Correspondence

Child Abuse and Neglect

N Engl J Med 1995; 333:1012-1013October 12, 1995

Article

To the Editor:

In his review of child abuse and neglect (May 25 issue),1 Wissow defines child maltreatment as “intentional harm or a threat of harm to a child by someone acting in the role of caretaker, for even a short time.” Intent is not generally included in the definition of abuse and should not be considered a necessary prerequisite for characterizing an injury as abusive.2,3

Most abusive injuries are not intentional, nor are they truly accidental in the conventional sense. The parent who shakes an infant, causing brain injury or death, does not intend to cause harm; he or she simply wants the baby to stop crying. The parent who twists an infant's leg, fracturing the femur, does not intend to break the leg but simply wants the baby to lie still so the diaper can be changed.

The factor that characterizes abusive injuries is the reckless use of inappropriate force in excess of that which would be employed by a reasonable, prudent parent. Children who have been injured by their parents, regardless of whether that injury was intentional, are at great risk for additional, potentially more serious injury. Injuries should be reported to child-protection agencies without an attempt to assess the caretaker's apparent intent.

Bruce J. McIntosh, M.D.
J.M. Whitworth, M.D.
Children's Crisis Center, Jacksonville, FL 32203

3 References

1. 1

   Wissow LS. Child abuse and neglect. N Engl J Med 1995;332:1425-1431
   Full Text | Web of Science | Medline

2. 2

   Ludwig S, Kornberg AE. Child abuse: a medical reference. New York: Churchill Livingstone, 1992.
   

3. 3

   Behrman RE, Kliegman RM, Nelson WE, Vaughn VC III. Textbook of pediatrics. 14th ed. Philadelphia: W.B. Saunders, 1992.
   

To the Editor:

We believe the most common cause of child abuse and neglect in the United States is the exposure of children to tobacco smoke by parents and care givers at day care centers. There is ample evidence of the harmful effects of parental smoking on children's health. A recent review cited a report by the Environmental Protection Agency estimating that the condition of 200,000 to 1 million children with asthma in the United States is worsened by exposure to environmental tobacco smoke and that such exposure is a risk factor for new cases of asthma in children.1 Because at least 25 percent of adults in the United States continue to smoke tobacco, despite knowledge of the detrimental effects of smoking on health, the number of exposed children is large.

William F. Schoenwetter, M.D.
Richard J. Sveum, M.D.
David F. Graft, M.D.
Park Nicollet Medical Center, Minneapolis, MN 55416

1 References

1. 1

   MacKenzie TD, Bartecchi CE, Schrier RW. The human costs of tobacco use. N Engl J Med 1994;330:975-980
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Wissow replies:

To the Editor: Both McIntosh and Whitworth and Schoenwetter et al. raise important issues about the definition of child maltreatment. Intentionality is frequently not included in the definition of physical abuse, though it is often a consideration in defining neglect.1 Failure to protect children from certain environmental hazards has at times been viewed as criminally negligent, on the part of both individuals2 and society.3

The process of defining child maltreatment belongs to what Engelhardt has identified as a class of public-policy discussions involving not just scientific questions but also political and ethical issues.4 Intentionality, for example, presents wide areas of ambiguity circumscribed by the extreme cases in which injuries to children are cruelly premeditated or tragically unavoidable. McIntosh and Whitworth argue that rather than intention, force beyond some “reasonable, prudent” threshold should serve as a marker for physical abuse. Such a standard raises questions about fairness to parents, children's rights, and the ability of state authorities to legislate family functioning.

Physicians cannot escape making individual decisions, to paraphrase Engelhardt, about which parental acts shall be considered merely unfortunate for children and which shall be considered not just unfortunate but also unfair. Laws mandating the reporting of suspected maltreatment encourage physicians to pass these decisions along to public agencies and to seek protection for children without trying to place blame or ascertain an intention to harm. One hopes that these laws reflect and reinforce, rather than drive, clinical judgment about how families can best nurture and protect their children. As the factors that place children at risk are better understood, physicians have an obligation not only to change clinical practice but also to participate in the wider process of changing societal standards of child protection.

Lawrence S. Wissow, M.D., M.P.H.
Johns Hopkins University School of Medicine, Baltimore, MD 21205

4 References

1. 1

   National Research Council, Panel on Research on Child Abuse and Neglect. Understanding child abuse and neglect. Washington, D.C.: National Academy Press, 1993:66.
   

2. 2

   Golden T. Jury told failure to buckle up girl was homicide. New York Times. May 3, 1991:A19.
   

3. 3

   Wilson MH. Childhood injury control. Pediatrician 1983;12:20-27
   Medline

4. 4

   Engelhardt HT Jr. Allocating scarce medical resources and the availability of organ transplantation: some moral presuppositions. N Engl J Med 1984;311:66-71
   Full Text | Web of Science | Medline