Abuse and Neglect

Based on a lecture series by

Peter Ash, M.D.

As a health care provider, you MUST violate patient confidentiality and report suspected abuse if you have "reasonable cause" to suspect it. Note that this is a judgment call and a sticky legal and ethical issue. Most agencies are primarily concerned with physical or sexual abuse (as opposed to psychological abuse).

You can file a medical neglect petition if a parent refuses treatment for a child, e.g., a Jehovah's Witness who refuses to grant permission for a blood transfusion. The court can override the parent's refusal. Usually this is only done on an emergency basis.

The mission of DFACS (Department of Family and Child Services) is to return the child if at all possible to the family of origin. The standard for an "unfit parent" is extremely high. The repeated foster care trap is to be avoided at all costs, since usually after several foster homes, a 6-7 y/o child will have a very low probability of being adopted. (Note that foster care parents have no legal rights that adoptive parents enjoy; the children remain wards of the state, and the foster parents often are paid for taking the children into their home.)

When asking about suspected abuse, it is important to remember that children are extremely suggestible, so leading questions should be avoided. For example, in a study of children asked every week for 10 weeks whether their hand had ever been caught in a mousetrap, half of those who initially reported no said yes by the end of the study. "Experts" interviewing children have about a 50% success rate at distinguishing those telling the truth from those who aren't.

The prevalence of childhood sexual abuse in the general population is highly politicized and controversial, with wide variance between survey results depending on how sexual abuse is defined and the population surveyed. Reasonable figures are most likely in the 10% range for girls and 2% range for boys (which still means 1 out of every 10 girls has been the victim of sexual abuse, but the figure is somewhat lower than some surveys showing the prevalence to be as high as 38%).

Another related issue is that of "recovered memories," that is memories that lay dormant until unearthed, usually by a therapist, often using leading questions, and sometimes under hypnosis. The validity of these memories is questionable although this is a highly controversial and politically charged issue. Recovered memories, in which the patient has no conscious recollection of a childhood event whatsoever until adulthood, then suddenly remembers that some sexual abuse occurred, is quite different from distorted or repressed memories that are nevertheless available to various degrees to the patient. In the latter, the patient always remembers or at least highly suspects that sexual abuse occurred, but some of the details may be lost or fuzzy. The recovered memory patient on the other hand has no recollection whatsoever until the memories are recovered. Legally, these are very suspect, although they have torn apart families (for example of a daughter who "remembered" while under hypnosis that her father sexually molested her; the father in this case successfully sued the therapist).