Ending Gaze Aversion Toward Child Abuse And Neglect
2019; Project HOPE; Volume: 38; Issue: 10 Linguagem: Inglês
10.1377/hlthaff.2019.00573
ISSN2694-233X
Autores Tópico(s)Ethics and Legal Issues in Pediatric Healthcare
ResumoNarrative MattersViolence Health AffairsVol. 38, No. 10: Violence & Health Ending Gaze Aversion Toward Child Abuse And NeglectRichard D. Krugman Affiliations Richard D. Krugman ([email protected]) is a distinguished professor of pediatrics at the Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine, Anschutz Medical Campus, in Aurora.PUBLISHED:October 2019Free Accesshttps://doi.org/10.1377/hlthaff.2019.00573AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractFor more than fifty years, not enough has been done to tackle the national problems of child abuse and neglect.TOPICSChild abuseChildren's healthNursesEmergency departmentsMaternal healthPublic healthClinicsDiseasesMorbidityViolenceIllustration by Brett RyderI was a third-year medical student at New York University in March 1967 when C. Henry Kempe, then a forty-five-year-old visiting professor from the University of Colorado (CU), presented a grand rounds titled "The Battered-Child Syndrome." Kempe was the chair of the Department of Pediatrics at CU and a renowned infectious disease expert whose advocacy led to the elimination of routine smallpox vaccination in the US (since smallpox had not been seen in the US since 1949 and the morbidity and mortality of the vaccination exceeded the risk of smallpox infection). In 1962 he had published what would become a landmark paper in JAMA titled "The Battered-Child Syndrome." His riveting talk on child abuse led me to apply to CU for my pediatric internship, and exactly a year later I was accepted.My first night on call at the Denver General Hospital emergency department (ED) was December 1, 1968. At 8 p.m. a mother brought her five-month-old baby boy to the ED, saying that she had taken the baby to the movies, and when the lights came up, she noticed that he was not breathing. We could not resuscitate the infant, and the next morning, in the Denver Office of the Medical Examiner, we learned why. The baby had massive brain hemorrhaging, twelve fractured ribs, a ruptured liver and spleen, and a month-old fracture of the right humerus that had begun to heal. Kempe asked me to find all the medical records I could on the mother and her baby and to present the case the following week at a morbidity and mortality conference.The records started with the mother's first prenatal clinic visit to Colorado General Hospital in the eighth month of her pregnancy. Public health nurses visited all newborns in Denver at least once in those days, and one nurse who was visiting a new mother had heard that the mother's neighbor was "pregnant and depressed." The nurse brought the pregnant neighbor to the prenatal clinic at Colorado General Hospital. The record stated that the woman had gained only fifteen pounds during her pregnancy, and the OB-GYN thought that she needed to see the social worker in the clinic. The social worker was home sick, so the mother was given an appointment to come back the next day. The next sheet in the chart was for a "missed appointment," followed by the ED note a month later when she arrived in active labor.At birth, the baby was small for gestational age, and the OB nurses' notes described the woman as not interested in the baby and reluctant to feed him. The nursery nurses had similar notes and fed the baby for the mother. When it was time for discharge, there were referrals to Child Welfare, the Colorado Visiting Nurse Association, and the pediatric clinic for follow-up in one week. The next pages in the baby's chart contained a note from the public health nurse that there was "no answer at the door" and a Child Welfare message conveyed through the hospital social worker that "there was no abuse yet so there was nothing they would be doing."The next note in the baby's chart detailed an ED visit at two weeks of age. There was a five-line note in "SOAP" format: "Subjective: The mother says the baby has a rash. Objective: Normal exam. No rash noted. Assessment: Well baby. Plan: 1) Gave the mother a lecture on the appropriate use of the emergency room; 2) Told her to see the dermatologist if the rash came back."The next five pages in the baby's record consisted of a very thorough note from a medical student when the baby was brought to the pediatric clinic at two months of age. The chief complaint was "a cold," and the student provided an exquisite two-page history and two-page physical exam report, with the assessment of "upper respiratory infection," a plan of using saline nose drops and a bulb syringe, and instructions to "come back if things get worse." The student noted on his physical exam that there were two linear purple bruises on the right side of the baby's thorax and two oval bruises on the right arm. It was not clear whether these bruises were discussed with the attending physician, whose scribbled note at the end of the fifth page said "agree with above."The next note in the chart was at four months of age, this time with the complaint that the baby had not moved his right arm for two days. An x-ray showed a spiral fracture of the right humerus, and he was hospitalized. A report to Child Welfare led to a visit by a Denver detective who was the triage person for Child Welfare. "Looks like abuse to me," he said, and reported the case to Child Protective Services. The next day a report came back from the county that staff had visited the home, that it was "neat and clean," and that it was "OK to send the baby home." The next time the baby was seen was when I saw him that night at Denver General Hospital, dead on arrival.Gaze AversionAs I presented the history of this case the following week at the department morbidity and mortality conference, Kempe was putting chalk marks on the blackboard. At the end there were twenty-seven marks. "Each of these represents a professional who could have prevented the death of this baby," Kempe said. "Three people did their job: the public health nurse at the start, whoever reported the broken arm, and the detective. Everyone else failed!"I was intrigued—not just by the behavior of the mother, but by that of professionals who seemingly had done everything they could to look away from what (to Kempe) was obvious child abuse. One term for this behavior is "gaze aversion," originally used to describe a behavior seen in autistic children. Christopher Ounsted, a British child psychiatrist, applied the term to the behavior of many of his colleagues to describe their collective indifference to child abuse. Kempe experienced this when he submitted "Battered-Child Syndrome" abstracts to the Society for Pediatric Research in 1959 and 1960 and had them rejected because he had not ruled out genetic disorders to explain children's bruising and fractures. To counter this, he got himself appointed to the American Academy of Pediatrics council that organized the group's annual meeting. He presented a "Battered Child" symposium in November 1961. At the end of three hours, with presentations by a pediatrician, psychiatrist, radiologist, social worker, lawyer, and family court judge, no one asked questions. Instead, everyone filed out silently. A reporter from the Chicago Tribune wrote a story the next day, and child abuse started to get attention.Within four years every state in the US had passed legislation that made it mandatory for physicians, other health professionals, and people working with children (such as teachers and day care workers) to report any suspicion of child abuse to their local Child Protective Services agency.Unlike many of my colleagues, who hated dealing with abuse cases, I found myself comfortable with them. It was also clear that many of my pediatric colleagues believed that they were accusing parents of abuse if they asked about it. Kempe always said that "abusive parents love their children very much, but not very well," and our job was to help them parent better. He taught us to tell parents, "You and we want to be sure that whatever happened, whoever was responsible, it should never happen again." That would often let families relax (especially if they had no idea what happened to their baby, who could have been abused by someone at school or day care).Developments In The FieldAfter my residency and two years of working at the National Institutes of Health (NIH) as a member of the Public Health Service, I returned to Denver in 1973. Kempe had received a grant from the newly established Robert Wood Johnson Foundation to start the National Center for the Prevention and Treatment of Child Abuse and Neglect (named the Kempe Center for the Prevention and Treatment of Child Abuse and Neglect after his death in 1984) in the pediatrics department of the CU School of Medicine. Professionals from all over the world were coming to Denver to learn how to recognize, evaluate, and treat families affected by physical abuse and neglect. As a general pediatrician, I worked with Henry Silver, who helped launch the first pediatric nurse practitioner training program in the US, but I covered the Child Protection Team at Colorado General Hospital when Kempe was out of town.After other positions, including a year in Washington, D.C., working as a Robert Wood Johnson Health Policy Fellow in Congress, I returned to Denver, and in 1981 I became the second director of the Kempe Center. As one of about a dozen pediatricians in the US who were doing this work, I soon became known as a national and international expert on child abuse.The next nine years were a remarkable time for the field of child abuse and neglect. We had "discovered" sexual abuse as an issue, and the US was in the midst of a child abuse and neglect "emergency." Pulitzer Prize–winning articles had documented that 30–50 percent of the more than 1,600 children who died of abuse and neglect in the US each year had "open cases" with Child Welfare departments and called for more funding to hire more workers. At the same time, the science behind understanding how to diagnose sexually abused children was soft at best, and some people were unfairly convicted of sexual abuse and jailed inappropriately. Such cases led to the formation of Victims of Child Abuse Laws (VOCAL), which spearheaded a backlash against Child Protective Services with calls to shut the agencies down. Congress did what it always does when it hears opposing views: It formed a committee to study the situation and issue a report.I became the chair of that committee, the US Advisory Board on Child Abuse and Neglect, which had a broad charge from Louis Sullivan, the health and human services (HHS) secretary. We issued several reports, the first of which called the status of Child Protective Services in 1990 "a national emergency." Other reports focused on what the federal government could be doing to improve research, training, and collaboration among agencies. Congress held hearings after the first report was released and congratulated the board for its work. The Administration for Children and Families, however, was uncomfortable (we were later told) with what they perceived as a micromanaging of their mission, and the recommendations languished. Ultimately, despite federal inaction, several of the recommendations were implemented by the private sector, including home visitation services for new mothers, child fatality review boards, and programs to change the culture within neighborhoods. President Bill Clinton replaced Louis Sullivan with Donna Shalala as the HHS secretary, and she abolished the board in 1996 as the focus seemed to shift to other issues, such as poverty.Ending Gaze AversionIn 1990 I became acting dean of the CU School of Medicine, dropping the "acting" part of the title after a formal search in March 1992. I thought being dean would last no more than five years, but it turned into a twenty-three-year stint. At the end of March 2015 I stepped down and returned to the faculty to go back to work in the child abuse field. During the twenty-five years I was away from full-time work in child abuse, I witnessed the extraordinary growth of not only the university's medical school, but also the entire academic health science community in the US. Appropriations to the NIH increased exponentially. The ensuing positive impact on the morbidity and mortality of most of the adult and pediatric diseases in the US has been dramatic.Yet the same gaze aversion that plagued many of the professionals involved in my 1968 child abuse case seems to be operative today in the paucity of research on the causes, treatment, and impact of all forms of child abuse and neglect on the health and well-being of children, adolescents, and adults. We have not-for-profit organizations that raise money for hundreds of adult and pediatric diseases, every major organ of the body, and at least a dozen genetic disorders that lead to rare diseases. These organizations have done a superb job of raising awareness of their issues and have dramatically improved the lives of millions of children and adults. Yet child abuse and neglect has been relatively ignored, in spite of its being a problem that affects at least 1–2 percent of children annually and was experienced by at least 25–30 percent of adults during their childhood, according to the Children's Bureau and the Centers for Disease Control and Prevention. As a result, the field is now—in my view—at least twenty to thirty years behind the rest of child health.This is not to say that there has been no progress in the child abuse field over the past fifty years: There has. Data from the Crimes against Children Research Center of the University of New Hampshire suggest that substantiated cases of physical and sexual abuse have fallen by 50–60 percent over the past twenty years, although we do not know why. There are now several thousand, not dozens, of physicians and other health professionals working in the child abuse field. All fifty states have Children's Trust and Prevention Funds that fund programs to prevent child abuse and neglect. The rapid expansion of child advocacy centers over the past thirty years has helped law enforcement officials and prosecutors punish perpetrators of sexual abuse and severe physical abuse and neglect. In addition, the American Board of Pediatrics has created a new subspecialty board for child abuse pediatrics.In spite of these advances, we still have five child abuse deaths a day in the US, according to the Children's Bureau. Millions of children are abused outside the family, and most of these children—particularly boys—never disclose their abuse. The NIH devotes little of its funding to research on the health and mental health consequences of child abuse and neglect. State and county child protection systems, which process millions of reports, have no culture of looking at the quality and outcomes of their practice and may have no idea whether the children and families they served are better or worse off than before their involvement. Finally, most health professionals view their role as mandatory reporters and not as part of the team that needs to be treating as well as preventing child abuse and neglect in their patients.A Dedicated EntityTwo years ago Lori Poland, a former patient of mine, and I founded the National Foundation to End Child Abuse and Neglect (EndCAN). We had spent a year visiting dozens of existing foundations to assess whether there was a need for a new entity focused on ending child abuse and neglect. Nearly everyone we met with said, "There must be one." Not only was there not one in existence, but those foundations funding research on conditions that are downstream consequences of abuse—alcohol and substance abuse, depression, suicide, obesity, eating disorders, and many others—have rarely if ever funded studies that could shed light on how child abuse and neglect contribute to the etiology of these conditions and how best to address the comorbidity of these conditions with abuse and neglect.Do laws that mandate health care professionals to report to Child Welfare cause the health system to view abuse and neglect as a "social problem"?How did this happen? Do laws that mandate health care professionals to report to Child Welfare cause the health system to view abuse and neglect as a "social problem"? Twenty-one years after the publication of the seminal Adverse Childhood Experiences (ACE) Study by Vincent Felitti and colleagues that clearly linked childhood abuse and neglect to major health conditions in adulthood, how can it not be standard for physicians and specialists to ask patients about possible histories of abuse and neglect in childhood? How can millions of dollars be awarded annually to researchers on suicide, depression, and obesity, with no complementary study of the contribution of abuse and neglect to these conditions? This is gaze aversion, and it needs to end.As I begin what is likely the last phase of my career in medicine, I hope that our new foundation (EndCAN) can make the types of strides that the March of Dimes, American Cancer Society, American Heart Association, and others have made over the past half-century. We will not be able to catch up on our own; partnerships and collaboration will be essential.It is an exhilarating challenge. Every day is an opportunity to open more doors and focus more eyes. A Research!America poll conducted on our behalf found that 42 percent of a national sample of US adults said that child abuse and neglect was a significant public health issue in their community. That is a good start, but ultimately we need all Americans (and the health professionals who serve them) to view child abuse and neglect not just as a social and legal issue, but as a health, mental health, and public health concern. We need to remove the shame and stigma that accompany the diagnosis. If we can be successful, we can end gaze aversion for good. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 10 History Published online 7 October 2019 Information© 2019 Project HOPE—The People-to-People Health Foundation, Inc.PDF downloadCited byLessons for Child Protection Moving Forward: How to Keep From Rearranging the Deck Chairs on the Titanic13 January 2023 | International Journal on Child Maltreatment: Research, Policy and Practice, Vol. 6, No. 1Adverse Childhood Experiences and Their Relevance to Hypertension in Children and Youth10 January 2023National Institutes of Health Funding PrioritiesJAMA Pediatrics, Vol. 176, No. 3Pediatric ResearchSilenced No More! 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