When 4-year-old Danny arrived at the emergency room at Harbor-UCLA Medical Center last year, his heart had stopped. His abdomen was distended and he was taken urgently to the operating room. The surgeons found extensive trauma to his liver, spleen and intestines. The story that he had fallen down the stairs didn’t match his injuries. In reality, he had been beaten by his mother’s boyfriend.
The internal bleeding couldn’t be stopped and Danny died.
My colleague, Kelly Callahan, told me Danny’s story. His name has been changed for his mother’s protection. Callahan is a pediatrician with expertise in child maltreatment and the director of the Suspected Child Abuse and Neglect (SCAN) team at Harbor. The SCAN team cares for children who are suspected victims of maltreatment.
The odds were not in Danny’s favor. He was living in poverty in South Los Angeles with a single, unemployed mother. Children living in high poverty neighborhoods—a disproportionate number of whom are children of color—are more likely to die from child abuse.
But, the role of the community in child abuse is just starting to be explored.
A recent study reported that children from impoverished communities, such as Danny’s, have triple the rate of death due to abuse than children in communities with less poverty.
The researchers evaluated abuse fatalities for about 11,000 children 4 and younger using 1999-2014 data from the federal Centers from Disease Control and Prevention. Poverty and population statistics were obtained from the U.S. Census. African American children, including those from low poverty areas, accounted for 37 percent of the fatalities, though they make up only 16 percent of U.S. kids younger than 4.
Higher fatalities were noted in communities that have 10 percent or more of the population living in poverty. Possible reasons for this include the lack of community resources in these neighborhoods, difficulties accessing health care, environmental stressors, and the disparities in overall health.
In addition, the stressors associated with living in poverty are known risk factors for child maltreatment. This risk is increased if poverty is confounded with depression, substance abuse or social isolation.
However, most parents in financial straits do not mistreat their children and child abuse occurs across all socioeconomic lines.
Also, there are potential biases for causes of death recorded on death certificates. Researchers have shown that the cause of death influences the coroner’s classification of the deceased person’s race, which may be different than the race identified by living relatives. For example, African Americans are more likely than whites to be recorded as a victim of homicide. Another concern is that the poverty rate in the community could influence the medical examiner’s determination of cause of death with over-reporting of maltreatment in poor counties or under-reporting in affluent counties.
In the U.S., nearly 700,000 children are victims of maltreatment every year. Maltreatment includes neglect and physical, sexual and emotional abuse. Neglect is the most common and occurs when children’s physical, emotional or medical needs are not met.
Nationwide, about 1,600 deaths due to maltreatment occur annually, which means about four children die every day from abuse. Nearly three-quarters of the fatalities occur in children younger than 3. Because there is no standard, mandated reporting system for child-abuse deaths, experts believe that many cases go unrecognized and unreported.
California is home to more than 9 million children younger than 18 and nearly 23 percent of them live in poverty. In 2014, about 75,000 cases of child maltreatment and 131 deaths due to abuse were reported in the state.
The state’s 58 counties have a wide range of poverty rates, from 7.5 percent in San Mateo County, in the Bay Area, to 25 percent in Fresno and Tulare counties, in the Central Valley. The rates of reported abuse don’t appear to correlate with county poverty, but abuse fatality rates for each county are not readily available.
“The relationship between poverty and child maltreatment is complicated,” Callahan said.
She noted that single mothers have less social support and higher rates of poverty, unemployment and stress. Some have a history of abuse as children or intimate partner violence. These impair their ability to cope and increase the chance that they’ll become abusive.
About one-third of survivors of child abuse grow up to be abusive to their children, according to researchers. A study on adverse childhood experiences by the Centers for Disease Control and Prevention and Kaiser-Permanente found that many survivors of maltreatment suffer long-term health consequences, including substance abuse, mental disorders, physical illnesses and early death.
My patients in my clinic in South Los Angeles are children from high poverty areas. However, regardless of where they practice, pediatricians have a critical role in the recognition and prevention of child abuse.
Knowing the symptoms of maltreatment is only a fraction of our job. Creating a supportive clinic environment may give parents and kids the chance to ask for the help that they need.
In my clinic, I ask questions about parents’ finances (Do you have enough food this week for everyone?), about their support (Who has your back?) or about how they deal with stress (What do you do when you think you might lose it?). Sometimes simply sitting down in theexam room affords children and adults the comfort to discuss their stressors.
Several government agencies and community organizations are working to prevent abuse. For example, the LA County Department of Child and Family Services has increased its number of social workers. The County Department of Mental Health is adding more mental health providers to SCAN teams to provide therapy for victims and families.
The County Department of Public Health has the Nurse-Family Partnership home visiting program. This partnership uses specially trained nurses to work with high-risk, low-income pregnant women and has proven successful in reducing child abuse for the participants.
“I would like to solve poverty” to prevent abuse, Callahan said. “But, for now education, education, education! We need to give families and communities tools to deal with stress.”
Danny’s death is heartbreaking. Hopefully, with understanding the risk factors for abuse, families and communities can be made safer for children.
Pediatrician ChrisAnna Mink writes the bimonthly Doctor’s Notes column on children’s health.