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Child abuse is one of society’s darkest secrets, a problem often too painful to discuss. An estimated 903,000 children in the United States — 12.4 of every 1,000 — were abused in 2001, according to the National Child Abuse and Neglect Data System maintained by the federal Department of Health and Human Services. State agencies reported that about 1,300 abused children died from neglect or physical abuse. The pediatric subspecialty of child protection is relatively small, although it began in the early 1960s. There are few programs for training pediatricians in the field, and only one-third of children’s hospitals have a child protection specialist on staff. “Fortunately, the number is increasing. Society is more willing to think about the possibility that children are being abused,” said Timothy Kutz, M.D., director of the division of child protection at SSM Cardinal Glennon Children’s Hospital.
“States across the country count on the benevolence of health care institutions and universities to provide doctors who can help them with testifying in court and deciphering complex medical cases and issues,” said Kutz, who is an assistant professor of pediatrics at St. Louis University School of Medicine. Kutz completed a fellowship in child protection at the University of Colorado, where the study of child abuse was pioneered four decades ago. He came to Cardinal Glennon to replace James A. Monteleone, M.D., a noted author on child abuse, who retired. Kutz is responsible for medical assessments and evaluations of children suspected of being abuse victims. The Glennon staff reported 255 cases of suspected abuse to state authorities in 2002. Nationally, 59.2 percent of abused children suffer from neglect, which is defined as “not taking care of your children according to community standards,” Kutz said. Some of those children were victims of medical neglect, the failure to receive needed health care. The federal statistics show that 18.6 percent of abused children and teens are victims of physical abuse and 9.6 percent are sexually abused. Another 6.8 percent are emotionally or psychologically mistreated. State family services agencies provide preventive services to about three million children in the country annually. One in five abused children is removed from the family.
About half of abuse cases referred to state agencies are reported by social service or mental health workers, law enforcement personnel or teachers. Medical personnel initiate 8.3 percent of cases. During 2001 there were 51,752 cases of suspected abuse investigated in Missouri and 59,139 in Illinois. Those cases resulted in 9,237 confirmed abuse victims in Missouri, 33 of whom died. There were 27,557 confirmed victims and 79 deaths in Illinois. Glennon serves patients in both states. Abused children typically are referred to Glennon by community pediatricians, state social services workers or law enforcement officers. Many investigations are initiated when suspicious injuries turn up in a hospital emergency room.
There are 20 to 30 children who continue to be treated at Glennon for permanent neurological injuries resulting from abuse years ago, said Wayne Munkel, M.S.W., supervisor of social services at Glennon. “Children who have severe closed head injuries are going to be neurologically impacted. Sometimes we will see them for the rest of their childhood. “We saw a child in the emergency room last week who had bruises to the face and burns on three extremities. There wasn’t an accidental cause that could account for that,” he said. “Sometimes it is very clear-cut. We call the state hotline and that starts the investigative process.” Kutz believes that ruling out incorrectly suspected abuse is as important as identifying probable abuse. “When we have the time to sit down and talk to the family and get all of the information, occasionally it becomes fairly clear that the injury was most likely accidental,” he said. His evaluations can end strife within families when a parent or relative mistakenly believes someone has abused a child. “Sometimes a child has not been abused, but there is enough interest and energy drummed up in the family that circumstantial facts make them think the child was abused. Then everybody is in an uproar and the snowball keeps growing,” he said. “It is nice to have someone with experience look at the case and determine it probably doesn’t represent abuse.” When children arrive at the emergency room with injuries that do not appear to have been caused by accidents, the emergency room staff calls the hospital’s social services and child protection team to investigate.
Kutz examines the child and interviews parents to analyze possible causes for the injuries. “Does the injury match the history given by the parents? Does the energy that caused the injury seem consistent with the mechanism stated?” he asks. “Was there a significant delay in seeking medical attention? If the injury happened three days before, did they only seek medical attention because grandma came by or the child wasn’t getting better?” Other warning signs of abuse: Multiple bruises that could not have been caused by a single fall. Bruising found on a child who is too young to walk. Breathing difficulties that could result from broken ribs or brain trauma. Substantial burns that could not have been caused by accidentally touching a hot iron or pot or reaching into a scalding bathtub. Kutz works with other specialists at Glennon to diagnose injuries that could be evidenced by bleeding within the brain or abdomen, or injuries within the eyes. “It is not hard to miss abuse cases when the injuries are more subtle,” he said. Because Kutz is evaluating the possibility of abuse, other physicians can care for the patient and family without being viewed as adversaries. “On almost every case I am solely a consultant. There is a physician who can hopefully be more objective in looking for the true cause of the child’s problem, and the parents have somebody to talk to besides the ‘abuse’ doctor,” he said. Kutz also responds when a doctor is needed to testify in court or depositions, a process that can require at least half a day. That allows other doctors to stay at the hospital to care for their patients. Dealing with Anger
The incidence of physical abuse declines as children grow older. “It is rare for us to see kids over five or six years old,” he said. “They are not as likely to be abused because they are more skilled at getting out of the way when somebody is losing their temper.” Child abuse knows no socioeconomic boundaries. While neglect cases often involve poor families, physical and sexual abuse strike families in all walks of life, Kutz said. Four of every five perpetrators turn out to be a parent of the abused children. Mothers acting alone are identified as abusers in 40.5 percent of cases while fathers acting alone are identified as abusers in 17.7 percent of cases. Parents acting together or in concert with others are responsible for 19.3 percent of the cases. Mothers are responsible for 47 percent of cases of abuse by neglect while fathers are involved in 12 percent of those reports. Female and male parents are responsible for nearly equal numbers of physical abuse cases. Anger management is an issue in many cases of child abuse. There are parents who cannot handle frustration with a colicky baby that won’t stop crying or a toddler that is not getting the hang of toilet training and has an accident at an inopportune moment. “Certainly there are issues that make parents angry. Part of that anger arises from not having realistic expectations about what a child should or should not be doing. There may be ignorance about what is normal behavior for a child of a certain age,” Kutz said. “Of course there are things that a child can do to make you angry. But how do you manage that anger? Do you lash out at the child, and hit them or throw them, or do you walk away and come back when you can handle things?” Investigating Sexual Abuse
“People still don’t want to believe that sexual abuse happens. If a child wavers at all in the way they disclose abuse, people presume that may not be telling the truth,” Kutz said. “They are extremely difficult cases because the vast majority of kids won’t have permanent physical changes from the kind of contact that happens. So most of what we rely on is what the child says. Child sexual abuse cases often come about when the child makes a disclosure to a family member or someone at school.” The rates of neglect and physical abuse are nearly identical for boys and girls, but girls are four times as likely as boys to be sexually abused. The median age of sexually-abused girls is 11 years. “I have seen a child as young as two weeks old who had been sexually abused,” Kutz said.
The stress surrounding a sexual abuse investigation can make it difficult to determine what actually happened, Kutz said. “There can be a lot of pressure from the family for the child to recant. Often these children actually like the person who is abusing them. When the child’s world is turned upside down, the police are coming around and a relative is going to jail, they decide maybe it was better if they didn’t tell anybody. They feel very guilty about the fact that something happened, that it might have been their fault.” Providers of social and medical services can find themselves caught in the middle of family disputes. “There are divorce custody situations when a parent is looking for something to blame on the other parent,” said Karen Bly, R.N., M.Ed., nurse counselor for the special assessment and management service of Glennon’s child protection division. “Some of these kids end up in the emergency room every time they get back from visitation with one of their parents.” In any case, it is difficult to evaluate charges of sexual abuse. “It is very hard to prove an allegation, even when kids have physical findings,” Bly said. “Our role is to listen to them, believe them, protect them and let the judge and jury make final decisions.” Bly handles dozens of phone calls each week from parents, pediatricians, social services workers and attorneys who suspect a child has been sexually abused. Many of the children she assists are never patients at the hospital or even visit it. Knowing the warning signs of sexual abuse can be subtle, anxious parents can assume the worst when a child’s behavior changes slightly. “If the child comes home acting funny after visiting a relative, that does not necessarily mean she has been abused,” Bly said. “When a call comes in, the parent can be crying and angry and doesn’t know what to do. We give them some guidance on how to talk to their child to indirectly find out what is going on.” In many cases, Bly refers the child back to the family pediatrician to make sure a physical symptom does not result from a typical infection or condition. She has prepared educational materials that help parents, teachers and other adults learn how to discuss abuse with children.
The Glennon staff works closely with state family services representatives when they determine the child should be removed from an abusive environment and receive needed services. “Counseling is a real important need for these kids, and usually for their parents, too,” said Bly. “A lot of what I do is redirecting parents to the services they need.” State workers strive to keep children in their families by providing parents with the skills they require to be better parents. “They can remove the child and place him in foster care while the parents receive psychological evaluations and assistance to work on their issues prior to having the child returned,” Kutz said. Many abusive parents were abused themselves as children and do not know other ways of dealing with children. “Sometimes it is a matter of re-parenting people who were not adequately parented,” Erickson said. “That is not an easy fix.” Families cannot always be kept intact. “The injury and abuse can be so heinous that there isn’t anything that can be done to provide a safe environment for the child, so the state will pursue a permanent termination of parental rights,” Kutz said. A few research projects have suggested that the incidence of child abuse can be reduced through public awareness campaigns and high school-based parenting education. Kutz, who grew up in the St. Louis area, would like to undertake such projects here, but realizes there are few public resources available these days. “There are a handful of different organizations trying to address these issues. The question is, how do we get these plans into action?” Assuming a Difficult Responsibility
“If it is one of ten patients that concern us, we are asking another nine families to deal with a lot of questions, many of them very personal, so as a society we can protect that one child,” Kutz said. “That is a lot to ask. Some families are fine with that and are very understanding. Some respond to that as an affront to their character. “A number of kids are cared for out of the home these days, so physical and sexual abuse can occur in day-care settings. If a child ends up in the hospital with injuries consistent with abuse, it is very easy to see how the family would feel everybody thinks they did it. And maybe they did. It can be very difficult to convince parents that we are honestly looking out for the best interests of the child.” Munkel and Erickson have been part of the Glennon social services staff for 23 years. Bly is working on her twelfth year in child protection. “We have expertise here that is hard to beat,” Munkel said. When child abuse is suspected, health care workers are legally required to notify their state family service agency. Erickson finds that can make her unpopular with the families she is assisting. “People think I’m the one who took their child away from them. No matter how skillful you are, there are going to be people who are not happy with you.” By taking on a job that can be stressful and thankless, however, the child protection and social services staffs know they assist in making the world safer for children who can not protect themselves. “A hospital is all about the protection of kids,” Erickson said. “I do this because I really think it helps kids and families,” Bly said. “Sexual abuse was swept under the carpet for so long. There is a need for this service. Still, if I had a very young child at home, I don’t think I could do this.” “It is an important part of the hospital’s mission to provide this service to the community, so kids who are abused don’t slip through the cracks,” Kutz said. “Child protection is a very important piece of what pediatricians do, yet there aren’t many people who want to do it. I decided to do child protection for the most part because nobody else wanted to do it.
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The divisions of child protection and
social services at the hospital work with
Missouri and Illinois family services
workers and law enforcement officers to
identify abused children and attempt to
protect them from further abuse. The
hospital staff provides expertise that the
government agencies do not possess.
“Some of the patients have an unusual
bruise or mark and their physician may
not feel comfortable with further
evaluation and management,” Kutz said.
“The vast majority of physically abused
children come through the emergency
department. Often there are significant
fractures — broken legs, broken arms and occasionally broken ribs. A
number of the children
have severe head injuries.”
A social worker interviews the family to prepare a social history of
potential sources of stress. “We try
to assess the social factors in the family, how the family functions and
what some of the risk areas
might be,” said Donna Erickson, A.C.S.W., a Glennon social worker who
handles abuse cases. “We tell
the parents, ‘You have to help us figure out what happened. If you don’t
know how this happened, you
can’t adequately protect your child from having it happen again.’”
“We see children from newborns, literally a couple of weeks old, who have
been abused,” Kutz said.
The federal statistics identify about one
in four perpetrators of sexual abuse as
someone outside the family. Fathers are
identified as the cause of about one in
five sexual abuse episodes. When very
young children are sexually abused,
family members and friends are the most
likely culprits. “Other relatives” are
believed to be responsible for 31.5
percent of sexual abuse cases.
When additional evaluation is
warranted, Bly assists Kutz in
conducting an assessment. Kutz and
Bly often evaluate children at a child
advocacy center in St. Louis so the
child does not have to visit the
hospital.
The job is difficult nonetheless.
