Under the Gun: Threat Assessment in Schools: Virtual Mentor Feb No. 4

Nancy Rappaport, MD, and James G. Barrett, PhD

School shootings such as the Columbine and Virginia Tech tragedies have heightened administrators' and teachers' fear that their students are capable of lethal violence. Initiatives to ensure safety have ranged from zero tolerance for weapons and expanded security measures (e.g., metal detectors or school resource police officers) to student threat assessments by multidisciplinary teams. Some schools have taken extreme measures and garnered national media attention for their response to the threat of student violence. For example, one school district in Texas certified its teachers to carry weapons in the classroom and sanctioned them to respond to a threat with deadly force if necessary [1].

LEARNING OBJECTIVEIdentify some ways in which physicians can aid schools in assessing threats of violence and treating students whose aggressive behavior may pose a threat to others.

Arming teachers can give schools a false sense of security and may distract staff from critical preventive efforts. Despite the amount of media attention they receive, school shootings are rare events; schools are one of the safest places for children to be. Indeed, a child has a greater chance of being hit by lightning than being shot in school [2]. Less than 1 percent of all homicides among children ages 5 to 19 years occur in and around the school [3]. Still, lethal violence occurs in American schools more often than in schools in other developed industrial countries. But a teacher's discharging a weapon in response to a student's threat creates a potentially dangerous scenario that could escalate an already volatile situation. Although it is difficult to predict with accuracy what will deter potential school assailants, many school shooters also killed themselves. In such cases an armed teacher may not have been a successful deterrent.

Arming teachers is a desperate school policy initiative, one that illustrates the degree to which some school personnel feel under siege. Frightened teachers describe walking on eggshells and waking up at night afraid of the secret volatility of students. Concerns for the safety of both students and staff should not be dismissed. Schools are struggling with the urgent and pressing need to differentiate between students who are sounding an alarm when in crisis and those who may jeopardize the safety of themselves and others.

Better Approaches to Reducing Violence in Schools

In response to the schools' needs to address possible threats to safety, it is critical to employ a multifaceted strategy that, among other approaches, makes it more difficult for students to bring weapons to school. This strategy is analogous to public health interventions for reducing traffic fatalities that put the emphasis not only on the driver but also on changing the car by, for example, improving the window strength or the flexibility of the steering wheel. Similarly, control of firearms can improve safety in schools. A 1995 study of a nationally representative school-based sample of adolescents in grades 7 through 12 found that access to a gun at home was associated with carrying a gun to school [4]. Educational and medical organizations could advocate together for more stringent gun-control laws that restricted access and banned the sale of military-style assault weapons like those used in the Virginia Tech, Columbine, and Northern Illinois University killings.

While restricting access to guns is a critical step in reducing the threat of student violence, schools need to implement policies to identify and help students who may pose a threat to staff or students. Efforts such as infectious-disease control and mandatory immunizations have set a solid precedent. Following these models, school and medical organizations could develop consensus guidelines for safety measures that, if enacted and enforced, would reduce school violence. Schools can build on the numerous programmatic options they have already implemented, including conflict-resolution programs, bullying-prevention programs that discourage students from ostracizing others, programs that teach student bystanders to deter aggression, and incentives to encourage positive behavior [5, 6]. Yet schools have a long way to go; the implementation of sound policies is inconsistent and relies on the confidence, knowledge, and perceived self-efficacy of school personnel.

Physicians can partner effectively with schools through advocacy, encouraging preventive measures, and helping respond to individual students. Indeed, clinicians (e.g., physicians, psychiatrists, psychologists, interns) who work in or with schools may encounter students who have threatened a peer or teacher with violence, gotten into a physical fight with another student, carried a weapon to school, or thought of obtaining a weapon for self-defense. It is critical that these clinicians have guidelines for determining how to care for students who may pose a threat to others or be in danger of being the victim of violence. Some promising approaches follow for clinicians who work with or consult to schools on matters of safety.

Threat Assessment

Clinicians who work with schools have a valuable resource to offer when consulting with staff and administrators on threat and safety assessment. Staff members frequently witness a variety of behaviors from students that are cause for concern, such as a poem written in an English class that mentions harming a teacher, a message on a MySpace page threatening another student, or hallway gossip about a student's weapon in his locker. It can often be difficult for staff to differentiate between behaviors that are harmless expressions of frustration and those that pose a more serious threat. At the same time, it is unrealistic that the medical professional will “clear” the student to return to school. It is not possible for anyone to predict with certainty a student's potential for violence. Schools should have a clear understanding of both the utility and limitations of physicians' evaluations and use them as opportunities to improve the safety net for vulnerable students.

Over the last 9 years, Nancy Rappaport has supervised or examined more than 150 students who were identified as potential safety risks to help schools with decision making and accessing resources. These safety assessments include home visits; interviews with the child, parents, and teachers; and analysis of reports of the violent incidents and school records [7]. Some of the fundamental concepts of threat assessment that are particularly useful for physicians, interns, and other clinicians working with schools can also be adopted by physicians who find themselves involved in threat assessment. Pediatricians and emergency room physicians may be asked to evaluate a student who has a physical injury that occurred during a school fight. A psychiatrist in an emergency room may evaluate an explosive student who has made inflammatory threats. A medical student may have a frightened teenager confide that her ex-boyfriend is planning to bring a gun to school to “even the score.”

Frameworks for Examining Threats and Aggression

A team of FBI experts created principles for conducting threat assessments based on their careful analysis of school events in which students killed multiple individuals [8]. Rather than presenting a checklist to profile students, the guidelines emphasize the process of evaluation, providing questions for uncovering a student's motives and goals as a means for determining the extent to which the student has the motivation, intent, and resources to carry out the threat. Currently, there are no standardized guidelines for clinicians regarding the information they should obtain before sharing responsibility with the school about the safety of a student, what kind of follow-up should be provided, and who takes responsibility for ensuring this happens. It would be useful for physicians to create such guidelines, based on a case consultation model, as a standard of medical care when working with aggressive students [9]. These standards of care would clarify expectations and responsibilities for both clinicians and schools.

While it is beyond the scope of this article to enumerate all guidelines that would be helpful, some recommendations follow for assessing situations that involve violence or threats of violence.

Distinguishing between Transient and Substantive Threats. One way to classify threats is to distinguish them as transient or substantive [10]. Transient threats are those that are made while a student is upset but has no real intent or plan. An example is the student who says, “I wish I could blow up this school” after he earns detention time. When the student is questioned about the statement, it is discovered that he has no motive to blow up the school and has no access to explosive materials. A substantive threat involves a more formalized plan with means and intent to carry it out. Here an example is the student who posts a threat online to harm a peer and, when questioned, has access to a gun and has planned how and when the attack will occur. Clearly, substantive threats require immediate action, and the clinician should work with the school to notify the parents and police for the safety of all parties involved. Most transient threats require monitoring rather than urgent intervention.

Evaluating and Treating Students with Aggressive Behavior. Clinicians are not only called upon to assess a formal threat; sometimes they are asked to evaluate a student who has a pattern of aggression to help determine risk for further dangerous behavior. When assessing such students, a distinction should be made between proactive and reactive aggression. Reactive aggression is characterized by a response to a threat or perceived threat (e.g., a student flipping over a desk when he finds out he failed a class). In contrast, proactive aggression typically involves premeditated aggression toward an intended victim (e.g., an adolescent waiting after school to “jump” a peer). Proactive aggression is of greater concern in threat assessment; students who exhibit past instances of it are considered more capable of carrying out a planned assault [11].

The student who is aggressive in school warrants a comprehensive diagnosis and treatment plan. Schools often do not have resources to contain students' aggression. At the same time, practicing clinicians rarely have the flexibility to mobilize intensive resources quickly enough to stabilize an escalating crisis. This can cause clinicians who are not familiar with school policies to feel powerless in trying help families advocate for necessary resources [12]. Accessing mental health services and community resources is often daunting even for the most savvy consumers and seasoned clinicians, but in these precarious situations where timely access is essential, it can be even more difficult to acquire appropriate, timely therapeutic support. Schools have sometimes responded with on-site services, although frequently these services do not involve necessary family treatment [13]. To successfully manage these students, communities need to develop continuity of services from easy access to clinicians, home-based family services, emergency services, and hospitalizations. Strong partnerships between schools and mental health services will improve the treatment for these vulnerable students.

Identifying At-Risk Students. In addition to assessing individual students or events, clinicians should be aware of resources for both students who are at risk for carrying out a violent act and for those at risk of being the victim of such an act. By linking students to resources, clinicians can help prevent violence or the threat of it before it occurs. Following are two programs that have demonstrated early success in helping prevent youth violence.

Gun Buyback Programs

Clinicians are afforded the opportunity to provide a confidential space where students can talk about the threats and fears they experience and the steps they take to feel safe. Some students obtain firearms as a means to feel safe or to defend themselves in their neighborhoods but later recognize the dangers of possessing an illegal firearm and do not know where to turn for help. Clinicians should be aware of resources for students to turn in weapons—one being the Boston Gun Buyback Program, which provides a location for Boston residents to turn in guns, no questions asked, in exchange for a $200 Target gift card. This program has demonstrated success in getting guns off the street; between 1993 and 1996, when the program originally ran, approximately 2,800 guns were turned in to authorities [14].

Anonymous Reporting of Threats

While many violence-prevention efforts in schools understandably focus on identifying possible offenders, students who are victims of threats or harassment and those aware of students who may threaten violence should not be overlooked. Indeed, other students are often the best source of information about possible violence perpetrated by their peers; many, however, are reluctant to notify adults of a possible threat due to fear of retaliation. Moreover, a “no snitching” culture in schools deters students from informing adult supports of threats. One innovation to combat this is the use of anonymous web- and text-message-based reporting of threats. A student can log on to a web site such as http://www.schooltipline.com and post an anonymous message alerting school officials to a potential threat. While anonymous tips present the risk of false accusations and alarms, using new technologies to offer students a safe and reliable way to report possible deadly threats has shown promise in pilot programs [15].

Publicized incidents of school violence, especially school shootings, can cause school officials to believe that they must explore every possible option for deterring violence. We believe that extreme measures, such as arming teachers, are not likely to be effective and actually may put students and staff at greater risk. Instead, a coordinated, systemic approach to responding to threats is considered the best practice, and psychiatrists, psychologists, interns, and medical students can play key roles in the process. Clinicians can be front-line defenses—identifying and classifying a threat and mobilizing resources to respond without carrying a weapon. The threat of aggression warrants a rapid and thorough response by the medical profession which mobilizes services to schools and students to guarantee safety.

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References

1. McKinley JC. In Texas school, teachers carry books and guns. New York Times. August 29, 2008: A1.
2. Verlinden S, Hersen M, Thomas J. Risk factors in school shootings. Clin Psychol Rev. 2000;20(1):3-56.
3. Kachur SP, Stennies GM, Powell KE, et al. School-associated violent deaths in the United States, 1992 to 1994. JAMA. 1996;275(22):1729-1733.
4. Swahn MH, Hammig B. Prevalence of youth access to alcohol, guns, illegal drugs, or cigarettes in the home and association with health-risk behaviors.Ann Epidemiol. 2000;10(7):452.
5. Olweus D. Bullying at School. What We Know and What We Can Do. Cambridge, MA: Blackwell; 1993.
6. Walker HM, Colvin G, Ramsey E. Antisocial Behavior in School: Strategies and Best Practices. Pacific Grove, California: Brooks/Cole Pub. Co.; 1995.
7. Rappaport N, Flaherty LT, Hauser ST. Beyond psychopathology: assessing seriously disruptive students in school settings. J Pediatr.2006;149(2):252-256.
8. Federal Bureau of Investigation. The school shooter: a threat assessment perspective. 2000. http://www.fbi.gov/publications/school/school2.pdf. Accessed January 14, 2009.
9. Rappaport N. Survival 101: assessing children and adolescents' dangerousness in school settings. In: Esman AH, Flaherty L, Horowitz H, eds. Adolesc Psychiatry. 2004;28:157-181.
10. Cornell DG, Sheras PL, Kaplan S, et al. Guidelines for student threat assessment: field-test findings. School Psych Rev. 2004;33(4):527-546.
11. Raine A, Dodge K, Loeber R, et al. The reactive-proactive aggression questionnaire: differential correlates of reactive and proactive aggression in adolescent boys. Aggress Behav. 2006;32(3):159-171.
12. Hurwitz KA. A review of special education law. Pediatr Neurol.2008;39(3):147-154.
13. Flaherty L, Weist MD, Warner BS. School-based mental health services in the United States: history, current models and needs. Community Ment Health J. 1996;32(4):341-352.
14. Smalley S. Gun buybacks make return to Boston. Boston Globe. May 31, 2006.
15. Web site invites kids to report bullies incognito [news release]. Salt Lake City, UT: Associated Press; October 14, 2008.

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Nancy Rappaport, MD, is the director of school programs at Cambridge Health Alliance and assistant professor of psychiatry at Harvard Medical School in Boston. She has clinical expertise in identifying and safely managing aggressive students in schools, and has published extensively in chapters, requested reviews, and peer-reviewed journals.

James G. Barrett, PhD, is an instructor of psychology in the Department of Psychiatry at the Harvard Medical School and a staff psychologist in the Cambridge Health Alliance Child and Adolescent Outpatient Department working in school-based health centers. His clinic work is in Everett, Cambridge, and Somerville. Dr. Barrett has presented at numerous national conferences and is a contributor to The Community Psychologist,Professional School Counseling, and The Handbook of Human Development for Health Professionals.

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.

AMA EFFORTS TO FIGHT INSURER SCHEME PRODUCE RESULTS FOR CURRENT AND FORMER MEDICAL STUDENTS

The American Medical Association (AMA) is alerting medical students and residents that they may be entitled to settlement money if they were covered by Aetna Student Health while at college between 1998 and 2008. Aetna Student Health, formally known as Chickering Student Health, is a health plan administered by Aetna and sponsored by colleges and universities.

 

Aetna recently announced an agreement with the New York attorney general requiring the insurer to pay $5 million plus interest and penalties to 73,000 students from more than 200 colleges across the U.S. who were shortchanged on reimbursements for out-of-network care.

 

The inadequate reimbursements stem from outdated information that Aetna Student Health used from the databases of Ingenix, a UnitedHealth Group unit. During the last nine years, the AMA has worked diligently with regulators and the courts to expose how the Ingenix database has corrupted the system used by health insurers for out-of-network reimbursements.

 

"Medical students were particularly vulnerable to this insurer scam because they simply can't afford to overpay for health care while pursuing an expensive medical education," said AMA President Nancy H. Nielsen, M.D. "We fought many years to expose the flawed data insurers were using to under-reimburse patients and physicians for out-of-network care, and those efforts are paying off."

 

Evidence gathered by the AMA was brought to the attention of New York Attorney General Andrew Cuomo.  The AMA's insight into the insurer scam led Attorney General Cuomo to investigate the abuses and forced Aetna to announce plans to reimburse students it underpaid.

 

Aetna's announcement comes on the heels of a historic January 13 settlement in which UnitedHealth agreed to pay up to $350 million in damages for using the flawed Ingenix database to determine out-of-network reimbursements. That agreement resolved a class-action lawsuit brought by the AMA and others.

 

"Our litigation is definitely having a ripple effect throughout the insurance industry," said Dr. Nielsen. "The AMA has sent a clear signal that it will no longer tolerate the improper business practices of health insurers who decide to play by their own rules without regard to patients or the legitimate costs required to care for them."

 

Under pressure from the AMA and others, several insurers including UnitedHealth and Aetna have agreed to underwrite the creation of a new independent database that will be used in determining out-of-network reimbursement rates in the future.

 

Current and former medical students who were covered by Aetna Student Health between 1998 and 2008 will have their claims for out-of-network reimbursement re-processed by Aetna. Those who were under-reimbursed will be notified by letter and paid directly by Aetna – it will not be necessary to file a claim.  Details of the Aetna agreement with the New York attorney general can be reviewed at: http://www.oag.state.ny.us/bureaus/health_care/HIT2/pdfs/Aetna%20Student%20Health%20AOD.pdf

 

If you think you have been affected, please contact an Aetna customer service representative at (866) 805-7643. 

Doctors Baffled by U.K. Baby That Refuses to Grow

At 14 months old and only seven pounds, seven ounces, Suraya Brown has doctors all over England baffled. She weighs barely more than an average newborn, and seems to have stopped growing entirely. At her age, she should have an approximate weight of 22 pounds and height of 30 inches, but instead she measures 19 inches—and doctors can’t seem to figure out why.

Suraya was born four weeks early and underweight, at just over 2.5 pounds. But nine out of ten babies born under similar circumstances will start to grow and gain weight immediately, according to doctors. Suraya, however, gained no weight during her first eight months of life, and in the last six she’s grown to just two ounces more than the birth weight of her sister, who is one year older and in good health.

Myriad tests have all come back negative, including a genetic test for Silver-Russell syndrome, a form of dwarfism, and an X-ray showing no bone abnormalities. Groping for answers, doctors plan to explore the possibility that “her body has become resistant to its own growth hormones.” They grabbed onto this theory after Suraya’s blood sugar became unstable and, at times, dropped significantly.

Suraya has also experienced seizures, and is now being placed on a special mat when she sleeps so her breathing can be monitored more closely.

Doctors are hoping these other symptoms may lead to more conclusive results—or that she just starts growing, already.

2 Doctors Used Typhus to Save Thousands in Wartime

The AMA honored a physician who created a fake epidemic that spared many of his Polish countrymen from German labor and death camps.

By Damon Adams, AMNews staff. July 5, 2004.

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Chicago -- Eugene Lazowski, MD, spent three years of his life with a cyanide pill at the ready. Better to take his own life than to die at the hands of the Germans if they discovered he was saving the lives of fellow Polish villagers during World War II.

"I was afraid, but I controlled it," Dr. Lazowski said.

The Polish doctor and a colleague hatched a plan to inject healthy villagers with a killed strain of typhus bacteria, which made residents test positive for typhus. Germans, who occupied Poland at the time, feared infection and an outbreak among soldiers, so they quarantined 12 villages instead of shipping villagers to German labor or death camps.

Over three years, the fake typhus epidemic saved about 8,000 villagers from camps where scores of their countrymen would die.

"People said I'm a hero. I just found an opportunity to do something good," said Dr. Lazowski, 90, a humble man who appears frail with his shuffling walk but still commands a firm handshake. He was honored for his efforts by the AMA Senior Physicians Group at a luncheon during the AMA Annual Meeting in Chicago in June.

During World War II, Dr. Lazowski was a young physician living in Rozwadow, Poland. The Germans rounded up Polish men and women and sent them to slave labor camps while Jews were deported to death camps.

Dr. Lazowski sought a way to fight back. A fellow doctor, Stanislaw Matulewicz, MD, discovered that, if a healthy person was injected with a killed strain of typhus bacteria, that person would test positive for typhus. It was the weapon they would use to scare the Germans into quarantining Polish villages.

History of Violence as a Public Health Problem: Virtual Mentor Feb No. 3

Linda L. Dahlberg, PhD, and James A. Mercy, PhD

Violence is now clearly recognized as a public health problem, but just 30 years ago the words “violence” and “health” were rarely used in the same sentence. Several important trends contributed to a growing recognition and acceptance that violence could be addressed from a public health perspective. First, as the United States became more successful in preventing and treating many infectious diseases, homicide and suicide rose in the rankings of causes of death. Tuberculosis and pneumonia were the two leading causes of death at the turn of the 20th century. By mid-century, the incidence and mortality from these infectious diseases along with others such as yellow fever, typhus, poliomyelitis, diphtheria, and pertussis were dramatically reduced through public health measures such as sanitary control of the environment, isolation of contagious disease cases, immunization, and the application of new therapeutic and medical techniques. Since 1965, homicide and suicide have consistently been among the top 15 leading causes of death in the United States [1, 2].

LEARNING OBJECTIVEUnderstand when and how violence came to be recognized as a matter for national—and then global—public health intervention.

There are other reasons why violence became a greater focus for public health. The risk of homicide and suicide reached epidemic proportions during the 1980s among specific segments of the population including youth and members of minority groups. Suicide rates among adolescents and young adults 15 to 24 years of age almost tripled between 1950 and 1990 [3]. Similarly, from 1985 to 1991 homicide rates among 15- to 19-year-old males increased 154 percent, a dramatic departure from rates of the previous 20 years for this age group [4]. This increase was particularly acute among young African American males. These trends raised concerns and provoked calls for new solutions.

Another important development was the increasing acceptance within the public health community of the importance of behavioral factors in the etiology and prevention of disease. It is now generally accepted that prevention of three of the leading causes of death in the United States—heart disease, cancer, and stroke—rests largely on behavioral modifications such as exercise, changes in diet, and smoking cessation. Successes in these areas encouraged public health professionals to believe that they could accomplish the same for behavioral challenges underlying interpersonal violence and suicidal behavior. Finally, the emergence of child maltreatment and intimate partner violence as recognized social problems in the 1960s and 1970s demonstrated the need to move beyond sole reliance on the criminal-justice sector in solving these problems.

Calls for Action

These trends and developments led to the publication of several landmark reports that highlighted the public health significance of violence. In 1979, the Surgeon General's Report, "Healthy People,” documented the dramatic gains made in the health of the American people during the previous century and identified 15 priority areas in which, with appropriate action, further gains could be expected over the course of the next decade [5]. Among the 15 was control of stress and violent behavior. This report emphasized that the health community could not ignore the consequences of violent behavior in an effort to improve the health of children, adolescents, and young adults. The goals for violence prevention established in this report were translated into measurable objectives in “Promoting Health/Preventing Disease: Objectives for the Nation” [6]. These objectives called for substantial reductions by 1990 in: (1) the number of child-abuse injuries and deaths, (2) rate of homicide among black males 15 to 24 years of age, (3) rate of suicide among 15 to 24 year olds, (4) number of privately owned handguns, and (5) improvements in the reliability of data on child abuse and family violence. In 1985, the “Report of the Secretary's Task Force on Black and Minority Health” identified homicide as a major cause of the disparity in death rate and illness experienced by African Americans and other minorities relative to non-Hispanic whites [7]. And the 1989 “Report of the Secretary's Task Force on Youth Suicide” provided a comprehensive synthesis of the state of knowledge about youth suicide and recommended a course of action for stemming the substantial increases that had occurred over the previous 3 decades [3].

Response to the Call

The emergence of violence as a legitimate issue on the national health agenda spurred a variety of responses from the public health sector during the 1980s. In 1983, the CDC established the Violence Epidemiology Branch, which was integrated into the Division of Injury Epidemiology and Control (DIEC) 3 years later. The creation of DIEC was a direct consequence of a National Research Council (NRC) and Institute of Medicine (IOM) report, “Injury in America: A Continuing Public Health Problem” [8]. This report recommended establishing a federal center for injury control within the CDC and called for funding that would be commensurate with the size of the problem. Support for the NRC/IOM report recommendations contributed to a gradual increase in the number of staff and the size of the budget devoted to violence prevention research and programmatic activities at the CDC.

Further evidence of increased concern from the public health community during the 1980s was provided by the Surgeon General's Workshop on Violence and Public Health in 1985 [9]. This workshop was the first time that the Surgeon General clearly recognized violence as a public health problem and encouraged all health professionals to respond.

Applying the Tools of Epidemiology

During the same period, the CDC undertook a number of high-profile epidemiologic investigations, looking into a series of child murders in Atlanta and a suicide cluster in Plano, Texas [10, 11]. These investigations helped to demonstrate that epidemiologic research methods could successfully be applied to incidents of violence. Public health professionals contributed to the understanding of violence through the use of epidemiologic methods to characterize the problem and identify modifiable risk factors. In particular, efforts were made to: (1) describe the problem of homicide and suicide as causes of death, (2) monitor public health objectives for homicide and suicide, (3) examine epidemiologic characteristics of different types of homicide, (4) characterize homicide as a cause of death in the workplace, (5) describe patterns of homicide and suicide victimization in minority populations and among children, (6) study physical child abuse, and (7) quantify the risks of homicide and suicide associated with access to firearms [12-14].

Determining What Works

Beginning in the early 1990s the public health approach to violence shifted from describing the problem to understanding what worked in preventing it. These efforts were bolstered by a number of appropriations from Congress. In 1992, the CDC received its first appropriation aimed at curbing the high rates of homicide among youth. The following year, the CDC published “The Prevention of Youth Violence: A Framework for Community Action,” an influential document that outlined the steps necessary to implement a public health approach to youth violence prevention [15]. By 1993, numerous violence-prevention programs were being developed and undertaken in schools and communities across the United States. In 1993, the CDC received its second appropriation for youth violence and used it to evaluate some of the more common prevention approaches being tried across the United States. These evaluation studies were among the first randomized control trials to specifically assess the impact of programs on violence-related behaviors and injury outcomes. Overall, they helped demonstrate that significant reductions in aggressive and violent behavior were possible with applied, skill-based violence-prevention programs that address social, emotional, and behavioral competencies, as well as family environments.

The achievements made in the prevention of youth violence throughout the 1980s and 1990s were published in “Youth Violence: A Report of the Surgeon General,” which provided a comprehensive synthesis of the state of knowledge about youth violence, including what was known about the different patterns of offending, risk and protective factors within and across various domains (e.g., peer, family, school, and community), and about the effectiveness of prevention programs [16]. The report also highlighted the cost effectiveness of prevention over incarceration and set forth a vision for the 21st century.

The early successes in youth-violence prevention paved the way for a public health approach to other violence problems such as intimate partner violence, sexual violence, and child maltreatment. Efforts were made to document each problem, understand the risk and protective factors associated with each type of violence, and begin building the evidence-base for prevention. In 1994, for example, the CDC and the National Institute of Justice collaborated on the first national violence-against-women survey. Conducted over the next 2 years, the survey produced the first national data on the incidence, prevalence, and economic costs of intimate partner violence, sexual violence, and stalking [17]. In 1994, Congress passed the Violence Against Women Act (Title IV of the Violent Crime Control and Law Enforcement Act)—landmark legislation that established rape prevention and education programs across the nation, in Puerto Rico and six other U.S. territories and called for local demonstration projects to coordinate the intervention and prevention of domestic violence. The CDC was given the federal responsibility to administer both efforts. The appropriations for these programs and their subsequent reauthorization from Congress were instrumental in building the infrastructure and capacity for the prevention of intimate partner violence and sexual violence at the local and state level.

Moving Forward in a Global Context

As public health efforts to understand and prevent violence gained momentum in the United States, they garnered attention abroad. Violence was placed on the international agenda in 1996 when the World Health Assembly adopted Resolution WHA49.25, which declared violence “a leading worldwide public health problem.” The resolution requested the WHO to initiate public health activities to: (1) document and characterize the burden of violence, (2) assess the effectiveness of programs, with particular attention to women and children and community-based initiatives, and (3) promote activities to tackle the problem at the international and country level. In 2000, the WHO created the Department of Injuries and Violence Prevention to increase the global visibility of unintentional injury and violence and to facilitate public health action. The organization's “World Report on Violence and Health,” published in 2002, is used throughout the world as a platform for increased public health action toward preventing violence [18].

Next Steps

As we move into the 21st century, public health is placing greater emphasis on disseminating and implementing effective violence-prevention programs and policies. The need to document and monitor the problem and identify effective programs and policies through research remains critically important. Nevertheless, a strong foundation has been laid for future success.

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References

1. Centers for Disease Control and Prevention. National Center for Health Statistics. Leading causes of death, 1900-1998. http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf. Accessed November 18, 2008.
2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). 2009. http://www.cdc.gov/ncipc/wisqars. Accessed November 18, 2008.
3. Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary's Task Force on Youth Suicide. Vol. 1. Washington, DC: US Government Printing Office; 1989.
4. Centers for Disease Control and Prevention. Homicides among 15-19-year-olds Males—United States, 1963-1991. MMWR Morb Mortal Wkly Rep.1994;43(40):725-727.
5. US Department of Health, Education, and Welfare. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Washington, DC: US Government Printing Office; 1979.
6. US Department of Health & Human Services. Promoting Health/Preventing Disease; Objectives for the Nation. Washington, DC: US Government Printing Office; 1980.
7. US Department of Health & Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: US Government Printing Office; 1985.
8. National Research Council & Institute of Medicine. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press; 1985.
9. US Department of Health & Human Services. US Department of Justice.Surgeon General's Workshop on Violence and Public Health Report. Washington, DC: Health Resources Service Administration; 1986.
10. Blaser MJ, Jason JM, Weniger BG, et al. Epidemiologic analysis of a cluster of homicides of children in Atlanta. JAMA. 1984;251(24):3255-3258.
11. Davidson LE, Rosenberg ML, Mercy JA, Franklin J, Simmons JT. An epidemiologic study of risk factors in two teen suicide clusters. JAMA.1989;262(19):2687-2692.
12. Mercy JA, O'Carroll PW. New directions in violence prediction: the public health arena. Violence Vict. 1988;3(4):285-301.
13. National Center for Injury Prevention and Control. The Prevention of Youth Violence: A Framework for Community Action. Atlanta, GA: Centers for Disease Control and Prevention; 1993.
14. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327(7):467-472.
15. US Department of Health & Human Services, National Center for Environmental Health and Injury Control Division of Injury Control, Office of the Assistant Director for Minority Health. The Prevention of Youth Violence: A Framework for Community Action. Atlanta, GA: Centers for Disease Control and Prevention; 1992.
16. US Department of Health & Human Services. Youth Violence: A Report of the Surgeon General. Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration, National Institutes of Health for the National Institute of Mental Health. Washington, DC: US Government Printing Office; 2001.
17. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice, Office of Justice Programs, United States Department of Justice, Centers for Disease Control and Prevention; 2000.
18. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002.

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Linda L. Dahlberg, PhD, is the associate director for science in the Division of Violence Prevention in the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention (CDC) in Atlanta. In addition to serving as a senior science and policy advisor, she coordinates international research and programmatic activities for the division. Her research focuses on the etiology of firearm injuries as well as the efficacy of interventions to prevent interpersonal and self-directed violence.

James A. Mercy, PhD, is the special advisor for strategic directions of the Division of Violence Prevention in the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention (CDC). He received his doctorate in sociology from Emory University in Atlanta. His research focuses on understanding the health burden, causes, and prevention of child maltreatment, intimate partner violence, youth violence, and firearm injuries.

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.

Nuke Your Tumors! Surgeons Use Microwaves to Zap Cancer

Using microwaves to cook food was sooo yesterday. These days, microwaves can do nearly anything. Scientists are using them to kill off marine life, and police might soon use guns that shoot them to stop fleeing suspects. Now, doctors are trying to use microwaves to save lives—by zapping liver cancer.

Due to an increase in hepatitis infections and conditions like cirrhosis, liver cancer has become one of the most common cancers in the world. Normally, patients suffering from liver cancer would have to undergo invasive treatments, ranging from removal of the liver to chemotherapy. It’s often difficult for surgeons to remove bits and pieces of the cancer without removing the whole liver. But not every patient is lucky enough to get a liver transplant when they need one.

As a result, doctors in San Diego are tapping into microwave power as a less invasive and more available means of conquering tumors.

Microwave ablation works like this: First, the surgeon finds the tumor with an ultrasound or CT scan. Then, after piercing the skin or making an incision through a “laparoscopic port,” the surgeon sticks an antenna into the liver. When the antenna is turned on, it emits microwaves that heat up water molecules in the liver. When the cancer heats up to 140 degrees Fahrenheit, the cells essentially boil to death. And like magic, the surgeon has nuked a tumor in just 10 minutes.

Of course, the label of coolest manipulation of microwaves so far belongs to a Duke lab, where scientists are using them to build an invisibility cloak.

Vital Signs: When Modern Medicine Battles Genetics... and Loses

Despite the best care, a patient succumbs to a genetically predisposed disease.
by Claire Panosian Dunavan
published online January 14, 2009

After 30 years in the doctor trenches, every so often I think about patients I desperately wanted to save—and didn’t. At the top of my list is Arthur Lewis. A quiet, well-mannered teenager, Lewis developed a fungal infection that attacked multiple organs. Three years and many treatments later, the fungus claimed his life.

Most infectious diseases are color-blind; their outcome has nothing to do with their hosts’ hue. But Lewis’s illness, coccidioidomycosis, was different. His African American ancestry put him at special risk for the battle he bravely fought and lost.

His struggle reminds me of a basic truth in medicine. Although excellent care can tip the balance between life and death, in some cases patients have genetic vulnerabilities that all the high-tech care in the world simply cannot conquer. Genes aren’t everything when it comes to coccidioidomycosis, a rare soilborne illness that can be acquired by inhaling dust. Other variables (like the dose of inhaled organisms, underlying lung anatomy, and subtle or overt immune problems) also influence the course of the illness. But genes can gravely color the outcome. Some patients with acute coccidioidomycosis experience a short-lived infection that takes no more of a toll than the flu. In other cases, patients develop a chronic hacking cough, unexplained rashes, and joint pain. Many patients do not require specific treatment, but those who do can have tragically different outcomes.

Before I tell Lewis’s story, I’ll start with another man with the same infection and racial risk—and a happier ending. The year was 1985; the place, Van Nuys, California. A lanky African American in gym shorts and T-shirt practically bounded into the waiting room of the clinic where I worked, his mood and dress worlds apart from our usual clientele. Back then, most of our patients had HIV, tuberculosis, or a complication from IV drug abuse. When we opened our doors at 7:30 a.m., the AIDS sufferers were bundled in sweaters, the TB folks (hard-working immigrants, for the most part) wore everything from painters’ pants to saris, and the drug addicts had not yet arrived.

Through a window I peered at the lively newcomer and wondered: What brings you here, stranger? During my time as the sole infectious-diseases specialist at this small county outpost, no one ever visited our weekly clinic unless they had to. Ten minutes later, in an exam room, we learned Luke Jackson’s reason for coming.

The 34-year-old coach and substitute teacher told us that a month earlier, he had noticed a small crusty patch, roughly the size of a nickel, on his left flank. Lacking health insurance, he consulted our county dermatologist. No, it wasn’t cancer, he was told, and it didn’t look like eczema or psoriasis either. So Jackson agreed to a standard skin biopsy that took five minutes from start to finish, then forgot all about it.

Until a couple of weeks later, that is, when a dermatology clerk called and referred him to me. Something surprising had shown up on his biopsy. “I think she called them…spherules?” Jackson said, wrinkling his brow. “Frankly, Doc, I began to feel like a pod person from Invasion of the Body Snatchers. What the heck is a spherule?”

I imagined Jackson’s spherules—micro­scopic cysts stuffed with endospores—and realized why the clerk had used this word from the pathology lab report rather than the tongue-twisting term Coccidiodes immitis, the fungus responsible for Jackson’s tiny cluster bombs.

So far, so good. By the time they finished their rotation with me, every resident at my hospital had seen one or two patients with “cocci,” also known as valley fever—a label that harks back to the disease’s early discovery in California’s San Joaquin Valley. There, as in other semiarid pockets of the American Southwest, inhaling spore-laced dust was the usual way that humans (and the occasional pet dog) contracted C. immitis. Small outbreaks sometimes followed windstorms or earthquakes. For example, Ventura County, just north of Los Angeles, reported 203 cases of cocci, three of them fatal, after the January 1994 earthquake centered in Northridge. However, an earthquake was not to blame for Jackson’s infection. As a jogger and trail biker, he was a perfect candidate for ordinary exposure through dust inhalation.

The problem was that his case was far from the classic, quickly forgotten flulike variety. On the contrary, his single skin lesion teeming with cocci spherules confirmed a far more ominous scenario: After silently proliferating in Jackson’s lungs, fungal spores had traveled through his bloodstream and had been deposited in his skin.

Inwardly I shuddered. At that very moment, countless more spores could be incubating and multiplying in his prostate, lymph nodes, bones, or brain.

The unique susceptibility of certain dark-skinned people (Filipinos and African Americans in particular) to disseminated cocci—for reasons that are still not under­stood—has been common knowledge among infectious-diseases specialists for decades. In 1940 a landmark article in the American Journal of Public Health reported that African Americans were 23 times more likely to die of coccidioidomycosis than whites were. More recently, similar research in two California counties confirmed that, compared with their Caucasian counterparts, African American men stand a tenfold to thirtyfold increased risk of falling victim to the disease.

In some cases, patients have genetic vulnerabilities that all the high-tech care in the world simply cannot conquer.

The day I met Jackson, I asked myself: Do I really need to share these grim statistics with him? The bottom line was that he needed treatment. Once he grasped that fact, he quickly agreed to our best shot. Amphotericin B, an antifungal drug privately called “ampho terrible” by many former recipients, is just as noxious as its nickname suggests, but it did its job. After two months of infusions, Jackson was out of the woods. I still have the Betty Boop coffee cup he gave me as his parting gift.

Now back to Arthur Lewis. Ten years after treating Jackson, I met Lewis at the university medical center where I now work. A 17-year-old high school student who had just been transferred from another hospital, Lewis presented in far worse shape than Jackson: febrile, emaciated, doubled over in pain. Not only did he have scattered fungal scabs on his skin, but his scans showed multiple abscesses in his liver and spleen. Even more discouraging was his record of prior treatment. By the time I saw him, he had already received the same total dose of amphotericin B that had cured Jackson.

Over the next week, Lewis wasn’t dying, but he had little energy or appetite and even less motivation to study the textbooks next to his bed. Meanwhile, my team pushed his daily amphotericin dose while adding newer antifungal drugs to his regimen. We also tried immunologic therapies such as interferon and something called granulocyte-monocyte colony stimulating factor, a bioengineered molecule meant to boost Lewis’s ability to mount a strong immune-cell attack against C. immitis. Eventually his body temperature normalized, his pain abated, and he went home on long-term oral treatment. We hadn’t won the war, but we had made progress. Lewis felt well enough to start college in a nearby state.

My contact with him was sketchy for a year or two until I received a call from a doctor at his college. Lewis had never before complained of headaches, but now he was having migraines. Or so his doctor thought; I wasn’t so sure. Soon after, a CT scan and a spinal tap confirmed my worst fear. The fungal infection had invaded the base of his brain, producing cocci meningitis.

Over the next year, Lewis received amphotericin directly into his spinal fluid via a special injectable reservoir. The treatment helped, but only for a while. In the last months of his life—like so many patients with an incurable disease who continue to receive maximal high-tech care—Lewis experienced one complication after another, and he was in the ICU more than once. Finally he had a full-blown cardiac arrest and was gone.

Toward the end Lewis knew he was dying. But one thing brought him joy. While at school he had fathered a child. Despite his tragic downward spiral, talking about his little girl always brought a smile to his face.

In fact, a few months before he died, Lewis brought his gurgling daughter—the image of health and hope—to my outpatient office. As I sat her on my knee and gazed into her shining brown eyes, I couldn’t help but wonder what science might someday reveal about her father’s fateful genes—and perhaps her own.

Legislators Increase Cigarette Tax

Governor Signs Legislation into Law

 

With a $500 million dollar budget shortfall looming large, legislators increased the state’s tax on cigarettes to $0.60.  House Bill 144 passed the House on Wednesday and Senate on Friday morning.  The effective date of the act is March 31, and budget estimates are that the increase in the tobacco tax along with a 6 percent increase in the tax on packaged liquor will raise between $140 and $170 million.

 

With the budget shortfall situation worsening daily, Governor Steve Beshear signed the bill into law the same it passed..  That’s also the reason the legislature acted so swiftly – passing House Bill 144 and companion budget reduction legislation in the first 13 days of a 30-day legislative session.

 

Passage of the tax achieves the intent of a KMA House of Delegates resolution, and potentially improves the health of Kentuckians by reducing the number of smokers, particularly among young people.  The KMA Committee on State Legislative Activities had designated raising the tax as the Association’s priority for the 2009 Kentucky General Assembly.  KMA will likely continue efforts in future sessions to raise the tobacco tax further because of the health benefits of doing so.  KMA thanks those legislators who voted in favor of increasing the tax on tobacco products.

Hand washing, alcohol-based rubs help curb influenza outbreaks

Study suggests soap and water may be slightly more effective than hand rubs, but both work well.

By Victoria Stagg Elliott, AMNews staff. Posted Feb. 2, 2009.

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Lathering up with soap and water appears to be marginally better than using an alcohol-based rub for fighting the influenza virus, but both reduce the amount of the pathogen on the hands, says a study in the Feb. 1 Clinical Infectious Diseases.

"For the general public who have ready access to soap-and-water hand hygiene, this is highly effective," wrote Dr. M. Lindsay Grayson, lead author and head of infectious diseases for Austin Health in Melbourne, Australia. "For health care workers where alcohol-based hand rubs are a far more practical and effective option in our current busy hospitals, [these are] also highly effective with comparable results to soap and water."

Researchers tested the hands of 20 health care workers contaminated in the study setting with an influenza virus. After air-drying, 14 had live virus detectable on their hands and, if not cleaned, had it for at least an hour. Soap and water was most effective at getting rid of the contaminant, although only slightly more so than three types of alcohol-based rubs.

"For the general public or health care workers who forget to perform hand hygiene after contamination ... their hands will likely carry large amounts of live influenza virus, and they will be quite infectious and potentially spread the virus," Dr. Grayson continued.

Experts praised the study for documenting the impact of a strategy most expect to work, even though data have been limited regarding flu virus. It also reinforced that hand hygiene, no matter how it is done, is a vital part of infection control.

"The most important thing is to do one of them," said Aaron Glatt, MD, a spokesman for the Infectious Diseases Society of America and president of New Island Hospital in Bethpage, N.Y. "Both soap and water and alcohol hand rubs are clearly effective at diminishing the number of bacteria or virus on the hands."

Hand washing is particularly key in health care settings, and public health officials have been trying to increase this activity for the past several years. The Centers for Disease Control and Prevention released its guidelines on the subject Oct. 25, 2002. Those from the World Health Organization are in process, and WHO is launching its global hand hygiene awareness program, Save Lives: Clean Your Hands, on May 5. The American Medical Association urges both health professionals and the public to adopt hand washing as an important personal priority.

"Health workers need to think a little bit more about hand hygiene as one of the methods for reducing influenza transmission," said John Boyce, MD, lead author of the CDC directive and a member of the working group writing the WHO guidelines. He also is chief of the infectious diseases section at the Hospital of Saint Raphael in New Haven, Conn.

But while both hand hygiene strategies had comparable effects on the flu virus, experts said each had its advantages. Soap and water tends to be cheaper and is recommended to deal with hands that are visibly soiled. Alcohol-based hand rubs are quicker, and tend to be easier on the skin as well as more portable. This aspect is particularly important for health care workers who often have to wash their hands many times in a day.

It's unclear how often flu is transmitted by contact with a person's hands, but the authors suggest that the skin of the six volunteers that never tested positive for the virus may be naturally inhospitable to it.

RELATED CONTENT  You may also be interested in:
Alcohol hand rubs not enough to curb hospital infections  Feb. 25, 2008
New CDC report, recent events add to MRSA's infamy  Nov. 12, 2007
Only 77% wash hands after using the toilet  Oct. 8, 2007
Effort cuts down catheter-related infections  Jan. 22, 2007
New push for clean hands in hospitals  May 8, 2006
Study details staph's broadening reach  Jan. 30, 2006
The first defense: Soap and water  Editorial Nov. 28, 2005
Who's clean?  Column Oct. 13, 2003

What To Do when It Might Be Child Abuse: Virtual Mentor Feb No. 2

Commentary by Karen St. Claire, MD

Dr. Peterson took a deep breath and exhaled thoughtfully as she weighed the possible approaches toward a case that was scheduled for the afternoon. For several years, she had been the primary pediatrician for Adrian, now a rambunctious 7-year-old. During the course of that time, she had developed a constructive, friendly relationship with the boy's parents, who had been fastidious regarding his care and upbringing and seemed like involved, caring parents. Dr. Peterson had enjoyed appointments with this family, trusting that visits would be routine and the boy would be healthy, allowing some time to chat with the parents, who were both executives in a large company headquartered nearby. The boy had always been in good health, and seldom needed to come in for non-routine well-child visits.

LEARNING OBJECTIVEIdentify guidelines for helping physicians determine whether to file a report of suspected child abuse and neglect.

Dr. Peterson now questioned her original assumptions. For the past year, Adrian had been in to see her four or five times with a succession of injuries. Dr. Peterson noted numerous bruises and lacerations in different states of healing dispersed on the boy's knees, thighs, and buttocks. Adrian needed a couple of stitches on one occasion. The last time he came in he needed treatment for a broken leg. During all of these visits, his parents had appeared concerned and anxious, attributing the injuries to Adrian's simply being a very active youngster. They told Dr. Peterson that he'd been involved with soccer and martial arts for the past year, and usually had a sports-related explanation for every injury, though they could seldom give specific details. Dr. Peterson was aware that these parents spanked on occasion when the boy misbehaved, but they said that they only swatted lightly, never leaving a mark. Both had been working overtime to handle financial problems, and said that Adrian was often left in the care of a babysitter or aunt.

During recent visits, Dr. Peterson had often noted that Adrian seemed either visibly upset or quiet and withdrawn, behaviors that were completely natural, given his sports-related injuries. Now she had to act on her growing suspicions, but what would that do to her relationship with the family?

Commentary

The diagnostic method is the intersection of medical science with the art of medical practice. Its goal is to establish a broad framework of possible diagnoses and determine through information gathering which, if any, of these diagnoses is correct. Information gathering is chiefly dependent on history-taking but also relies on physical examination and testing. The diagnostic process ultimately leads to a medical conclusion upon which treatments and therapies are based. Child abuse and neglect (CAN) is one of many threats to child health that strongly relies on the diagnostic method to determine whether abuse or neglect have occurred so that treatment, intervention, and protection can be provided.

The situation in which Dr. Peterson finds herself with Adrian is universally uncomfortable and rarely produces an ideal outcome. If Adrian is an abused child, and if Dr. Peterson fails to recognize or address this issue, it is likely that Adrian will continue to be abused, with possibly devastating consequences. Moreover, if abuse is occurring, other children in the home are also at risk. Alternatively, if Dr. Peterson correctly identifies and addresses the problem, Adrian and his family will have to undergo a lengthy and difficult process of evaluation, intervention, and protection, but the outcome for Adrian will almost certainly be better. If Dr. Peterson suspects abuse, initiates the evaluation, and ultimately finds that no abuse has occurred, Adrian and his family will have had to undergo the evaluation process, but its positive outcome should provide closure for the family. Families that are experiencing dysfunction or stress at the onset of the evaluation may be at particular risk for further deterioration of the family system. Although Dr. Peterson worries about her therapeutic relationship with Adrian and his family, many families who find themselves in this situation and work through the process with their primary care physician choose to remain in the care of that physician.

Physicians see children and families every day with various levels of physical, emotional, and psychosocial functioning. When one of these children or families begins to stand out because of patterns in history or physical findings, the physician must rely on both her training and instincts in determining whether to take a closer look at the situation. In Adrian's case, Dr. Peterson has had growing concerns about the possibility of abuse, and she recently added this concern to Adrian's list of diagnoses. At this point, the question facing Dr. Peterson is, “How should I proceed?”

Understanding the Problem

CAN occurs more commonly in childhood than many other serious childhood disorders. National child maltreatment statistics from the U.S. Department of Health & Human Services indicate that in 2006 there were 3.6 million reports of child maltreatment (47.8/1,000) accepted for investigation by state and local Child Protective Services (CPS) agencies [1]. From these reports, 905,000 cases of child maltreatment (12.1/1,000) were substantiated. Of them, 64.1 percent were for neglect, 16 percent for physical abuse, 8.8 percent for sexual abuse, and 6.6 percent for emotional abuse. In 74.9 percent of investigated maltreatment cases, the initial report was made by a professional. About 80 percent of identified incidents of CAN were perpetrated by a parent or close caretaker of the child. In 2006, there were 1,530 CAN fatalities, 78 percent of them in children less than 4 years of age. Child maltreatment spans all economic, social, racial, cultural, and educational strata, with risk factors that include domestic violence, substance abuse, mental illness, poverty, social isolation, and prior history of abuse. Many physically and sexually abusive acts perpetrated on children leave no specific long-term physical findings on the child's body, making the identification difficult.

Children who experience abuse or neglect are at high risk for developing long-term emotional, physical, and medical problems related to their early traumatic experiences [2, 3]. Studies on CAN recidivism indicate that maltreated children are six times more likely to experience recurrent maltreatment than children who have never been abused [4]. The risk for recurrence is highest in the first 30 days after the index episode. Clinicians should understand that they see only a small piece of the CAN puzzle in the clinical setting, and it is often other professionals and agencies that help determine whether or not abuse or neglect has occurred. Regardless of the outcome, the evaluation process is difficult for the children and families who undergo the necessary medical, social, and legal scrutiny. Whenever possible, the physician should remain involved with the patient and family to assist in providing support and medical care during the evaluation.

Physician Responsibility in Addressing Child Abuse and Neglect

The following steps offer guidelines for physicians who may confront situations in which they have to decide how to respond to suspicions of CAN.

Step 1

Maintain training in the recognition of and response to CAN and know how to perform a basic medical evaluation. Be familiar with your state's reporting statutes as well as the agencies empowered to investigate CAN [5]. Statutes generally require that reports of suspected CAN be made to CPS, law-enforcement agencies, or both. In most states, reports made in “good faith” are exempt from civil or criminal liability, even in cases where CAN is ultimately ruled out. On the other hand, failure to report suspected CAN may have adverse legal consequences.

Step 2

Review all available medical history and physical-exam information to determine if there is a reasonable concern for CAN versus an alternative explanation. This includes prior medical records and x-rays pertaining to previous clinic or emergency room visits for injuries. Consider conferencing with an experienced colleague or a local CAN consultant.

Step 3

Obtain additional information. Meet with the family and talk separately with the caretaker(s) and child.

If the additional information substantiates your concern, talk about it honestly and thoroughly with the caretaker(s). Emphasize that you will assist them in determining whether their child has been harmed so that they can best protect him or her. Avoid accusing or assigning blame at this point, inasmuch as there may be no clear indication of who might be harming the child. Ask about the child's symptoms and prior known injuries. Request specifics to determine whether there is consistency between reported mechanisms of injury and clinical findings. Ascertain whether anyone witnessed the injuries or heard the child talk about how they occurred. Ask about family functioning, stressors, and risk factors, as well as the child's environment at home, school, and with other care providers. In the case we are discussing, Dr. Peterson should ask about Adrian's coaches and supervision during sports-related activities.

If there has been a change in the child's affect, ask the caretaker(s) about potential causes. Explain clearly to the caretaker(s) that at some point state statutes may require the involvement of other professionals and agencies, but that you will let them know if you have reached that level of concern. Reiterate that your concern is for the health and well-being of their child, and that you want to work with them to assure their child's safety.

With permission of the caretaker(s), talk separately with the child about whether something is bothering or hurting him or her. Developmentally normal children older than 3 years of age are usually able to participate in an interview to provide reasonable responses to open-ended questions about their experiences and environment. They are also capable of offering supporting details. Dr. Peterson, for example, should ask Adrian about his sports activities and hear from him how his injuries occurred.

Step 4

Following the interview with the child, complete a comprehensive physical examination of him or her, including inspection of all skin surfaces. Ask the child who he or she would like to have present during their exam. Ask the accompanying caretaker(s) to allow the child to answer questions during the exam. Directly ask the child about any scars, marks, or bruises seen on his or her body and how these occurred. If the child is reluctant to talk in front of the caretaker(s), meet separately with him or her following the exam.

Step 5

Perform or schedule any indicated tests and studies.

Step 6

Determine if additional expertise is needed, and make referrals to a clinical social worker, child-abuse pediatrician, or psychologist as indicated. One advantage to Dr. Peterson's referring Adrian and his family to a CAN specialist is that the family can then identify the abuse issues primarily with the specialist rather than with Dr. Peterson and her primary care practice.

Step 7

Based on information from the evaluation, determine whether the concern for abuse has risen to a suspicion. If so, report to CPS, a law-enforcement agency, or both, as dictated by the state's CAN statutes. Review your conclusions and your reporting decision with thecaretaker(s). If Dr. Peterson decides a report to CPS is not necessary, she may still want to refer Adrian for mental health counseling to explore the reasons for his change in affect (“often visibly upset or quiet and withdrawn”), which may be unrelated to his sports injuries but can be directly related to the family's financial stresses.

Step 8

Address any issues related to the child's safety or mental health and emotional needs as indicated.

Conclusion

Ultimately, Dr. Peterson's responsibility is to the well-being and safety of her young patient. She should be prepared to approach the possible diagnosis of child abuse or neglect in the same manner and with the same diligence that she approaches any other disorder or disease of childhood. By providing the best medical assessment, Dr. Peterson will help to identify whether or not Adrian has been abused or neglected. If her assessment concludes that CAN is suspected and she appropriately files a report, she will help assure that Adrian's case receives the most comprehensive assessment possible; that his medical, mental health and safety needs are addressed; and his family receives support and services.

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References

1. US Department of Health & Human Services, Administration for Children and Families. Child Maltreatment 2006. Washington, DC: US Government Printing Office; 2006.
2. Corso PS, Edwards VJ, Fang X, Mercy JA. Health-related quality of life among adults who experienced maltreatment during childhood. Am J Public Health. 2008;98(6):1094-1100.
3. Chapman DP, Dube SR, Anda RF. Adverse childhood events as risk factors for negative mental health outcomes. Psychiatr Ann. 2007;37(5):359-364.
4. Hindley N, Ramchandani PG, Jones DPH. Risk factors for recurrence of maltreatment: systemic review. Arch Dis Child. 2006;91(9):744-752.
5. Flaherty EG, Sege RD, Griffith J, et. al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics. 2008;122(3):611-619.

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Karen St. Claire, MD, is the medical director of the Duke Medical Center Child Abuse and Neglect Consult Service in Durham, North Carolina, and works as a clinician and educator in child maltreatment.

Related in VM

To Report or Not Report: A Physician’s Dilemma, February 2009

Suspected Child Abuse, November 2007

Liability for Failure to Report Suspected Child Abuse, December 2007

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.