For example, a child might have inadequate clothing or the family could be homeless—situations that can affect children’s health. Children might not be enrolled in school. A child could have learning difficulties and the school’s response inadequate. A broad view of health and interest in children’s health and development includes attention to their environment. Neglect is a disparate problem that needs varied responses to address each case.

Outcomes Child maltreatment has short and long-term medical, mental health, and social sequelae.152 Children in hospital who have been abused or neglected have more severe injuries, longer hospital stays, worse medical outcomes, higher hospital charges, and are more likely to die during the stay in hospital than other children admitted to hospital.153 Children with abusive head trauma have a worse 1895

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short-term outcome than those with head trauma that was not inflicted.154,155 The above descriptions of different injuries due to abuse suggest their sizeable morbidity and mortality. Physically abused children are at risk of developing behavioural and functional difficulties, including conduct disorders, aggressive behaviours, decreased cognitive functioning, and poor academic achievement.156,157 Neglect is similarly associated with many potential problems.149 In adulthood, maltreatment is associated with an increased risk for several health risk behaviours and physical and mental health disorders.158 Maltreated children are at risk of becoming abusive parents.159 Preliminary research has shown persistent neurobiological effects of abuse on the developing brain, which could account for some of these sequelae.160,1161 Some children seem to be resilient and might not manifest sequelae of maltreatment, perhaps because of protective factors or interventions. The benefits of intervention have been seen in even the most severely neglected children, such as those from Romanian orphanages, who were adopted. Early intervention brings the greatest benefit.162

Reporting and documentation Many countries have laws mandating physicians and others to refer suspicions of child abuse or neglect to designated public agencies. The referer does not need to be certain that maltreatment has taken place. The amount of suspicion that meets the threshold for reporting might be a judgment call. Consultation with an interdisciplinary team that is expert in child maltreatment, a paediatric expert, or the public agency, can help to make this decision. Reporting of child maltreatment is not easy.163,164 But ensuring the child’s safety is the priority, and reporting could be life-saving. Parental inadequacy or culpability is at least implicit, perhaps evoking anger. Physicians should inform families directly of their concerns and their report in a supportive manner. The referral can be explained as an effort to clarify the situation and provide help, or as a professional (and legal) responsibility. To explain what the ensuing process will probably entail is useful. Ideally, physicians should work cooperatively with the public agency to help ensure children’s and families’ needs are met. Clear and comprehensive documentation is especially important because of the possible legal ramifications.165,166 Key statements or quotes should be copied verbatim, including the question that prompted the investigation. Physicians often avoid documenting awkward information, such as a parent’s hostility toward a child or showing signs of drug abuse. However, such information can be important and should be objectively documented. Good documentation helps to ensure that crucial information is shared and contributes to appropriate interventions.

Treatment and advocacy The interventions needed depend on the specific issues contributing to a child’s maltreatment, and their sequelae, but there are some general principles that can be helpful. 1896

Physicians must know the local laws, regulations, and programmes for child maltreatment. They are responsible for addressing medical problems, and for recognising and reporting suspected maltreatment. Although they help to ensure children’s safety, decisions about out-of-home placement are the responsibility of the public agencies.167 Substitute care is sometimes needed, at least temporarily. A comprehensive assessment of the child, the parents, and the family is key to guide appropriate interventions.24 Neglect should initially be approached with unintrusive interventions.168 For example, if an infant’s poor growth is due to an error in mixing formula milk, education of the parents and home visits by a nurse should be tried. By contrast, severe failure to thrive needs hospital admission, and in some circumstances (eg, a mother with psychotic illness), out-of-home placement might be needed. If initial efforts fail, reporting to the public agency is necessary. Physicians should then try to remain involved, and offer families support and guidance. Physicians should also make a referral when other professional intervention is needed (eg, treatment for substance abuse).169 The importance of addressing families’ needs should not be overlooked. Access to nutrition programmes or help with housing, for example, can be urgent. The problems that led to child maltreatment might need long-term support and monitoring, rather than quick fixes. Advocacy on behalf of children and families can be to individuals, families, communities, and the society.170 Explaining to a parent that a hyperactive toddler is normal, albeit challenging, and offer alternatives to corporal punishment, illustrates advocacy on behalf of the child.171 Encouraging a depressed mother to accept treatment is also advocacy. Physicians’ efforts to strengthen families, such as encouraging fathers’ involvement in childcare, are forms of advocacy. In the community, physicians can be influential advocates for resources for children and families by, for example, supporting parenting programmes. Working with colleagues in child protection, mental health, education, and law enforcement, physicians can help to address child maltreatment. Finally, in society, physicians can advocate for governmental policies and programmes that support children and families.172,173 Physician advocacy fits well with a vision of improved child health in the 21st century.174 Conflict of interest statement We declare that we have no conflict of interest. Acknowledgments We thank Raymond Daniel for help with searches of published work for this paper. References 1 Bifulco A, Bernazzani O, Moran PM, Jacobs C. The childhood experience of care and abuse questionnaire (CECA.Q): validation in a community series. Br J Clin Psychol 2005 November; 44: 563–81. 2 Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry 2003; 160: 1453–60. 3 Schuck AM, Widom CS. Understanding the role of neighborhood context in the long-term criminal consequences of child maltreatment. Am J Community Psychol 2005; 36: 207–22.

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