Child abuse: behavioral aspects and other associated problems.

Although researchers in psychology and the social sciences will need to continue to identify the behavioral consequences of abuse and treatment strategies, pediatricians may still be the first line professionals to suspect and intercept victims. Remember that, especially in cases where there have been threats or falsification of illness, it is wise to enlist integrated multidisciplinary services to ensure the safety of the child before confronting any potential perpetrators. Physicians have become better trained to be more vigilant in detecting signs of physical abuse, but it seems that psychologic and sexual maltreatment may cause more long-term problems but are more difficult to detect. Although a book by Everett and Gallop is written for mental health professionals, the chapters on why a history of childhood trauma is often missed, recognizing signs and symptoms, and asking about abuse, are all helpful for pediatricians and other health care professionals. In certain situations, physicians should attempt to talk to children privately, so that those who are old enough might have an opportunity to relate events that are traumatic, and so that abusive parents will not have an opportunity to interrupt, instill additional fear in the child, or abruptly change providers. Children need someone to ask them directly about their experiences and act on any suspicions. Asking once may not be enough, because a frightened child may initially deny physical or sexual abuse, but be ready to tell at another time. A vocal adult survivor of Munchausen syndrome by proxy and severe physical abuse explains: The dilemma is how to be loved and accepted. Even once a child recognizes that it is wrong, victims may be afraid to speak up for fear of anger and more abuse at the hand of the abuser. By the time I reached eleven, I was angry enough at what my mother had gotten away with, I would have been more truthful. It would have been a relief to have someone else voice their own suspicions. But, no one ever asked and I could not be the one to give away my mother or the love of my family. Although society is still struggling with its ability to prevent abuse, it must also be concerned with dealing with its consequences. The problem seems overwhelming in its enormity and the resources do not seem to be adequate to tackle these issues so basic to the care and nurturing of children. Nonetheless, physicians must keep their eyes open to behaviors that signal distress, recognize and strive to eliminate the underlying cause, and make certain that children receive treatment to minimize the myriad of behavioral and other long-term problems that are associated with child abuse.