The neglect of child neglect

Abstract

As a rule of thumb, the more difficult and problematic the nature of research, the more pressing is the need that it should be done. In the developed world today, perhaps the foremost example of this research imbalance is the neglect and physical, sexual, or psychological abuse of children. Maltreatment is one of the biggest paediatric public-health challenges, yet any research activity is dwarfed by work on more established childhood ills—especially those that lend themselves to drug treatment. Take, for example, the nature of popular media reports on aspects of child health. Hardly a week goes by without headlines promising “hope” and “breakthroughs” or the discovery of “life-saving treatment” for the classic diseases of childhood. When does the public ever read stories in the same vein about breakthroughs in our understanding of child maltreatment? The answer, of course, is almost never. Child abuse comes to our attention almost exclusively when something has gone wrong. Two prominent examples flooded the UK headlines last week. In the first, a lawyer who had been jailed for murdering her two babies was released. The Court of Appeal ruled that her convictions were unsafe since important medical evidence had been withheld from the trial jury. In the second case, the report of an inquiry by Lord Laming into the neglect, abuse, and murder of an 8-year-old by her guardians was published. The professional failings in the case of the wrongly convicted lawyer have yet to be investigated. However, those surrounding the murder of Victoria Climbié were spelled out in graphic detail by Laming. The poor response of the medical professionals involved led him to question “the status and priority given to child protection in the context of paediatric medicine”. Laming was surprised and disturbed to discover that it is difficult to find doctors who wish to work in the field of child protection. “One might have expected that the scale of the problem would act as an inducement to those doctors who wished to make a significant impact on the health and well-being of the child population to enter the field. In such circumstances it is vitally important that those practitioners who do work in the field are adequately equipped to do so effectively.” He is surely right to prick the conscience of the paediatric community. In a study to be published in Child Abuse and Neglect, Leah A Behl and colleagues from the Center for the Study of Family Violence and Sexual Assault, Northern Illinois University, USA, review the trend in the published research on child maltreatment during the past 22 years. They found that the percentage of articles examining child physical abuse declined over the period of study, whereas the proportion of research published on sexual abuse rose. However, the percentage of articles examining child neglect and emotional abuse remained consistently low. The investigators noted a “scientific maturation” during the two decades studied, with theoretical papers giving way over time to quantitative reports. Behl and colleagues did not investigate the quality of the papers reviewed, but there is little doubt that robust data are lacking. A recent US National Institutes of Health grant awards announcement admits that “Current research on child maltreatment, by and large, lacks a level of sophistication necessary to address adequately the critical scientific and clinical issues … There have been only a handful of longitudinal studies on course and outcome of maltreatment in children.” Thus the work reported on page 471 of this week's Lancet is especially welcome. David Skuse and colleagues report a longitudinal study of male former victims of abuse and their propensity to become abusers themselves. Skuse and colleagues found that only a small proportion of male victims of sexual abuse subsequently displayed paedophilic behaviour. Moreover, Skuse and co-workers identified early life experiences, such as physical neglect, that greatly increased the risk of sexually abusive behaviour. While lessons must be learned from high-profile examples where child protection has failed, future strategies cannot be based on crisis responses to individual cases. As with any other clinical problem, that of child maltreatment requires the development of a comprehensive research agenda to inform and improve prevention, diagnosis, interventions, and public-health provisions. Without such commitment, the true scandal is not the failure of a handful of individual professionals in notorious cases, but the systematic failure of all relevant professions towards the generations of children at risk to come.