Doctors have a responsibility for revealing and acting on cases involving child abuse, but they often fail to do so. There is sufficient knowledge available to see, investigate and take responsibility. Doctors and other professionals use a number of psychological mechanisms to protect themselves against seeing what is going on.
The case of Christoffer and the Alvdal incident, in which children were exposed to neglect, murder and sexual abuse, have affected us all. In these cases there were no professionals in the schools, the social services or the health services who were capable of seeing, understanding or acting. The child welfare services had no opportunity to act, since nobody reported any concerns. The environment – the social networks – also did nothing to stop the abuse.
The primary responsibility rests with those who are the first to see the child. They will often be paediatricians, orthopaedic surgeons or child psychiatrists (1, 2). If they are worried about the care situation of the child, they are obligated to send a report of concern to the child welfare services. If abuse is involved, they are obligated to report the matter to the police. The fact that this is rarely done in practice may be due to an excessive distance between the available knowledge and those who should apply it in practice. Professionals (and non-professionals) make use of a number of psychological mechanisms to avoid seeing and having to take responsibility (3, 4). We believe that teaching of matters related to neglect and child abuse is too little emphasised in the training of health personnel.
The professionals’ resistance to seeing
The fact that doctors and other health workers tend to resist seeing and acting was documented by a project undertaken in the Department of Paediatrics at Ullevål University Hospital in the late 1970s (5). It was also documented that health, social and educational professionals make use of various mechanisms to avoid seeing. This has later been confirmed in studies from other countries (6).
These mechanisms involve survival strategies, over-identification with the parents, downplaying, rationalising, distancing, projection and problem displacement. By over-identification we ascribe to the parents more positive characteristics than they actually have, and this prevents us from seeing the realities. This will often result in downplaying the risk that the child is facing. We distance ourselves from the child’s vulnerability, anxiety, suffering and loneliness. If we see something that worries us, we find ways to rationalise and explain away the things we surmise. We can distance ourselves by retreating, referring the case to someone else – «this is not my patch» – and place the responsibility on someone else’s shoulders.
When facing an extensive and complex set of problems, with domestic violence, substance abuse and mental problems, and where the child in the family has behavioural problems, it is easy to shift the attention onto the child’s behaviour. The case of Christoffer is a prime, though tragic, example of problem displacement. Serious neglect and physical abuse were redefined into a diagnosis of ADHD, and active efforts to investigate the relationships in the family and the parental functioning were replaced by medication (7). In this way, the professionals did not have to assume the difficult and painful task of relating to Christoffer’s loneliness and fear. They did not have to relate actively to the parents, the child welfare services or the police.
According to Torleiv Ole Rognum, professor of forensic medicine at the University of Oslo, five deaths occur each year as a result of serious neglect, head injuries or asphyxiation (8). It has been well documented that physical abuse is a common cause of head injuries or fractures in infants (9 – 11). Long-term injuries are common (12). Bruises have been shown to be a key marker of physical abuse (13).
Knowledge from care research
Children too have their survival strategies. They protect their parents. They know a lot about social taboos long before they have heard this term, and they know full well what the adult world does not want to hear. Research on interplay in the care nexus shows us how infants notice the faces and attitudes of adults, and adapt to the adults. There is ample documentation to show that emotional neglect and psychological abuse are precursors of physical and sexual abuse as well as violence in the family (14). By developing a deeper understanding in professional helpers of emotional neglect and psychological abuse, we may improve our opportunities to prevent physical and sexual abuse.
Neglect has previously been difficult to define and identify, but research on care and interaction has rendered this task easier. Emotional neglect concerns parents who fail to establish a positive emotional engagement with their child. They are not emotionally available, and the child has no interaction to engage in. Two forms of emotional neglect are commonly described. The best known form is the one which is seen in combination with nutritional, physical, material, medical and social neglect. This form is well known, and can be seen as well as smelled. The other form is less well known, and can be obscured by an exaggerated attention to nutritional, material, medical and social needs (14).
Knowledge from brain research
Serious neglect is harmful not only to the child’s physical, but also to his or her psychological development (15). The fact that infants need a supply of proteins for their brains to develop has long been known.
Recent brain research has shown that the development of the brain is also dependent on the quality of the emotional care provided and the quality of the interaction between parents and children (15, 16). Emotional neglect is one of the most serious threats to the physical, emotional, cognitive, social and behavioural development of children.
Psychological abuse can be defined as a permanent attitude of or action by the parents, which is detrimental to the child’s development of a positive self-image. The child is living with the constant worry of whether his or her parents will be able to take care of and protect him or her as well as themselves.
This will often concern children with parents who have problems with substance abuse, have a conjugal relationship characterised by violence, mental disorders and/or twisted ideas of their child, whereby the child is ascribed with particular characteristics and treated accordingly. The child develops a persistent worry about the «predictable unpredictability». This could include the so-called «Münchhausen by proxy» syndrome, in which the child is ascribed with an alleged disease and subjected to treatment (17 – 19). Alcohol abuse, injuries from substance abuse and serious psychosocial strains can be related to somatic symptoms in children.
Knowledge as well as attitudes
The ability to see, understand and act constructively in these situations depends on knowledge as well as attitudes. This presupposes something more than a manual. There is a need for better training – not only in diagnostics of neglect and abuse, but also in cooperation with the parents, cooperation with the children and cooperation across disciplines. There is a need for better guidelines on how schools, the social services and the health services should identify and react to physical abuse, emotional neglect and sexual abuse of children. There is a need for more and better cooperation and action.