Time to medicalise child maltreatment

Abstract

Last year marked the 50th anniversary of the founding of one of the original multidisciplinary child-protection teams, in the US city of Denver, by paediatrician C Henry Kempe and psychiatrist Brandt F Steele. Their experience with nine children treated on the paediatric service of Colorado General Hospital led to the publication of their landmark paper, “The Battered Child Syndrome” (JAMA 1962; 181: 17–24). That paper estimated that there might be as many as 749 abused children in the USA annually at that time. On the basis of the public and professional horror that such maltreatment could be happening, all 50 US states passed laws in the mid-1960s that mandated all professionals to report suspected cases of abuse and neglect, and fixed the responsibility for investigating and treating the children and families with public child-welfare agencies.In 1975, Kempe brought several dozen of his colleagues from around the world to a meeting in Bellagio, Italy. This gathering led to the founding of the International Society for the Prevention of Child Abuse and Neglect, the First International Congress held in Geneva, in 1976, and many other efforts to address child maltreatment throughout the world, including work by WHO and UNICEF.The next three decades saw consistent increases in the number of reports of child maltreatment in the USA: from 60 000 in 1970, to 669 000 in 1980, to well over 2 million in the early 1990s. The re-recognition of sexual abuse in the late 1970s and 1980s significantly complicated the ability of child-welfare agencies to function adequately, since that form of abuse is clearly a crime and requires law-enforcement involvement (whereas the beating of children in the earlier period was not noted for such interest by the law-enforcement agencies). In 1990, the US Advisory Board on Child Abuse and Neglect called the situation “a national emergency”. Their report, among many recommendations, decried the lack of data collected by federal, state, and local agencies that could guide policy on child maltreatment, called for the professionalisation of child-protection-services personnel, pled for the specific elucidation of child-protection policies at national and local levels, and suggested a focus on prevention. The Board's recommendations were mostly ignored and the Board was eliminated by the Clinton Administration.Nearly two decades later, David Finkelhor, a long-time scholar in the field, has published a must-read book, Childhood Victimization: Violence, Crime and Abuse in the Lives of Young People. There is a great deal to learn about the fields of child maltreatment and violence in this book, but in particular the chapter called “Good news: child victimization is declining—but why?” is enormously important from my perspective. I have worked in child maltreatment since 1981. I moved to Denver in 1968 to work with Henry Kempe after hearing his presentation on “The Battered Child” as a medical student in New York in 1967. For all those years, the assumption by the public and professionals has been that child maltreatment was increasing. So caught up were many of us in our zeal to help increase public and professional awareness that we always spoke of the epidemic of more and more cases in somewhat desperate attempts to get attention from those in political power and from those philanthropists who have fuelled most of the research, training, and programmatic activity in the USA. We decried the lack of precise data that would tell us how many child abuse fatalities there were each year, and how many children were being maltreated. We always assumed things were getting worse. We almost needed it to be getting worse.Now, it seems, things are improving in the USA. Finkelhor has tracked the notoriously poor (but consistently poor) child maltreatment estimates of incidence in the USA and has shown that physical and sexual abuse has declined by 46% and 51%, respectively, between 1990 and 2005. I guess I could claim that the US Advisory Board reports were a success after all, but I know better than that. I will not go into all the proposed reasons why this decline could be happening—there are 11 that are enumerated by Finkelhor—but I will highlight one because in my personal view, just the possibility that it could be true may be enough to tweak the interest of medical scientists and researchers and help maintain the decline, and even accelerate it.I refer explicitly to the possibility that the dramatic increase in the use of psychopharmacological agents in our population over the past decade could explain part of the decline in rates of child maltreatment. I believe this is an important hypothesis to study further because, quite independently, there has been increasing attention paid to the genetic and biological aspects of abusive and neglectful behaviour in animal and human studies. In a 1996 editorial written as editor-in-chief of Child Abuse and Neglect: The International Journal, I asked our readers “Suppose it were a genetic problem?” I asked this on the basis of a study of knockout mice missing the immediate early gene fosB. I was accused by many of our readers of “medicalising” a social problem.The accusation is valid, but I do not view it as a pejorative. Rather, I have always felt that the single greatest difficulty we faced as a specialty in the USA is that child maltreatment is viewed by the public and our politicians as a social problem, not as a health problem. Truth be told, we do not raise private funds for social problems, and further, our politicians will not put government resources where there is not a lot of public support. In the past 5 years, the US National Institutes of Health allocated only about US$36 million of its nearly $30 billion budget to study child maltreatment. The American Board of Pediatrics has certified Child Abuse Pediatrics as a subspecialty, but there are few funds available for training or research to fuel the growth of this discipline.Finkelhor picks up many of the recommendations of the Advisory Boards and Commissions of yesteryear in his constructive suggestions that include the professionalisation of workers in child-protection services and increasing community-based prevention programmes. He also points out that no one has ever accused the child-protection system anywhere of having an evidence base to their practice. Few, if any, systems collect and maintain data for the decades necessary to know whether their practice has been of quality. This is certainly something the medical profession can bring to bear.Could we imagine that certain drug therapies could help depressed parents treat their children better? Could we imagine that certain therapies could even out the behaviour of individuals who find themselves exploding with rage at some of the behaviours of their children? Could we actually have clinical trials that include the standard social interventions of “parenting classes” with and without pharmacotherapy?We have spent a half century building the child welfare and legal responses to child maltreatment. These systems are struggling under the weight of the task. Although we must acknowledge how much they have done given the capacity and resources they have had, the time is now right to spend the next decade building what has been a far less well developed medical response to its full potential. Abused children and their families deserve no less. Last year marked the 50th anniversary of the founding of one of the original multidisciplinary child-protection teams, in the US city of Denver, by paediatrician C Henry Kempe and psychiatrist Brandt F Steele. Their experience with nine children treated on the paediatric service of Colorado General Hospital led to the publication of their landmark paper, “The Battered Child Syndrome” (JAMA 1962; 181: 17–24). That paper estimated that there might be as many as 749 abused children in the USA annually at that time. On the basis of the public and professional horror that such maltreatment could be happening, all 50 US states passed laws in the mid-1960s that mandated all professionals to report suspected cases of abuse and neglect, and fixed the responsibility for investigating and treating the children and families with public child-welfare agencies. In 1975, Kempe brought several dozen of his colleagues from around the world to a meeting in Bellagio, Italy. This gathering led to the founding of the International Society for the Prevention of Child Abuse and Neglect, the First International Congress held in Geneva, in 1976, and many other efforts to address child maltreatment throughout the world, including work by WHO and UNICEF. The next three decades saw consistent increases in the number of reports of child maltreatment in the USA: from 60 000 in 1970, to 669 000 in 1980, to well over 2 million in the early 1990s. The re-recognition of sexual abuse in the late 1970s and 1980s significantly complicated the ability of child-welfare agencies to function adequately, since that form of abuse is clearly a crime and requires law-enforcement involvement (whereas the beating of children in the earlier period was not noted for such interest by the law-enforcement agencies). In 1990, the US Advisory Board on Child Abuse and Neglect called the situation “a national emergency”. Their report, among many recommendations, decried the lack of data collected by federal, state, and local agencies that could guide policy on child maltreatment, called for the professionalisation of child-protection-services personnel, pled for the specific elucidation of child-protection policies at national and local levels, and suggested a focus on prevention. The Board's recommendations were mostly ignored and the Board was eliminated by the Clinton Administration. Nearly two decades later, David Finkelhor, a long-time scholar in the field, has published a must-read book, Childhood Victimization: Violence, Crime and Abuse in the Lives of Young People. There is a great deal to learn about the fields of child maltreatment and violence in this book, but in particular the chapter called “Good news: child victimization is declining—but why?” is enormously important from my perspective. I have worked in child maltreatment since 1981. I moved to Denver in 1968 to work with Henry Kempe after hearing his presentation on “The Battered Child” as a medical student in New York in 1967. For all those years, the assumption by the public and professionals has been that child maltreatment was increasing. So caught up were many of us in our zeal to help increase public and professional awareness that we always spoke of the epidemic of more and more cases in somewhat desperate attempts to get attention from those in political power and from those philanthropists who have fuelled most of the research, training, and programmatic activity in the USA. We decried the lack of precise data that would tell us how many child abuse fatalities there were each year, and how many children were being maltreated. We always assumed things were getting worse. We almost needed it to be getting worse. Now, it seems, things are improving in the USA. Finkelhor has tracked the notoriously poor (but consistently poor) child maltreatment estimates of incidence in the USA and has shown that physical and sexual abuse has declined by 46% and 51%, respectively, between 1990 and 2005. I guess I could claim that the US Advisory Board reports were a success after all, but I know better than that. I will not go into all the proposed reasons why this decline could be happening—there are 11 that are enumerated by Finkelhor—but I will highlight one because in my personal view, just the possibility that it could be true may be enough to tweak the interest of medical scientists and researchers and help maintain the decline, and even accelerate it. I refer explicitly to the possibility that the dramatic increase in the use of psychopharmacological agents in our population over the past decade could explain part of the decline in rates of child maltreatment. I believe this is an important hypothesis to study further because, quite independently, there has been increasing attention paid to the genetic and biological aspects of abusive and neglectful behaviour in animal and human studies. In a 1996 editorial written as editor-in-chief of Child Abuse and Neglect: The International Journal, I asked our readers “Suppose it were a genetic problem?” I asked this on the basis of a study of knockout mice missing the immediate early gene fosB. I was accused by many of our readers of “medicalising” a social problem. The accusation is valid, but I do not view it as a pejorative. Rather, I have always felt that the single greatest difficulty we faced as a specialty in the USA is that child maltreatment is viewed by the public and our politicians as a social problem, not as a health problem. Truth be told, we do not raise private funds for social problems, and further, our politicians will not put government resources where there is not a lot of public support. In the past 5 years, the US National Institutes of Health allocated only about US$36 million of its nearly $30 billion budget to study child maltreatment. The American Board of Pediatrics has certified Child Abuse Pediatrics as a subspecialty, but there are few funds available for training or research to fuel the growth of this discipline. Finkelhor picks up many of the recommendations of the Advisory Boards and Commissions of yesteryear in his constructive suggestions that include the professionalisation of workers in child-protection services and increasing community-based prevention programmes. He also points out that no one has ever accused the child-protection system anywhere of having an evidence base to their practice. Few, if any, systems collect and maintain data for the decades necessary to know whether their practice has been of quality. This is certainly something the medical profession can bring to bear. Could we imagine that certain drug therapies could help depressed parents treat their children better? Could we imagine that certain therapies could even out the behaviour of individuals who find themselves exploding with rage at some of the behaviours of their children? Could we actually have clinical trials that include the standard social interventions of “parenting classes” with and without pharmacotherapy? We have spent a half century building the child welfare and legal responses to child maltreatment. These systems are struggling under the weight of the task. Although we must acknowledge how much they have done given the capacity and resources they have had, the time is now right to spend the next decade building what has been a far less well developed medical response to its full potential. Abused children and their families deserve no less.