Abstract

Child abuse and neglect is a common problem that is potentially damaging to long-term physical and psychological health of children. As society and culture have progressively changed different configurations of child abuse and neglect have emerged. Few attention has been focused on these types of child maltreatment that represent the new emergency in this field. Pediatricians should be trained to play a major role in caring for and supporting the social and developmental well-being of children raised in variously conditions and in new types of problems. Pediatric care has been based on the increased awareness of the importance of meeting the psychosocial and developmental needs of children and of the role of families in promoting the health.

Keywords: Child abuse, neglect, emergency

Child abuse and neglect is a common problem that is potentially damaging to long-term physical and psychological health of children. Over the past, researchers have documented this relationship and have identified two possible mechanisms that can explain the increased incidence of childhood stress and consequent adult somatic disease: the increased incidence of health harming behaviors and causes epigenetic and other changes that predispose individuals to disease through a raised non-specific inflammatory profile. (1) Abuse survivors, as well as persons who have experienced other types of childhood adversities, are more likely to participate in high-risk behaviors. (2) According to federal definition of Child Abuse Prevention and Treatment Act (CAPTA) by the term “child abuse and neglect” we mean any act, or failure to act, by a parent or caregiver, meaning by this term the teacher, coach and anyone who has an educational role or caregiving, which leads to physical or emotional harm, sexual exploitation or abuse, or death; or an act, or failure to act, that results in imminent risk of injury. (3)

Child maltreatment is a common event, even if it is not always recognized, disclosed or reported. Identifying the real number of maltreated children is a challenge because of the large variability in reported prevalence data across studies.

In 2014 there were a nationally estimated 702,000 victims of abuse and neglect. Three-quarters (75.0%) of victims were neglected, 17.0 percent were physically abused, and 8.3 percent were sexually abused. Moreover, 1,580 children died of abuse and neglect at a rate of 2.13 per 100,000 children in the national population. (4)

These data are undervalued and they do not reflect the real prevalence of the problem so they need a careful evaluation.

Child neglect exposes children to cognitive and language problems, with fewer positive social interactions, they lack of coping ability, they are dependent, and unhappy and during adolescence and adulthood, child neglect is associated with criminal behaviour, personality disorders, substance abuse and stressful life events. Studies about the health status of children in foster care detect that the health care needs are strongly dependent by the factors that determine foster placement. The placement is due to different reasons such as: abandonment, poverty, neglect, physical or sexual abuse, drug use by biological parents, parental psychopathology and family breakdown; based on that, it is not surprising the high prevalence of mental health problems. The particular experience of each child affects greatly his or her health from a physical, mental and social point of view. (5-7).

Injuries from physical abuse can leave permanent scars, disfigurement or impaired physical functioning. Childhood physical abuse seems to be another risk factor for ischemic heart disease, in addition to the traditional ones and increases the risk for both overall and central obesity in adulthood. (8,9) Other physical problems of these vulnerable children include growth failure, lead poisoning, untreated vision problems, atopic dermatitis, infectious diseases. (10) Finally, physical abuse exposes children to increased risk of depression, alcohol abuse, anxiety, and suicidal behaviour. (2, 11)

Sexual child abuse can lead to three main types of outcomes: physical, psychological/psychiatric sequences and the risk of revictimization. It can cause gynaecological consequences such as chronic pelvic pain, dyspareunia at the beginning of sexual activity, vaginismus and non-specific vaginitis and can cause inappropriate sexualized behaviour, such as repeated object insertion into vagina and/or anus, age-inappropriate knowledge of sex, ask for being touched in genital area. (12,13)

Another key point and emergency problem is the economic burden of child maltreatment in high income countries. Recent studies and data analyses from different countries have reported that the costs for medical treatments, social rehabilitation programs, justice and long term support plans for maltreated children lead to an increase of public expenses which could be preventable Implementation of preventive programs, improvement of medical care quality and rationalization of health and social services are among the measures suggested to contain the costs. (14) Of course, socio-economic costs are different for each type of abuse, and usually reflect the general social, economic, and health conditions within the states and their local communities, as well as the differences of public health programs among countries in general.

New types of emergency

A) Few and sparse attention has been focused on children whose mother was murdered. For child psychiatry teams these are difficult cases and few individuals have experience of working with such children in their professional lifetime. Where children should live and with whom, whether they should attend the funeral, see their father in prison are questions that require consideration and discussion. Judges, police, social workers, or offices that attend the victims could make decisions about protection, on the basis of empirical data and not merely using intuitive criteria. For this reason, long-term studies are needed to ascertain what happens to these children (especially when they grow up), to understand what are the most appropriate psychological treatments, the best decisions about the contact with their father (when he is the murderer) and the best placement for these children. (15)

B) Injuries in stationary vehicles for children younger than 14 years old are poorly recognized type of vehicle injury and receive far less attention than motor vehicle crashes. (16) Recent researches confirm that the leading cause of death for children is stroke and hyperthermia after being left unattended in motor vehicles. Unattended children tended to be younger than children who died while playing. Three quarter of our cases occurred during warmer months: spring and summer. According to these data, one might well ask how it can happen that a parent leaves his child unattended in the car. A scientific explanation could be related to the Working Memory (WM). WM refers to the system or systems that are assumed to be necessary in order to keep things in mind, while performing complex tasks such as reasoning, comprehension and learning. (17) There is great evidence that stress and enhanced glucocorticoids levels can influence memory performance with both negative and positive consequences. A recent study assessed the effects of stress and cortisol on a variety of memory tasks in male human subjects and demonstrated that there is a stress-induced working memory impairment. (18) These could explain how stress and busy everyday life could influence our behavior and bring a parent to leave unattended his child in the car. Leaving a child alone in a car can be considered a form of neglect.

C) Factitious disorders (FD) are defined as the intentional production or feigning of symptoms and disabilities, which are either physical or psychological in nature, in an attempt to assume the patient role. (19,20) The motivation to assume the patient role, rather than to obtain an external reward, distinguishes FD from malingering. Malingering and FD both differ from somatoform disorders and dissociative/conversion disorders. While the symptoms of somatoform disorders are characterized by active dissimulation, the symptoms of dissociative/conversion disorders are presumed to arise from unconscious conflicts and to be unintentionally produced. In 1977, Meadow described cases in which a parent or a caregiver, produce or feign symptoms or even signs of a nonexistent illness in their children that had to undergo innumerable harmful examinations and treatments. (21) This condition was defined as MS by proxy (MSBP), and it was considered the hinterland of child abuse. For this reason, the pediatric recent literature has paid great attention to the MSBP. Moreover, this condition is associated with high mortality, morbidity, abuse, family disruption, and harm to siblings and in some cases, there was a tendency for the children to grow up believing to be disabled.

D) During the first six months of 2015 more than 106,000 children have asked for asylum to the European Union (EU). (22-24) The number of unaccompanied children entering the EU is increasing. Particularly, in Italy, while they were 5,821 in December 2012, the number of unaccompanied minors was 6,319 and 10,536 respectively at the end of 2013 and 2014 (increases of 8.4% and 31.7%). They come from different countries: the majority of them are from Egypt, Albania, Gambia, Somalia. Most of them are male (95.4 % of male vs 4.6% of female) and 16-17 years old. They are not hosted in equal number in every Italian regions: more than 60% of them live in Sicilia, Lazio, Lombardia or Puglia. Latest available data (September 2015) underline the presence of 9,699 (94.9% female and 5.1 % male) separated children in Italy. Of them, 54% are 17 years old, 27.1% are 16 years old, 10.6% are 15 years old, 7.8% are aged between 14 and 7 years, while only 0.4% are aged between 0 and 6 years. The majority of them are from Egypt, Albania, Eritrea, Gambia and Somalia. Alarming data about the destiny of many of these children come from Ministero del Lavoro e delle Politiche Sociali: once arrived in Italy, about one third of the minors vanished. The report of September 2015 shows that, among unaccompanied children, 5,588 can’t be found. These children may fall victim of kidnapping, trafficking, labour and sexual exploitation, prostitution. Then number of female children who disappear yearly is higher that the male one: up to 50% of female minors vanish yearly, while only 30% of them disappeared during the last year. All children have the right to live in a safe environment where they can grow up and achieve their potential. There must not be a right or wrong place to be born. (25)

E) Every day, millions of children are exposed to violent and traumatic news and images that can damage the quality of their lives. Indeed, media, providing a constant stream of updates, video and images about violence, trauma and death, play an important role in the development of stress reactions in children, even if they are not directly exposed to the events. (26,27) It became clear after the 9/11 attacks that young children could develop acute stress reactions and post-traumatic stress disorder simply from cumulative exposure to media coverage of the event, even though the attack itself did not impact anyone they knew personally. Children are particularly fragile and vulnerable to the impact of traumatic events because of their lack of skills and experience in the management of such information. They may be unable to fully understand the information they get and to integrate them into their schema, so that they usually count on caregivers to deal with stressors, to have reassurance and explanation about every upsetting or unfamiliar event. Individual, family, and social factors influence disaster reactions and the diverse ways in which children cope. Thus, it’s important for caregivers to understand which is the best way to answer to children’s questions and to discuss with them about their fears and emotions in order to help them dealing with this kind of distressing events. Disasters and traumatic events can take any form. Children reactions to them vary, as well: a lot of children don’t develop psychological or psychiatric conditions, a number of children can experience distress that decreases with time, while other can experience long-lasting effects, like academic failure, post-traumatic stress disorder, depression, anxiety, bereavement, behavioural problems.

F) Interest in health care inside prison has grown in recent years. (28) However, little attention has been paid to the health care of children under the age of 3 years in jail with their mothers. Italian law, in agreement with European directives, dictates that the same sanitary assistance given to the population outside prison must be equally guaranteed to prisoners. (29) For the first few years of life the interactive context of children coincides with the maternal figure and the mother’s psyche becomes an integral part of the child’s mind. We think that the nest areas can guarantee a suitable environment for the normal psychophysical development of such children and promote health care for this vulnerable group. Access to the prison health service may be the first opportunity for an inmate to receive medical care. Moreover the period in prison could offer opportunities to improve the prisoner’s health.

G) Several definitions of modern baby abandonment are available. (30,31) The US government has distinguished between “boarder babies”, “abandoned infants” and “discarded infants”. The first two abandonment types refer to babies left in hospitals, with abandoned infants defined as newborn and boarder babies aged up to 12 months. Discarded infants are those abandoned in other public places without care or supervision, and include neonaticide cases. In an attempt to reduce the number of infanticides and abandonment in unsafe places such as public restrooms, many states have enacted legislation to provide “safe places” for mothers to abandon their newborns. In Italy, like in other country, there are for the babies abandoned in the hospital the “baby hatch”, a comfortable space, usually near the hospital, where mothers can leave their babies anonymously with the certainty that the baby will be cared for. Other countries where these structure were established are Germany (more than 90 locations), Poland, Czech Republic, Hungary, Austria, USA, India and South Africa. (32). It needs to identify the categories of parents at risk and to give them a particular help. In particular, the prevention should begin before birth and the assistance must be extended in the months after delivery, with structured strategies.

In conclusion, as society and culture have progressively changed different configurations of child abuse and neglect have emerged. Pediatricians should be trained to play a major role in caring for and supporting the social and developmental well-being of children raised in variously conditions and in new types of problems. Pediatric care has been based on the increased awareness of the importance of meeting the psychosocial and developmental needs of children and of the role of families in promoting the health (33).

References

  1. Ferrara P, Guadagno C, Sbordone A, Amato M, Spina G, Perrone G, Cutrona C, Basile MC, Ianniello F, Fabrizio GC, Pettoello-Mantovani M, Verrotti A, Villani A, Corsello G. Child abuse and neglect and its psycho-physical and social consequences: A review of the literature. Population Research and Policy Review 2016 Nov; 12(4): 301-10.
  2. Ferrara P, Ianniello F, Cutrona C, Quintarelli F, Vena F, Del Volgo V, Caporale O, Malamisura M, De Angelis M, Gatto A, Chiaretti A, Riccardi R. A focus on recent cases of suicides among Italian children and adolescents and a review of literature. Ital J Pediatr 2014 Jul 15;40(1):69.
  3. The Child abuse Prevention and Treatment ACT of 2010 [monograph on the Internet]. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau [cited 2015 December]. Available from: (www.acf.hhs.gov/sites/default/files/cb/capta2010.pdf).
  4. Child maltreatment 2014 [monograph on the Internet]. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau [cited 2015 December]. Available from: (www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf).
  5. Hildyard K, Wolfe D. Child neglect: developmental issues and outcomes. Child Abuse & Negl 2002; 26 (6-7):679-95.
  6. Ferrara P, Romani L, Bottaro G, Ianniello F, Fabrizio GC, Chiaretti A, Alvaro F. The physical and mental health of children in foster care. Iran J Public Health 2013 Apr;42(4):368-73.
  7. Ferrara P, Corsello G, Sbordone A, Nigri L, Ehrich J, Pettoello-Mantovani M. Foster care: a fragile reality needing social attention, and economic investments. J Pediatr 2016 June; 173: 270-1.
  8. Dong M, Giles WH, Felitti VJ, Dube SR, William JE, Chapman DP et al. Insights into causal pathways for ischemic heart disease adverse childhood experiences study. Circulation 2004; 28; 110(13):1761-6.
  9. Boynton-Jarrett R, Rosenberg L, Palmer JR, Boggs DA,Wise LA. Child and adolescent abuse in relation to obesity in adulthood: the black women’s health study. Pediatrics 2012; 130(2):245-53.
  10. Garcovich S, Gatto A, Ferrara P, Garcovich A. Vulvar pyoderma gangrenosum in a child: a case report. Pediatr Dermatol 2009 Sep-Oct; 26 (5): 629-31.
  11. Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med 2012; 9(11):e1001349.
  12. Maniglio R. The impact of child sexual abuse on health: A systematic review of reviews Clin Psychol Rev 2009; 29(7):647-57.
  13. American College of Obstetricians and Gynecologists. Committee on Health Care for Underserved Women. Committee opinion no. 498: Adult manifestations of childhood sexual abuse. Obstet Gynecol 2011; 118(2 Pt 1):392-5.
  14. Ferrara P, Corsello G, Basile MC, Nigri L, Campanozzi A, Ehrich J, Pettoello-Mantovani M. The economic burden of child maltreatment in high income countries. J Pediatr 2015 Dec; 167(6): 1457-9.
  15. Ferrara P, Caporale O, Cutrona C, Sbordone A, Amato M, Spina G, Ianniello F, Fabrizio GC, Guadagno C, Basile MC, Miconi F, Perrone G, Riccardi R, Verrotti A, Pettoello-Mantovani M, Villani A, Corsello G, Scambia G. Femicide and murdered women’s children: which future for these children orphans of a living parent? Ital J Pediatr 2015 Sep 29; 41(1): 68.
  16. Ferrara P, Vena F, Caporale O, Del Volgo V, Liberatore P, Chiaretti A, Riccardi R. Children left unattended in parked vehicles: a focus on recent italian cases and a review of literature. Ital J Pediatr 2013 Nov 6; 39(1): 71.
  17. Baddeley A. Working memory. Curr Biol 2010; 20:136-40.
  18. Luethi M, Meier B, Sandi C. Stress effects on working memory, and implicit memory for neutral and emotional stimuli in healthy men. Front Behav Neurosci 2008; 2:1-9.
  19. Ferrara P, Vitelli O, Bottaro G, Gatto A, Liberatore P, Binetti P, Stabile A. Factitious disorders and Munchausen’s syndrome: the tip of the iceberg. J Child Health Care 2013 Dec; 17(4): 366-74.
  20. Bass C, Glaser D. Early recognition and management of fabricated or induced illness in children. Lancet 2014 Apr 19;383(9926):1412-21.
  21. Meadow R. Münchausen syndrome by proxy. The hinterland of child abuse. Lancet 1977; 13;2: 343-5.
  22. Ferrara P, Corsello G, Sbordone A, Nigri L, Caporale O, Ehrich J, Pettoello-Mantovani M. The “invisible children”: uncertain future of unaccompanied minor migrants in Europe. J Pediatr 2016 Feb; 169: 332-3.
  23. Ministero del Lavoro e delle Politiche sociali. I minori stranieri non accompagnati (MSNA) in Italia report di monitoraggio – 30 aprile 2015. Available from: www.lavoro.gov.it.
  24. UNHCR. UNHCR Guidelines on Determining the Best Interests of the Child. www.unhcr-centraleurope.org/pdf/who-we-help/children/unhcr-guidelines-on-the-best-interest-of-the-child.html.
  25. Ferrara P, Amato M, Hadijpanayis A, del Torso S, Stiris T. The rights of children arriving in Europe. Lancet 2015 Nov 14; 386: 1939-40.
  26. Ferrara P, Corsello G, Ianniello F, Sbordone A,Ehrich J, Pettoello-Mantovani M. Impact of distressing media imagery on children. J Pediatr 2016 Jul;174: 285-6.
  27. Pfefferbaum B, Newman E, Nelson SD. Mental health interventions for children exposed to disasters and terrorism. J Child Adolesc Psychopharmacol 2014 Feb;24(1):24-31.
  28. Ferrara P, Gatto A, Nicoletti A, Emmanuele V, Fasano A, Currò V. Health care of children living with their mother in prison compared with general population. Scand J Public Health 2009 May; 37 (3): 265-72.
  29. Council of Europe. Recommendation R (98) 7 of the Committee of Ministers to member states concerning the ethical and organisational aspects of health care in prison. Council of Europe Committee of Ministers, Strasbourg; 1989.
  30. Mueller J, Sherr L. Abandoned babies and absent policies. Health Policy. 2009 Dec;93(2-3):157–64.
  31. Ferrara P, Gatto A, Paolillo P, Vena F, Ianniello F, Romagnoli C. Abandoned newborn: neglected phenomenon? Early Human Development 2013;89: S45-6.
  32. Evans S. The “baby box” returns to Europe. Berlin: BBC News Magazine. 2012; http://www.bbc.co.uk/news/magazine-18585020.
  33. Corsello G, Ferrara P, Chiamenti G, Nigri L, Campanozzi A, Pettoello-Mantovani M. The child health care system in Italy. J Pediatr 2016 Oct; 177S: S116-26.

Corresponding Author:
Prof. Pietro Ferrara, MD,
Institute of Pediatrics
Catholic University Medical School
L.go Francesco Vito, 1
00168, Rome, ITALY
Email pietro.ferrara@unicatt.it

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