New Studies by RWJF Clinical Scholars Examine Child Abuse in United States and Five Other Countries

Twin studies find that parents commonly resort to physical punishment to discipline children and that bias in evaluation for child abuse persists at U.S. children's hospitals.

    • December 6, 2010

Child abuse is as old as humanity.

Ever since the days of antiquity, parents have abandoned and neglected children, physically and sexually abused them, and even murdered them.

Human society, of course, has come a long way in the past few millennia, according to Desmond Runyan, M.D., Dr.P.H., who is national program director and an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program. But abuse persists in some families.

Moderate physical discipline—defined as being slapped, spanked, hit, shaken, forced to kneel or stand in one position, force-fed spicy food, or having one’s hair pulled or ear twisted—is common in communities around the world, according to a study Runyan published in the September 2010 issue of Pediatrics, the journal of the American Academy of Pediatrics.

Runyan is medical director of the Center for Child and Family Health in North Carolina and a renowned expert on child abuse. In his study, 55 to 89 percent of mothers in six countries (including the United States) said they or their partners used moderate physical punishment to discipline children.

Harsher forms of physical punishment, such as beating, choking, burning, smothering and kicking, were comparatively low, Runyan and his team found. The median community had a rate of harsh punishment of 16.5 percent. When being hit with an object was included in the definition of harsh physical punishment, the rate shot up to 39 percent.

In addition, more than 20 percent of mothers said they shook children under two years old—a form of punishment that can lead to death and disability.

“The findings are stark,” Runyan and his co-authors write in the report, International Variations in Harsh Child Discipline. Fourteen percent of children experienced harsh physical punishment—the team’s definition for child abuse, Runyan notes. Rates were higher in low- and middle-income countries than in wealthier ones like the United States. The study was conducted in Brazil, Chile, Egypt, India, the Philippines, and the United States between 1998 and 2003.

To gather data, researchers asked mothers in private face-to-face and telephone interviews about how often they and/or their partners used specific disciplinary acts. It is the first known report comparing harsh punishment rates across low-, middle- and high-income countries.

The data “provide a crude but chilling estimate of the child abuse burden for the world’s young people,” the study says. Its findings are all the more chilling, authors note, because they do not include estimates of neglect or sexual abuse. They call the data “a clarion call to health professionals to be educated about child abuse and neglect to improve their recognition of child abuse and develop effective prevention and intervention.”

Clinical Scholar Heeds Call to Improve Treatment for Victims of Child Abuse in U.S.

One health professional who is heeding that call is Joanne Wood, M.D., M.S.H.P., an RWJF Clinical Scholar (2007-2010) at the University of Pennsylvania who published a separate article on child abuse in the same issue of Pediatrics.

In her study, Wood explored physician biases in evaluating infants suspected of being victims of abuse.

She found that Black children admitted to hospitals for traumatic head injury were more likely to undergo extensive skeletal evaluations, which involve a series of radiographic images, than were White children. The same held true for children who had public or no insurance compared with children with private insurance—a factor Wood says strongly correlates with income levels.

In short, clinicians over-evaluate Black or lower-income infants for abuse and under-evaluate White children.

White children who were evaluated for abuse, however, were more likely to receive a diagnosis of abuse than were children who were Black. The same held true for children insured by private companies, compared to those insured by the government or without insurance.

This finding, Wood and her co-authors write, suggests that clinicians have a higher threshold for suspicion of abuse in White and wealthier families.

The consequences of bias are severe, Wood notes. Over-evaluation may result in unnecessary exposure to radiation, higher medical costs, longer hospital stays and anxiety among caregivers. Under-evaluation, on the other hand, may lead to additional abuse. If White infants had been treated as Black infants, an additional 14 percent of White infants would have been evaluated with a skeletal survey that may have led to a diagnosis of child abuse, Wood says.

For the project, Wood and her coauthors conducted a retrospective study of infants with non-motor vehicle-associated traumatic brain injuries admitted to 39 children’s hospitals around the country between January 1, 2004, and June 30, 2008.

One in 45 infants in the United States is a victim of child abuse or neglect, according to a 2007 estimate by Child Protective Services (CPS). But Wood suspects the true incidence is higher—and hopes her study will lead to a fuller, more accurate understanding of the extent of child abuse in society and the eventual elimination of it.

“I hope that it will lead to wider recognition that biases exist and that they are not limited to a single hospital,” Wood says. “Hospital systems need to start developing standardized protocols and developing guidelines that enable health professionals to better evaluate patients for abuse.”

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