International Critical Incident Stress Foundation, Inc.
International Critical Incident Stress Foundation, Inc.
By: Raymond B. Flannery, Jr., Ph.D., FACLP
Unit 42: immediate dispatch to 123 Meadows Lane. Four-year-old male with possible broken ankle secondary to fall from bicycle.
What again? was the simultaneous response from both Evan and his paramedic partner, Jose. Unit 42 had been more active in the days since the governor had relaxed the rules of the pandemic lockdown but this dispatch was for a known frequent flyer. Henri, the four-year-old in question, was a stoic kid, never cried, never complained. Previously, Henri had had three or four serious bruises, one very serious burn, one broken wrist, and now a possible broken ankle……
Henri lived in an expensive gated community on the north side of town. Both parents were busy professionals and both were politically well-connected. Unit 42 pulled into the driveway and Evan saw Henri on the ground by himself. Jose went to the boy’s side and began to provide care. He was assessing the boy’s leg and ankle, when Henri’s mother came to the driveway ten minutes later. Jose felt Henri’s leg muscles tense and freeze. Henri remained silent.
Both paramedics had wondered before but not this time. They radioed ahead to their receiving emergency room to request an assessment for possible child abuse.
Domestic violence is the purposeful infliction harm by one family member on another and may include acts of murder, physical abuse, sexual abuse, nonverbal and verbal threats, and neglect. Parents often abuse each other and, sadly, their children. During pandemics, such as covid-19, and other natural disasters, reports of child abuse usually decline. This is because the child victim is imprisoned in the home with the abuser. There are no teachers, couches, no band directors with whom to interact. Playgrounds are closed, youth sports are cancelled. There is no one to tell. However, when the pandemic lockdowns are lifted, as is happening now in all states, there are people to tell and reports of child abuse and its awful toll begin to emerge and that toll is staggering.
On January 15, 2020, the Children’s Bureau of Health and Human Services Administration for Children and Families reported statistics for 2018, the most recently documented full year. There were 678,000 documented cases of child abuse. Of these, 60.8% were cases of neglect, 10.7% were cases of physical abuse, 7.0% were cases of sexual abuse, and 1,770 deaths of children were due to abuse or neglect. Four-fifths of this abuse was perpetrated by parents. As painful as this is, researchers know that this abuse remains grossly underreported. Child abuse is a major national public health issue.
Child Abuse: A Brief Overview
Types of Abuse
As noted earlier, the active forms of child abuse span a continuum from murder through other various types of abuse to death by neglect. Murder of neonates is usually committed by the mother; murder of adolescents is usually committed by the father. Physical abuse may include punching, kicking, slapping, choking, stomping, cigarette burns, throwing scalding liquids, throwing a person across a room, and the like. Acts of sexual abuse may include any unwanted sexual activity including petting, oral sex, and forced penetration of any open body cavity. It becomes incest, if the assailant is a parent or legal guardian. Active abuse also includes verbal threats and nonverbal threats (e.g., holding as child at gunpoint) of harm. Recently, the federal government has begun to include the abuse of children through the trafficking of children for forced child labor or sexual behaviors. A more passive but more prevalent form of abuse is the neglect of a child. This neglect can include not feeding or clothing a child, not providing protection, basic health care, and/or a basic education.
The Assailants
There is no one type of abusing parent. Assailants include both genders, all races, all faith-traditions, and all social classes. The abuse usually occurs when the child is under age 4 and has been ongoing for one to three years. The parents are often in their late twenties, substance abuse is often present, and one or both parents have themselves been victims of untreated posttraumatic stress disorder. Often they are socially isolated. Some are self-centered, many have limited social supports, and all, obviously, have poor parenting skills.
This abuse occurs when the family unit is facing resource shortages such as housing or food insecurity but it may also increase in today’s age of time scarcity, when the complexity of tasks and the demands of life are fast paced. A pandemic or other type of natural disaster that requires some degree of locking down the community may substantially increase the likelihood of child abuse.
Children at Higher Risk
Some children are at higher risk for abuse. This includes congenitally malformed babies, children with other physical or developmental disabilities, special needs children, illegitimate children, and unwanted children.
The Warning Signs
There are frequently occurring types of injuries in child abuse cases. Often more than one is present. Common injuries included cheek bruises, hidden marks or bruises burns, distended stomach, head injuries, multiple fractures, unusual marks such as from electric cords and cigarette burns, aggressive behavior, social withdrawal, high anxiety, and depression with psychomotor retardation.
Does the adult or child’s explanation of the alleged incident adequately explain the somatic or psychological injuries that you have observed? Does the alleged fall off of the bicycle adequately explain two black eyes? Look for inconsistencies.
Long-Term Consequences
If left untreated, the effects of untreated child abuse can linger throughout the life cycle into late old age and death. There are obvious psychological consequences. These include, anxiety states, depression, untreated posttraumatic stress disorder, suicidal ideation, substance abuse, and impaired concentration and memory. Equally important is the fact that childhood life stress increases the body’s possible inflammation processes. Victims of child abuse during their lifespan may develop heart disease, diabetes, liver disease, chronic lung disorders, irritable bowel syndrome, asthma, chronic pelvic pain, migraine headaches, and fibromyalgia.
An additional major negative consequence is the development of the intergenerational transfer of violence. Research has shown that children who are abused and not treated are at a 66% increase to be violent in their own subsequent family lives.
First Responders and the Child Abuse Call
As we have noted, as the lockdown from the pandemic is gradually lifted, past disasters would predict an increase in calls that reflect cases of child abuse and this is the usual case. A few general principles may prove of assistance.
Suggested Readings:
Nemeroff, C.B. (2016): Paradise Lost: The Neurobiological and Clinical Consequences of Child Abuse and Neglect. Neuron 89: March 2.
Widom, C.S. (1989): Does Violence Beget Violence? A Critical Examination of the Literature. Psychological Bulletin 196:3-28
Raymond B. Flannery, Jr., Ph.D., FACLP, is Director of the Assaulted Staff Action Program (ASAP) and is on the faculties of the Harvard and the University of Massachusetts Medical Schools.
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