Thursday, July 05, 2012

HISTORY: 50 years ago today "The Battered-Child Syndrome recognized by medical professionals

Viewpoint | July 4, 2012
“The Battered-Child Syndrome” 50 Years Later:  Much Accomplished, Much Left to Do

John M. Leventhal, MD; Richard D. Krugman, MD

Author Affiliations: Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut (Dr Leventhal); and Office of the Vice Chancellor for Health Affairs, University of Colorado School of Medicine, Aurora (Dr Krugman).

A half century ago, Kempe and colleagues1 published in JAMA “The Battered-Child Syndrome,” an article that would change the way physicians and others care for children with injuries. Although this article was not the first in the medical literature to address the problem of physical abuse of children, the authors did report the first epidemiologic study and highlighted important aspects of the evaluation of suspected abuse: (1) the discrepancy between the stated history and clinical findings, (2) questions that can be asked of parents when physicians are concerned about possible abuse, (3) some of the key physical examination and radiographic findings in abused children, (4) associated findings such as poor hygiene and failure to thrive, and (5) reasons physicians might have difficulty believing that parents can hurt their children.

Since 1962, several major developments have occurred regarding maltreated children in the United States, including the development of state-mandated reporting laws; the establishment of county- or state-based child protective services (CPS) agencies, which are responsible for the investigation of suspected maltreatment, decisions about whether a child has been maltreated, placement of children in foster care when necessary, and services for the families when maltreatment has occurred; the broadening of the term “child abuse” to “child maltreatment,” which now includes physical abuse, neglect, sexual abuse, and emotional maltreatment; and the establishment in 2009 of a new pediatrics subspecialty, child abuse pediatrics.

The 50th anniversary of the article by Kempe et al is an opportunity to reflect on 3 salient lessons learned over the past 5 decades about the care of maltreated children: (1) many children and families are affected; (2) the consequences can be lifelong and intergenerational; and (3) treatment and prevention can work but need to be expanded.


Maltreatment is far more common than first reported by Kempe et al. Data about the scope of the problem have been obtained from CPS agencies, mortality statistics, hospital discharge data, and national surveys of adults, parents, and older children and adolescents.

In 2010, 3.3 million reports affecting 5.9 million US children were filed with CPS agencies; 695 000 children (0.9% of all children in the country) were substantiated as having experienced maltreatment.2 Approximately 78% were substantiated for neglect, 18% for physical abuse, and 9% for sexual abuse, and 1560—most younger than 5 years—died from maltreatment,2 although this number is likely an underestimate.

Based on data from CPS agencies, the incidence of substantiated cases of child physical abuse and sexual abuse has decreased since 1990 by more than 50%.3 These declines are believed to be attributable, in part, to increased services for children and families, including prevention programs; widespread use of psychiatric medications; and jailing offenders. Data from other sources have not provided as optimistic a picture about a decrease in the occurrence of specific kinds of maltreatment. For example, the national incidence of hospitalization of children for serious injuries attributable to physical abuse has remained stable at about 6 cases per 100 000 children from 1997 to 2009.4 These cases represent less than 4% of all physically abused children, but the marked difference in the results comparing these rates of hospitalizations with the CPS data suggests that different aspects of the phenomenon of physical abuse are being measured.

Research has clearly shown that children who have experienced one type of maltreatment often have experienced other types of maltreatment and often other types of violence, such as exposure to domestic violence.

The consequences of maltreatment to the child can range from mild to severe depending on many factors, including the length of time the maltreatment occurs, the age of the child, the relationship of the abuser to the child, other stressors affecting the child and family, individual vulnerabilities, and whether treatment is available. Felitti et al5 have examined the long-term relationship between adverse childhood experiences, including physical and sexual abuse and neglect, and adult functioning and health problems. The more adverse events a child experiences, the more serious the health outcomes are in adulthood. Some long-term consequences relate to adults trying to cope with the psychological pain of their adverse childhood experiences by adopting maladaptive behaviors, such as use of alcohol or other drugs, smoking, or overeating. An increasing number of studies show the lasting effects of child maltreatment on brain development and the hypothalamic-pituitary-adrenal axis.

Longitudinal studies of maltreated children and comparison children have demonstrated long-term consequences, including intergenerational effects. Thus, children who have experienced abuse or neglect in childhood are at increased risk of committing violent crimes as young adults.6 Girls who have experienced intrafamilial sexual abuse are at increased risk of teen pregnancy, and their children are about 10 times more  likely to be reported to CPS than are the children of sociodemographically similar girls who were not sexually abused.7

The effects of maltreatment extend to the family and society as a whole. For example, families may be disrupted by the placement of children in foster care or by the arrest of the perpetrator in cases of sexual or physical abuse. Fang et al8 estimated that in 2008 the total lifetime economic burden resulting from child maltreatment was approximately $124 billion.

During the last few decades, mental health interventions targeting children and families who have experienced trauma, such as sexual abuse or domestic violence, have been developed, tested in clinical trials, and disseminated through networks such as the NCTSN (National Child Traumatic Stress Network). Less attention has been paid to developing interventions to help parents who have neglected their children, although the SafeCare model, which has been evaluated in Oklahoma, has shown a marked decrease in repeat reporting of children for abuse or neglect by focusing home-based services on parent-child interactions, home safety and cleanliness, nutrition, and medical care.9

Efforts at prevention have included changing a community's approach to helping children and families; providing home visiting to socially high-risk, first-time mothers for extended periods during the prenatal period and when the child is young; and targeting specific behaviors, such as the prevention of shaken baby syndrome. Several home visiting models aimed at preventing abuse and neglect have been shown effective. Among these is the Nurse Family Partnership, which has demonstrated a significant reduction in physical abuse and neglect over the lifespan of children whose first-time mothers received 2½ years of services during pregnancy and early childhood.10


If Henry Kempe were alive today, how might he view this progress, and what concerns would he have? He would be surprised at the enormous medical and psychological literature on maltreatment, he would be most pleased about the proliferation of Children's Trust Funds (first suggested by his colleague, Ray Helfer) that focus on the prevention of abuse and neglect, and he would be impressed with the quality and quantity of home visitation programs. He also would be pleased by the number of physicians engaged in the field of child maltreatment. But he would be disappointed by the lack of any committed federal funding dollars for research and training focused on child maltreatment, and he would be vocal in his criticism of a child protection system that often fails to provide adequate treatment services for children and families.

Fifty years later, there is still much work to do. Now is the time to redouble efforts to get on with it.

Corresponding Author: John M. Leventhal, MD, Department of Pediatrics, Yale University School of Medicine, PO Box 208064, 333 Cedar St, New Haven, CT 06520-8064 (

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Leventhal reported serving as an expert witness in cases related to child abuse; receiving child abuse program funding from Connecticut state agencies, including the Department of Public Health, Department of Social Services, Department of Children and Families, and Office of Victim Services; receiving payment for serving as a guest speaker at the University of Pennsylvania; and receiving travel expenses from the American Academy of Pediatrics and the National Center on Shaken Baby Syndrome. Dr Krugman reported no disclosures.

Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome.  JAMA. 1962;181(1):17-24
US Department of Health and Human Services, Administration on Children, Youth and Families.  Child Maltreatment 2010. US Department of Health and Human Services website. 2011. Accessed February 1, 2012
Finkelhor D, Jones L, Shattuck A. Updated Trends in Child Maltreatment, 2009. University of New Hampshire website. Accessed February 1, 2012
Leventhal JM, Gaither JR. Has the incidence of serious physical abuse in children changed in the U.S. from 1997 to 2009? Presented at: Pediatric Academic Societies Annual Meeting; April 28, 2012; Boston, MA. Abstracts2View website. Accessed June 9, 2012
Felitti VJ, Anda RF, Nordenberg D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.  Am J Prev Med. 1998;14(4):245-258
Widom CS, Maxfield MG. An Update on the “Cycle of Violence.” National Criminal Justice Reference Service website. February 2001. Accessed May 1, 2012
Trickett PK, Noll J, Putnam FW. The impact of sexual abuse on female development: lessons from a multigenerational, longitudinal research study.  Dev Psychopathol. 2011;23(2):453-476
Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention.  Child Abuse Negl. 2012;36(2):156-165
Chaffin M, Hecht D, Bard D, Silovsky JF, Beasley WH. A statewide trial of the SafeCare home-based services model with parents in Child Protective Services.  Pediatrics. 2012;129(3):509-515
Olds DL, Eckenrode J, Henderson CR Jr,  et al.  Long-term effects of home visitation on maternal life course and child abuse and neglect: fifteen-year follow-up of a randomized trial.  JAMA. 1997;278(8):637-643
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