Book Review

Child Maltreatment: A clinical guide and reference

Child Maltreatment: A comprehensive photographic reference identifying potential child abuse

N Engl J Med 1995; 332:968-969April 6, 1995

Article

Child Maltreatment: A clinical guide and reference
Edited by James A. Monteleone and Armand E. Brodeur. 502 pp., illustrated. St. Louis, G.W. Medical, 1994. $95. ISBN: 1-878060-10-4

Child Maltreatment: A comprehensive photographic reference identifying potential child abuse
Edited by James A. Monteleone. 266 pp., illustrated. St. Louis, G.W. Medical, 1994. $110. ISBN: 1-878060-13-9

The first volume of what is essentially a two-volume set, the clinical guide, is a traditional textbook; its companion is a compendium of photographs. The clinical guide attempts to cover the whole range of issues associated with child abuse. Most of the material is presented in clear prose, with useful tables. There are helpful sample documents, including excellent forms for telephone referrals in cases of child abuse and telephone screening for possible abuse. The book also presents sample questions for use in interviewing parents and children about sexual abuse. Most of the material will be useful for the general clinician. Some of it is highly specialized, and it is important for clinicians to be aware of the controversial nature of some of the discussions, such as that of fetal abuse. Overall, the book's accessibility and relevance make it a fine reference for clinical personnel dealing with child abuse.

The clinical guide begins with a worthwhile analysis of conditions that can be mistaken for abuse, then presents a standard approach for identifying child abuse, including interpreting potentially abusive injuries contextually. The importance of a marked discrepancy between the history and the physical findings is emphasized. There are useful tables of suggested diagnostic studies and physical findings in abuse. The book's style makes it accessible to nonmedical providers — for example, social workers interested in learning about the medical presentation of child abuse.

The book of photographs addresses an important need in the field of pediatrics. The photographs follow the sequence of topics in the clinical guide, making it easy to refer to the relevant photographs while using the guide. Some of the key tables from the clinical guide, highlighting important principles, are duplicated in the book of photographs. The graphic images of abused children, although upsetting, do add to the clinical usefulness of the book. The text accompanying the photographs repeatedly emphasizes important issues, including the need to question the proferred history and the need for a developmental assessment of the child in every case of possible abuse, to determine whether the injury could have occurred as described. Classic examples of inflicted injuries are emphasized, and the mechanism of each injury is explained. Photographs from police investigations and drawings by abused children provide insight into aspects of child abuse rarely encountered by physicians.

These books have many strengths but also some weaknesses. An example of the latter is the chart of situations in which child abuse is possible. Although the format is extremely useful, summarizing a wide variety of areas, the chart contains several contentious, possibly incorrect statements. The suggestion that all children with failure to thrive without a medical cause should be reported for child abuse ignores the many children who may simply have a feeding disorder. The statement that all women who receive inadequate prenatal care should be reported for intrauterine neglect is debatable. These recommendations are not explored but simply presented with relatively little commentary.

The books examine in detail the threefold role of radiology in child abuse: documenting findings, identifying traumatic injuries, and recognizing their abusive origin. A table on key plain-film findings summarizes the basic tenets of the radiologic evaluation of child abuse. There is an excellent discussion of differential considerations in abuse, detailing such issues as the diffuse bony changes in congenital syphilis. The presentation of radiologic differential diagnosis is clear, as is the discussion of the clinical usefulness of magnetic resonance imaging, computed tomography, and bone scanning.

Each book deals with the clinical and laboratory approach to the differential diagnosis in possibly abused children. Because the effort is made to cover all possible diagnoses of apparent physical trauma, it is easy to find fault with some of the choices. For example, we disagree with the statement that the prothrombin and partial-thromboplastin times are the only measures necessary for evaluating a bleeding diathesis in a bruised child. The evaluation might include determination of the platelet count, bleeding time, and platelet function (to rule out von Willebrand's disease), as well as tests for specific coagulation factors. The overall approach, however, is concise, focused, and well conceived.

The section on the difficult problem of defining sexual abuse can guide the inexperienced clinician in useful ways of thinking about sexual assault. Sexual abuse is broken down into abusive or assaultive acts, incest, and exploitation. Child prostitution and pornography are included, and the social conditions that increase the risk of sexual abuse are discussed. A management protocol is presented that includes recommendations on the use of dolls and other aids in the evaluation of sexual abuse. The discussion of the physical examination of sexually abused children is a gem, with a table of the genital findings in abused girls, as well as unusual findings in nonabused children. This section alone makes the book worthwhile. The table of specific and nonspecific physical findings of sexual abuse, as well as conclusive findings, is a welcome addition to the literature on sexual abuse of children.

Another valuable section, perhaps the most valuable of all, concerns the sexual-abuse interview. The authors present a developmentally appropriate approach to interviewing children of various ages. They discuss how to differentiate normal from abnormal sexual behavior in children. Sample interview forms are provided that allow clinicians to organize their thoughts systematically and cover all the important areas. These forms will help inexperienced clinicians and those without easy access to specialists perform thorough clinical analyses of sexually abused children.

The discussion of emotional abuse is also welcome. It is difficult for clinicians to understand or intervene in cases in which children are verbally assaulted or terrorized. Protective agencies rarely, if ever, get involved in these cases, but it is important for clinicians to consider the possible deleterious effects of such abuse. Far too often, clinicians are unaware of the various types of emotional abuse and their effect on children. The table of parental behavior that has the potential for emotional abuse, although useful, is problematic if taken too literally. For example, the notion that living in poverty entails parental behavior that has the potential for emotional abuse is questionable.

Other sections, although extremely interesting and well presented, will be less useful to the practicing physician. The chapter on the investigation of childhood deaths may help clinicians organize their thinking about this nettlesome area. The final chapter, on the role of the medical examiner in child abuse and neglect, should have emphasized more the need to refer suspected cases of abuse and neglect to the coroner and to ensure that an adequate evaluation is performed. The chapter on multiple personality disorder is intriguing but of little or no use outside psychiatric practice.

Overall, these are worthwhile books. Busy clinicians will find the book of photographs especially useful.

William G. Bithoney, M.D.
Ronald C. Samuels, M.D.
Children's Hospital, Boston, MA 02115