PEDIATRICS Vol. 99 No. 2 February 1997,
p. e8
Copyright ©1997 by the American Academy of Pediatrics
ELECTRONIC ARTICLE:
Pediatric Injury Resulting From Family Violence
Cindy W. Christian*,
Philip Scribano
,
Toni Seidl§, and
Jennifer A. Pinto-Martin
From the Divisions of * General Pediatrics and
Emergency
Medicine, § Department of Social Work, and
School of Nursing,
Children's Hospital of Philadelphia, University of Pennsylvania School
of Medicine.
ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ABBREVIATIONS
REFERENCES
ABSTRACT
Objective. Children who live in
violent households are at risk for emotional and physical injury.
Although recent research has addressed the emotional impact of
witnessing family violence, no study has addressed the inadvertent
physical injuries that result to children who witness family violence.
The objective of this study was to describe the causes, types, and
patterns of pediatric injuries resulting from family violence.
Methods. We reviewed the medical records of 139 children
who presented to the emergency department with injuries resulting from
domestic violence for demographic information, mechanism of injury,
type, location, and severity of injury, treatment, and disposition.
Results. Children who were injured during domestic
violence ranged in age from 2 weeks to 17 years. Although the mean age of the children identified was 5 years, 48% of the children were younger than 2 years. Although the most common dyad involved in the
fight was the mother and father (57% of cases), extended family members and nonrelated adults were involved in almost one third of the
cases. The most common mechanism of injury was a direct hit (36%). Of
the injured children who were younger than 2 years, 59% were injured
while being held by parents. Thirty-nine percent of the children were
injured during attempts to intervene in fights. The majority of
injuries were to the head (25%), face (19%), and eyes (18%). Young
children sustained more head and facial injuries than older children,
who had disproportionately more extremity trauma. Medical intervention
was indicated in 43% of patients, of which 9% required hospital
admission and 2% required surgical or intensive care intervention. Of
the 91% of children discharged from the emergency department, 73%
returned home, and 27% went to alternative homes.
Conclusions. Children sustain a wide range of physical
injuries from family violence. Because the majority of injuries are minor, specific inquiry into the causes of all pediatric injuries may
help further identify children living among family violence. domestic violence, child abuse, family violence, physical injury.
INTRODUCTION
Family violence, traditionally defined as child and spousal
abuse,1 is prevalent in American society. In 1993, more than 1 million children were the victims of substantiated
maltreatment,2 and each year, approximately 2 million women
are severely assaulted by male partners.3 Intrafamilial
violence not only affects the physical health and emotional well-being
of the victim, it also affects those of all family members. It is
estimated that more than 3.3 million American children between 3 and 17 years of age are at risk of exposure to parental violence each
year.4 Recent work has highlighted the emotional impact on
children who witness domestic violence. Studies suggest that children
who witness family violence have increased behavior
problems,5 poor adaptive and social skills,6
and aggressiveness.7 Children who live in violent
households are also at risk for physical injuries, although little
empiric data exist describing the physical injuries children sustain
secondary to violence between adults in the family. To date, no study
has systematically described the range and severity of physical
injuries sustained by children secondary to adults fighting in the
household. This article describes the causes, types, and patterns of
pediatric injuries that result from family violence.
METHODS
Patient Population
A retrospective review of children seen in the emergency
department at Children's Hospital of Philadelphia with injuries
resulting from family violence between 1984 and 1994 was undertaken.
Patients were identified by a search of the hospital's child abuse
reporting logs for the period under study. For many years, including
all the years of this study, the hospital has reported children injured during family violence to the Child Protective Services (CPS) system
for investigation and intervention. The medical records of children
identified in the emergency department as being injured during
household adult violence and reported to CPS were obtained, and data
were abstracted. Children who were victims of direct physical abuse
were excluded.
Procedures
The following data were abstracted from the medical records
using a standardized form for data collection: (1) demographic information, (2) date of initial visit and age of the child, (3) the
adult accompanying the child to the hospital, (4) individuals involved
in the fight, (5) individual who actually injured the child, (6) the
use of drugs and/or alcohol by adults involved in the incident, (7)
history of events leading to the injury, (8) the location, type, and
severity of injury, (9) the mechanism of the injury, (10) treatment
required for the injury, and (11) disposition of the child.
Definitions
Family violence is defined as violence between two or more
household members: parents, relatives, intimate partners, or close family friends. Injury severity was stratified a priori as mild, moderate, or severe. Mild injuries were defined as those that did not
require laboratory tests or medical treatment; moderate injuries were
defined as those that required medical intervention (eg, suture
placement or fracture reduction) or hospitalization for observation or
medical treatment; and severe injuries were defined as those that
required hospital admission to the intensive care unit or surgical
intervention.
Statistical Analysis
Data were analyzed using EpiInfo version 6 statistical software.
All data are reported as means for continuous variables, medians ± SD, or frequencies for categorical variables. Chi square, Fisher's
exact test, and the Student's t test were used when
appropriate. P < .05 was considered statistically
significant. Odds ratios with 95% confidence intervals are also
reported.
RESULTS
We identified 159 children by review of the child abuse reporting
logs between July 1984 and June 1994 who were identified for review. Of
these 159 records, 139 (87.4%) met the criteria for the study and were
reviewed. The 20 charts not included for analysis were either not
available from medical records, or review of the medical records
revealed that the children were victims of child abuse. Victims ranged
in age from 2 weeks to 16.9 years. Although the mean age of the victims
was 5 years, the median age was 2 years. Of the total children seen,
10% were younger than 1 month, 33% were younger than 1 year, and 48%
were younger than 2 years. Seventy-five percent of the children were
younger than 9 years (Figure). Seventy-seven (55%) of
the children were boys. In 77% of cases, the mother brought the child
for medical care, whereas in only 2% of cases was the child
accompanied by the father.
Fig. 1.
Age distribution of children in the study.
[View Larger Version of this Image (12K GIF file)]
Individuals Involved in the Conflict
The mother of the child was involved in the conflict 81% of the
time. In 68% of cases the fight involved the child's father, in 13%
the mother's boyfriend, and in 16% another relative (grandmother, uncle, aunt, or adult sibling). In 12 cases (9%), more than two adults
were involved in the fight. The most common dyad involved in the fight
was the mother and father (57% of cases). In 115 (83%) of charts, the
person who injured the child was identified. The father was responsible
for the injury in 50% of the cases, the mother's boyfriend in 10%.
The mother was responsible for the injury in 13% of cases and another
adult relative in 9% of cases. Alcohol or drug use by at least one of
the fighting adults was present in 27% of cases. In 36% of cases,
there was a denial of substance use, and in 37% of cases this
information was unknown.
Mechanism of Injury
Specific mechanisms of injury are outlined in Table
1. In 9% of cases, the child was injured by another
mechanism, including burns (n = 4) or penetrating injuries, ie
stabbing (n = 3) or a gunshot wound (n = 1). In 29% of cases
(n = 40), the child was held in the arms of the parent during the
fight, leading to the child's injury. Of the injured children who were
younger than 2 years, 59% were injured while being held by a parent.
Twenty-four percent of the children (n = 33) were injured during
an attempt to intervene in the fight. Of the adolescents, 18 (78%)
were injured during an attempt to intervene. Injuries during attempts
to intervene were noted in 9 children between 9 and 12 years old, 5 children between 2 and 8 years old, and 1 child younger than 2 years.
Type and Location of Injury
Of the children identified by the CPS reporting logs, 137 of 139 sustained identifiable injuries. The majority of the 197 injuries
identified were isolated to one location (Table 2). Of
the children injured, 33% incurred injuries to two locations, and 10%
of children were injured in more than two locations. Children younger
than 5 years were five times more likely to sustain head or facial
injuries than children 5 years and older (odds ratio, 5.0; 95%
confidence interval, 2.5 to 9.7). Older children (older than 4 years)
sustained disproportionately more extremity trauma than younger
children (P < .05). Half of the injuries were
contusions, and another 29% were lacerations or abrasions. Four
children sustained fractured bones, and 4 children were burned.
Thirty-two percent of children sustained two types of injuries, and
10% had three types of injuries.
Severity of Injury
Minor injuries were noted in 57% of patients. Forty percent of
children required medical intervention and were considered to have
moderate injury severity. Of the total children seen, 9% required
hospital admission: 7 infants, 3 children between 2 and 7 years of age,
and 3 adolescents. Surgical and/or intensive care was required for 2%
of children: a 1-month-old girl who was hit in the head with a set of
keys, resulting in a complex skull fracture, subdural hematoma and
retinal hemorrhages; a 2.5-year-old child who sustained a gunshot wound
to the head, resulting in severe brain injury; and a 13-month-old boy
who sustained a penetrating injury to the eye when a glass object
shattered when thrown by his mother.
Of the children discharged from the emergency department, 73% returned
to their homes, and 27% were discharged to alternative homes.
DISCUSSION
Recent studies examining the effects of domestic violence on
children have stressed the emotional, behavioral, and developmental consequences of witnessing family violence. Few articles have specifically addressed the physical danger to children who witness family violence.8 Nelson8 describes three
children who inadvertently sustained injuries from deadly weapons (guns
or knives) during domestic violence disputes.
Our study indicates that children are at risk for sustaining a wide
variety of injuries as the result of family violence. Although a few of
the children sustained life-threatening trauma, most of the injuries
were minor injuries to the head or extremities. Unlike the injury
patterns that help identify child abuse, such as multiple or patterned
injuries and injuries of different ages, the majority of children who
were injured during domestic violence had no such identifiable
patterns. They were recognized as being victims of family violence
either because they presented with such histories or, less commonly,
because probing histories were obtained by the health care provider.
Without a disclosure from either the children or adults who accompanied
the children to the hospital, the causes of many of these injuries
might not have been recognized. Because minor injuries to the head or
extremities are so common in children, physicians may not question the
causes of isolated, minor injuries and, hence, may fail to recognize subtle physical indicators of family violence.
With the awareness that living among adult violence is detrimental to
the psychological development of children, physicians need to recognize
all of the indicators of family violence so that appropriate
intervention can be offered to families. Minor physical injuries to a
child may represent overlooked evidence of family violence. In fact,
the injury of a child during adult violence may serve as an immediate
precipitant to seeking help. Investigators have reported that the
physical abuse of children often is the impetus for women to leave
abusive relationships.9,10 A few of the children in the
present study sought care in a hospital emergency department but had no
identifiable injuries. This may either reflect a parent's concern
about potential injuries or may represent a family's reaching out for
help at a time of crisis. Although the setting for this study was an
urban emergency department, children with similar injuries are likely
to be seen in the primary care setting. In any medical setting, the
fact that a single, minor injury may be the result of intrafamilial
violence should encourage physicians to ask about the cause of any
newly identified injury.
The major limitation of this study is that we were only able to review
the medical records of those children who were recognized and reported
as victims of family violence. The 139 children may not be
representative of the larger population of children who are victims of
intrafamilial violence. Although the majority of children brought for
care were young, children of all ages were seen. It is possible that
minor injuries to young children are more easily identified as not
resulting from normal play. If this is true, we are likely to
underestimate and underrecognize the problem in older children. Many
additional children were likely to have been seen at the hospital
during the study period with injuries from family violence but were not
identified as such. Although we cannot estimate the incidence of
pediatric injuries that result from domestic violence, this study
identifies the wide range of injury type and severity that can result
from intrafamilial violence.
Because this was a retrospective study, the data were not always
available from the records. Additionally, we were not able to verify
the reliability of the information provided in the medical records
regarding the causes of the injuries. It is possible that a few of the
children were not injured indirectly but were abused children. However,
the majority of injuries in our series were minor, and in our
experience, abused children with minor injuries are not routinely
brought for medical care. Parents who do seek medical care for abused
children often identify accidental mechanisms as the causes of the
injuries, not domestic or family violence. The history provided
by the parents of an abused child is often inconsistent with the
injuries identified.11 In our series the injuries
identified were consistent with the mechanisms provided by either the
parents or the children. Few of the children had skeletal surveys or
laboratory evaluations done to search for occult injuries. Although
these procedures might have identified abused children, we reviewed
each medical record carefully and eliminated those that clearly
represented direct child abuse. Although it is still possible that some
of the children in this series were the victims of direct child abuse,
we think that the majority of injuries were correctly identified as
resulting from adult violence.
It is notable that the vast majority of children were brought for
medical care by the mothers alone. The possibility of reporting bias is
therefore significant. However, we think it is unlikely that mothers
would abuse their children and claim domestic violence as the
"accidental" mechanism of injury. In addition, 37% of the children
were at least 5 years of age and were able to provide their own reports
of the incidents.
From the findings of this study, we can appreciate the need to broaden
the definition of family violence. Research related to the
psychological and developmental effects of witnessing domestic violence
on the child has focused on parental violence or violence between
intimate adult partners. Additionally, the present data suggest that
although the most common dyads are mother and father and mother and
boyfriend, intrafamilial violence extends beyond parent figures to
extended family members and even friends. Despite little data that have
specifically addressed the effects of witnessing intrafamilial violence
between adults other than parents or parent figures, attention should
be paid to all forms of intrafamilial violence rather than what has
historically been defined as child abuse or domestic violence.
In conclusion, the present study indicates that children sustain
a wide range of physical injuries from family violence. Because the
majority of the injuries are minor, routine inquiry into the causes of
all pediatric injuries in both primary care and emergency settings may
help identify families experiencing violence.
FOOTNOTES
Received for publication Jun 13, 1996; accepted Sep 9, 1996.
Reprint requests to (C.W.C.) Division of General Pediatrics,
Children's Hospital of Philadelphia, 34th Street and Civic Center
Boulevard, Room 2416, Philadelphia, PA 19104.
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