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Physicians should not shy away from confronting parents

- Consider religious, ethnic customs when diagnosing child abuse

by Alison Sulaski Wyckoff, Staff Writer

Walter F. Lambert, MD, FAAP Walter F. Lambert, M.D., FAAP, is fond of asking audiences to raise their hands if they were hit by their parents as children. In a typical room, even of physicians, he gets an 80 percent affirmative response. Then he asked how many were hit with instruments, and most hands remain up.

When he poses the final question, "How many ever had a bruise as a result of the punishment," most hands go down, but one or two people admit to permanent marks. He asks those individuals if they feel they were abused.

"The reason I do this is that we tend to define what is acceptable and not acceptable by our own experience," said Dr. Lambert, associate professor of clinical pediatrics at University of Miami, in Florida.

"The truth is, as we become more global as a community, we have different traditions," and not all physical punishment constitutes abuse.

"Some (cases) don't rise to the legal definition of abuse," Dr. Lambert explained during a speech on international issues in child abuse and neglect at the 1999 AAAP Spring Session. "We have to prioritize which cases warrant our attention and identify those children at risk," taking into consideration the cultural groupings and social issues affecting most pediatricians' increasingly diverse patient populations.

His idea of child abuse might differ from most people's because of his role as a forensic expert. he is part of a statewide network of more than 20 child protection teams (CPTs) directed by Florida Pediatricians.

Florida's child protection teams exist thanks to J.M. Whitworth, M.D. FAAP, of the Children's Crisis Center in Jacksonville, who founded the network and oversees it. He is chair of the AAP Florida Chapter Committee on Child Abuse and Neglect and moderated the Spring Session presentation.

CPT directors share ideas and resources through regular meetings and via the Internet, consulting regularly to reach diagnoses and offer general support. As medical director of the three of the geographically based teams, Dr. Lambert remains in regular contact with the other team directors, who also make up the state chapter's Committee on Child Abuse and Neglect.

While some physicians need only report a suspicion of child abuse, he and the other directors are obliged to make a definite call. "I have a very different burden than other people, "Dr. Lambert said.

Conflict Over Punishment

According to Dr. Lambert America's inherent conflict about punishment reflects a changing society. While some maintain parents never should hit their childrenm most U.S. laws don't support that.

In addition, while at least seven countries now prohibit corporal punishment America, with its tradition of individualism, is "nowhere close to being like Sweden, where people don't hit their kids, " he said. He calls such an environment a wonderful cultural goal, yet far removed from his world as a child abuse expert. According to the Chicago based organization Prevent Child Abuse America, U.S. child protective service agencies received reports of more than 3 million children being abuses or neglected in 1997.

When questioned about a possible abuse incident, a common response among some immigrants is, "In my country, that was OK, " Dr. Lambert said. He said he constantly finds himself saying, "We have laws. Some things that may be alright there and that may be the social practice of some people in the Unites States are not OK."

Well-child visits offer pediatricians a chance to discuss definitions of acceptable and unacceptable behavior. Religious rites, herbal therapies, folk remedies and non-Western healing practices are among the customs that sometimes can be misinterpreted as child abuse.

For instance, in Mexico and South America, chest rattle might be treated with "cupping," in which warm cups are placed over the chest "to draw out illness." In Cambodia, fever could be treated with cao gao, in which hot coins are rubbed over a child's back or chest.

Problems also can arise from parents' confusion over the difference between punishment and discipline. "The goal of discipline is to get a positive behavior, whereas punishment is inflicted to obtain a negative reinforcement for a bad behavior. The idea is not to get rid of the bad behavior, but to get good behavior on a regular basis with less bad behavior, " he said.

"My biggest issue in the Americans who say, 'If I don't do this (beat their children), my kids are going to end up drug addicts.' I feel it's easier to deal with immigrants because they understand that there are laws ... They can always go home if they don't agree with the laws here."

Some findings, however, should always raise red flags. these include reports of chokinf episodes, as well as the physical findings of bite marks, all injuries toward the face, knuckle marks, etc.

When faced with a potential case of abuse, Dr. Lambert determines the age and specific behavior of the child, the length of time between punishment and behavior, the part of the body hit, whether there were any injuries, and whether there was the potential for significant injury.

He also asks how many different blows occurred on how many different occasions. Was there one bad beating, or did it happen 20 different times over a month?

"What I try to do is tell the people using instruments to please put down the instrument. At least if I am hitting with my hand, I know how hard I am hitting." He said it is easier to wean people to less violent or less physical types of punishment "than to ask somebody who always has seen people hit by belts to go straight to 'time out.'"

To avoid uncomfortable discussions about punishment and discipline, some pediatricians might be tempted to hand out pamphlets on time-out. "The physicians don't know how to deal with people telling them things they personally don't agree with or are worried that they are going to have to report," Dr. Lambert said.

"They've gone from giving specific advice and guidance to more general points. I think we forgot that we have social authority, that you can say to people that there is not just one strategy to use."

Among the AAP resources available to help pediatricians recognize child abuse are the side kit, "The Visual Diagnosis of Child Sexual Abuse"; the CD-ROM, "Focus on Child Abuse: Resources for Prevention, Recognition, and Treatment (ed. 2)"; the slide program, "The Physical Diagnosis of Child Physical Abuse"; and the second edition of A Guide to References and Resources in Child Abuse and Neglect, which includes AAP policy statements. All are available by contacting AAP Publications at 800-433-9016 or www.aap.org.

Aap news vol 15, #9, 9/99 pp 18-19