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

Procedures

Definitions

Statistical Analysis

RESULTS

Individuals Involved in the Conflict

Mechanism of Injury

Table 1. Mechanism of Injury [View Table]

Type and Location of Injury

Table 2. Location of Injuries [View Table]

Severity of Injury

Of the children discharged from the emergency department, 73% returned to their homes, and 27% were discharged to alternative homes.

DISCUSSION

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.