Child maltreatment 2002: recognition, reporting and risk.

Background: Child abuse is a major cause of morbidity and mortality in the USA and in all other countries which have studied its incidence. It is the second leading cause of death of children in the USA. To decrease the incidence of child abuse and improve the welfare of children there must be international efforts to recognize, and report child abuse and to decrease those risk factors, which place children in jeopardy. In the USA, reports of child maltreatment have decreased each year since 1994 after nearly two decades of increase. The increase was associated with the passage of laws that mandated reporting child maltreatment and increased recognition of maltreatment.

Results: Several theories have been proposed to explain the decrease. These include: improved economy with decreased caretaker stress and more vulnerable children in day-care, imprisonment of offenders, treatment of victims to prevent reactive abuse, decreased use of corporal punishment, earlier recognition and reporting, prevention programs including home visitors and less corporal punishment in schools. If early recognition is to occur there must be clearly defined and uniform laws that define abuse and the significant consequences to mandated reporters for failure to report. The laws must be concise, understandable and contain medically based definitions of abuse. A bruise should be considered a significant injury. The use of an instrument on a child, for any reason should be reportable as abusive. Society must be taught that a child's head and its contents are particularly susceptible to trauma. Heads should not be slapped, shaken, or struck. The purpose of a report of suspect maltreatment should be to obtain services for families. Without proper services, abuse will reoccur and victims will become victimizers. Any sexual act, including pornography, involving a child who is unable to give consent constitutes reportable sexual abuse. Recognition of what constitutes abuse would be simplified if all countries adopted laws that forbid corporal punishment in schools and homes. Parenting education, which offers alternatives to the use of corporal punishment and anger and stress management skills, should be universal and begun in preschool. In the older child, topics would include conflict management tactics, mate selection, child development, child health, and pregnancy planning.

Discussion: Professional knowledge of child maltreatment is inadequate. This multidisciplinary topic must be incorporated into the undergraduate and graduate curricula in medicine and other professions dealing with children. Child victims are unable to represent themselves. In most other childhood diseases the parents rise up in arms to lobby for their children's rights and raise money for research, professional education and clinical services. In child maltreatment, government and private organizations must take on this task. The valuable resources of Federal Public Health Services become available when child maltreatment is declared to be a disease. Other countries should emulate countries that have eliminated corporal punishment of children. Countries that do not protect children from maltreatment including the ravages of war must be seen as perpetrators of child maltreatment and answerable to the international community. One may adhere to the adage that one is not one's brother's keeper. This should never be applied to children. As the world's most precious resource, we must be the keepers of all children.