To evaluate in a national database the association of race and socioeconomic status with radiographic evaluation and subsequent diagnosis of child abuse after traumatic brain injury (TBI) in infants.
We conducted a retrospective study of infants with non–motor vehicle–associated TBI who were admitted to 39 pediatric hospitals from January 2004 to June 2008. Logistic regression controlling for age, type, and severity of TBI and the presence of other injuries was performed to examine the association of race and socioeconomic status with the principal outcomes of radiographic evaluation for suspected abuse and diagnosis of abuse. Regression coefficients were transformed to probabilities.
After adjustment for type and severity of TBI, age, and other injuries, publicly insured/uninsured infants were more likely to have had skeletal surveys performed than were privately insured infants (81% vs 59%). The difference in skeletal survey performance for infants with public or no insurance versus private insurance was greater among white (82% vs 53%) infants than among black (85% vs 75%) or Hispanic (72% vs 55%) infants (P = .022). Although skeletal surveys were performed in a smaller proportion of white than black or Hispanic infants, the adjusted probability for diagnosis of abuse among infants evaluated with a skeletal survey was higher among white infants (61%) than among black (51%) or Hispanic (53%) infants (P = .009).
National data suggest continued biases in the evaluation for abusive head trauma. The conflicting observations of fewer skeletal surveys among white infants and higher rates of diagnosis among those screened elicit concern for overevaluation in some infants (black or publicly insured/uninsured) or underevaluation in others (white or privately insured).
Comments
Some aspects of child abuse in the former Soviet Union
The well-being of children depends on trained and knowledgeable physicians who can identify, treat, and prevent child abuse (1). The key issue about child abuse prevention is often equivalent to eradication of a custom or a vicious pattern, persisting in families. Optimally, each case should be disclosed and exposed to the public. Firm and consequent position of a victim is of importance in this regard. It is easy to expose publicly an unprotected person, e.g., an alcoholic. In other cases, all thinkable mechanisms can be employed to prevent a scandalous disclosure: intimidation and/or subornation of the victim, appeals to preservation of honor and reputation: of a family, ethnic group, a nation etc. It should be commented, however, that over 99% of the publications on child maltreatment was based on research conducted in more developed countries (2); while in less civilized societies child abuse can persist without much publicity around it. Abuses have been chronically under-reported because children fear the loss of support, stigmatization, and retaliation (3). In some cases, there is a cultural acceptance to the abuse of children (3). The problem of child abuse can be formulated by a phrase: “Concealment means perpetuation”. The following text is factually true; only some proper names were changed.
In summer 1959 Sergei was 3 years old. His parents were divorcing, and he was sent together with Tania to a suburb village, where a room in a cottage was rented. They spent there also the summers of 1960 and 1961. Tania was a servant; a term "domrabotnitsa" (house worker) was used in the Soviet Union. Not many memories remained from that time. They had almost no contact with other summer residents. The house owners had oil-stoves but he could hardly remember Tania near them. From food, he recollect mainly bread smeared with something and cucumbers from the kitchen garden. In 1963 his mother married Uncle Grisha. Sergei remembers an episode with the lamp. Tania, who lived in the kitchen, had a cast-iron lamp in a form of a female figure. The faulty lamp would shock upon touch. Seven-year-old Sergei "repaired" it, wrapping around with insulation tape, while he was repeatedly shocked. Uncle Grisha, observing it, reasoned about the role of corporal punishment in upbringing of children, without specifying its difference from physical abuse, which he practiced rather frequently. The abuse was administered in the following forms: slapping or hitting in the face and, less frequently, whipping with a belt; the first episode, complicated by a nasal bleeding, took place when Sergei was 7 years old. The long-lasting psychological consequences in a victim (phobias in the first place) were caused also by intimidation accompanying assault and battery: verbal abuse, loud screaming, grimaces. These ploys were used also out of connection with the physical attacks, obviously with a goal of durable intimidation. In literature, it is sometimes stated that abusive encounters are heavily laden with emotion (4). According to my experience, it might be true in the beginning; but later, as the offender feels increasingly confident about his impunity, the scenes of abuse become more and more theatrical and less laden by a true emotion (on the part of the offender). Indeed, assault and battery often occurred before spectators: the mother, relatives, and even Sergei's friends.
As usual in such cases, Sergei was ashamed to tell to anybody. Once he answered affirmatively a question of a school teacher whether he is physically punished; it had no consequences. Another teacher, having reasons to suspect that something was going wrong in the family, made a home visit; it was followed by a "remission" of several months duration accompanied by improvement of his progress in school studies; then followed a relapse. Apparently, some family friends understood what was going on, but were rather inclined to make fun of it, and continued friendly relationships. In 1970 Sergei asked for help some of his friends, "hooligans" 2-4 years older than he; they discussed it but didn't do anything. The only person who really cared was the grandmother, who wrote letters to the authorities (without any result) and negotiated with the father, persuading him to take Sergei. The father's family of 4 persons lived in a small 2-room (not 2-bedroom!) apartment. Nonetheless, the grandmother succeeded in the late 1970, and he moved to the father's flat. His life there was much sounder, although it was technically hard for everybody. In 1973, during the last school year, he was in fact manipulated to return to the mother's flat. In spite of promises, the physical abuse had been resumed, and was discontinued only when Sergei became a student in September 1973. Obviously, it contributed to Sergei's alcohol consumption: drunkenness made him able to defend himself; it also alleviated shame. As far as Sergei can remember, one of the obstacles preventing him at that time from attacking the offender was an intensive disgust, which could be overcome only with the help of alcohol. Thanks to his mother, Sergei obtained his own room, which ended the conflict. However, because of drunkenness and poor discipline, Sergei was dismissed from the university and went to the army for 2 years in 1975; his education was interrupted for 4 years. It is in accordance with the known fact that victims of child abuse are prone to substance misuse in their later life (5). Besides, there is a considerable body of research demonstarting associations between childhood trauma and negative mental health, physical health, and social outcomes in childhood and later life (5,6).
The reported case should be classified as intimate partner violence (IPV), a common problem, affecting large numbers of children (7). In the countries of the former Soviet Union, there is a considerable backlog in prevention of child abuse and neglect. Apparently, the situation is improving nonetheless: a great part of child abuse cases occurred in connection with excessive alcohol consumption and heavy binge drinking, which appears to be in decline in today’s Russia (8). Therefore, cases unrelated to alcohol, similar to that described in this letter, gain in importance. For more efficient disclosure and prevention of such cases, they should be discussed both in professional literature and in the mass media.
1. Starling SP, Heisler KW, Paulson JF, Youmans E. Child abuse training and knowledge: a national survey of emergency medicine, family medicine, and pediatric residents and program directors. Pediatrics. 2009;123(4):e595-602
2. Mikton C, Butchart A. Child maltreatment prevention: a systematic review of reviews. Bull World Health Organ. 2009;87(5):353-61
3. Quiroga J. Torture in children. Torture. 2009;19(2):66-87
4. Herbruck CC. Breaking the cycle of child abuse. Minneapolis: Winston Press, 1979
5. Larkin W, Read J. Childhood trauma and psychosis: evidence, pathways, and implications. J Postgrad Med. 2008;54(4):287-93
6. Gonzalez A, MacMillan HL. Preventing child maltreatment: an evidence-based update. J Postgrad Med. 2008;54(4):280-6
7. Zolotor AJ, Denham AC, Weil A. Intimate partner violence. Prim Care. 2009;36(1):167-79
8. Jargin SV. Letter from Russia: minimal price for vodka established in Russia from 1 January 2010. Alcohol Alcohol. 2010;45(6):586-8.
Conflict of Interest:
None declared
SES disparities mark risk for abuse
Thank you for this important research. Race is not a risk factor for AHT or child maltreatment and should not be considered in clinical evaluation, but poverty and its attendant environmental effects place infants and children at risk (1). More detailed studies will be needed to better indicate how clinician decision making is carried out. The higher percentage positive findings of abuse on skeletal survey for white infants could result from a combination of racial bias (excess testing of nonwhite infants) and more visible markers of risk (physical appearance and behaviors of parents who are methamphetamine users) in young white parents, who may have a much higher rate of methamphetamine use than other groups (2).
1. The Pediatrician's Role in Child Maltreatment Prevention Emalee G. Flaherty, John Stirling, Jr, and The Committee on Child Abuse and Neglect Pediatrics 2010;126 833-841
2.www.whitehousedrugpolicy.gov/drugfact/minorities/minorities_ff.html
Conflict of Interest:
None declared