Child Abuse: Making an Invisible Problem Visible

Child abuse and neglect in Vermont increased 60% since 2012.

Every year more than 3 million reports of child abuse are made in the United States. In Vermont, child neglect and abuse has increased by 60 percent since 2012.

Here to talk to us about the signs of child abuse and much more is James Metz, MD, pediatrician at the University of Vermont Children’s Hospital and assistant professor at the Larner College of Medicine at UVM.

What causes child abuse?

Dr. James Metz: That’s a great question, and it opens up a Pandora’s box. I wish there was one answer, and I wish we could pinpoint it so that we could solve the problem easily. Unfortunately, child abuse and neglect is a huge problem with lots of different avenues to explore.

We do know that there are specific indicators that lead to child abuse more often than not. Social factors play a huge role: poverty, social stressors like losing a job, or economic hardship. There was a study done in Seattle that looked at the trend in abusive head trauma during the recent Depression. It showed that the rates of abusive head trauma went up considerably during that time. We know that during times of social stress for families and society in general, that levels of abuse go up.

We also know that there is an opioid crisis in Vermont, which has impacted the rate of child abuse. There are multiple issues at play. The most important one is some sort of social stressor.

What is the impact of the opioid crisis on child abuse and neglect?

Dr. James Metz: We have seen an increase in child abuse. Mostly, it takes the form of neglect. When we talk about child abuse there is a broad umbrella. You can have physical abuse, sexual abuse, medical child abuse, and/or neglect. In the wake of the opioid crisis, the most stunning increase has been in the neglect portion of child abuse.

What are risk factors for child abuse and neglect?

Dr. James Metz: One of the risk factors is when a child has higher medical needs. We know that children who are premature are at slightly higher risk for child abuse.We know that twins are more affected by abuse than others. We know that children with disabilities have a higher risk of child abuse. We know that teenage parents have a higher risk of perpetrating child abuse. So, there are specific factors that make child abuse more common in certain populations.Why is that? Well, for example,a child with special needs requires more attention. The child may be more demanding in some regards. That places a stress on the family. If it’s a young family who has little support, that can put the child at a higher risk.

What are the signs and symptoms of child abuse and neglect?

Dr. James Metz: This is a question that I educate people on most frequently, reason being that the signs can be subtle. We may all think that we’ll know it when we see it, but unfortunately, that’s not always the case. When I think about cases of abuse, I think about what we call “sentinel injuries,” or injuries that are subtle and a harbinger of worse injuries in the future.

For instance, a small bruise on the face of a two-week-old baby. We know that two-week-olds don’t do much other than eat and sleep. They do not move around a lot. So, a bruise on a two–week-old is concerning. In terms of neglect, when we see a child who isn’t growing properly, that is, not meeting their milestones developmentally, or not meeting their weight goals. Those kind of things make us concerned that they’re not getting the nutritional support that they need.

Oftentimes, there are no flagrant outward signs of abuse, although there are sometimes. We do get a lot of cases from schools calling us with reports of a child coming to school with a bruise on their ear or a bruise on their arm. Those are physical indicators of some sort of abuse, but there are also very subtle signs that we look for as well.

Are there behavioral signs?

Dr. James Metz: This is hard because children’s behavior is variable. Trying to understand their behavior and why they’re acting out in the way that they are is difficult. Yes, there are behavioral signs that we look at, but we try to look to physical findings. In the case of sexual abuse, when a child is exhibiting over-sexualized behavior or behaviors that are not appropriate for that age group, we get worried that either they’re being exposed to inappropriate content or they are being abused.

Do you find that it’s hard to talk about child abuse and neglect in the medical realm?

Dr. James Metz: Child abuse is the underbelly of medicine. To think that someone could harm a child or abuse a child is difficult. Unfortunately, if you don’t think about it, if you don’t recognize that it occurs, then you probably miss it, and that’s unfortunate because we have an opportunity to protect children. If we are blind to the fact that it happens, then children will continue to be abused.

What are some of the short-term effects of child abuse and neglect?

Dr. James Metz:In the short term, if a child presents to their physician, or they’re at school and abuse isn’t recognized, the immediate effect is that they go home and they get abused again.

Children come to the hospital frequently – and sometimes we miss the first signs of abuse, whether it’s bruising, fractures, or head trauma. Health care providers miss the first signs of abuse a third to a half of the time. That means that if a child comes in to the emergency department with fussiness, it’s often recognized as reflux or fussiness. When the child comes back a second time and is noted to have been abused, they get a head CT and we find signs of abusive head trauma that can be attributed to that first initial visit. We know that this happens not infrequently, and missing it the first time could set that child up for abuse in the future.

What are some of the long-term effects?

Dr. James Metz:Abusive and adverse experiences early on in childhood lead to a whole array of health, psychological, and other problems later on in life. We call these ACEs, or adverse childhood experiences. Child abuse, whether it’s physical, sexual, or neglect, fall under ACEs. We know that those can be causally linked to depression, alcoholism, suicide, and cardiovascular risk factors later on in life.

What can we do to reduce the risk of child abuse and neglect?

Dr. James Metz: We all want to somehow be a part of the solution. I think that the best way to do it is to recognize that child abuse happens. That’s the first step. So, recognition that it’s a problem. It’s not only a problem, it’s a big problem. I think we lose sight of how common a problem it is. Child abuse, whether it’s neglect or physical abuse, is more prevalent than childhood leukemia.

I think dedicating resources to the problem and addressing the different underlying causes of child abuse is also important. I don’t think there’s a silver bullet, but working with families on food insecurity, employment issues, and all of the social stressors that families experience may ease the burden and cause less stress on families, which can lead to child abuse.

What would you say to somebody who suspects that child abuse may be happening?

Dr. James Metz: It’s not something that we like to think about. By the time someone is thinking about child abuse, and by the time it reaches the level that it’s in your thoughts, it’s important to report it. I think we know that the threshold for people to think about child abuse is high. That’s unfortunate, because we probably miss it more than we should.

If you think that a child has been abused – and remember, for reporting, you don’t have to know for certain that a child has been abused; you just have to have a suspicion that something is not right or that a child may have been abused – report it. I would encourage people to step into the problem instead of stepping away from the problem, and see it as a civic duty to protect children.