When I have proposed that we ask every child on a regular basis whether they have or are being abused, I am met with a universal hesitation. Even though this is clearly an effective method of identifying and ending child abuse, people hesitate. Why? What is the nature of this concern?
- Asking seems intrusive.
- Asking seems disrespectful of the parents.
- We do not ask because we believe that the child may not be truthful.
- We do not ask because we do not want to upset the child if he or she is truthful.
- We do not ask because if the child says yes but is lying, tremendous distress for the parents, legal action, and needless conflict may be created.
- We do not ask because we believe that this will overload our system of care.
These rationales have collectively built the foundation of a cultural norm of silence around child abuse. What is interesting is that historically, on other issues, these arguments have failed.
Suicide Assessment. These same arguments were used to resist the implementation of a mandatory, proactive assessment of suicide potential. Debate over this issue persisted until the 1960s, when what is now established practice became the norm within mental health and hospital care. Proper suicide or homicide assessment requires that the professional ask the patient if they are suicidal/homicidal, if they have a plan, access to a means, and whether their action is imminent. The fact that the patient can lie and deny this, can lie and say they are suicidal when they are not in order to manipulate their way into the hospital; the fact that asking patients these questions can upset them or their parents; the fact that these questions are intrusive; all of these facts do not overcome the requirement to ask the patient and to document the answers. To fail to ask the client these questions is now considered malpractice. The reason these objections have been set aside, is that more often than not, patients tell the truth, and more often than not, asking these questions has led to the reduction of suicide and homicide. We ask our patients if they are suicidal because that is the best way to find out.
Airport Security. Have you ever wondered why you are asked the same questions each time you go to the airport? “Who packed your bags? Have your bags been in your possession since you packed them? Has anyone asked you to carry a package for them? Do you have anything in your bags that could be used as a weapon?” Why do they ask us the same questions? Do they expect the terrorists to tell the truth?
There are three reasons. The first is that it is important that someone else has not had access to your bag. The second is that it is often possible to tell if someone is lying. The third is that by asking these questions over and over again, people come to expect to be asked, and learn to be more vigilant. That is, new norms are set. That is why that announcement over the PA system keeps repeating, “If you see any unattended bags, please notify an airport security person.” And in just this way, if children are repeatedly asked by their pediatrician or other authorities whether they have been maltreated, over time everyone will know these questions, and new norms will be reinforced.
But questions are not the only thing we encounter in the airport. Everyone entering the airport is now scanned, sometimes with a full body X-ray scan, and bags are looked into, and sometimes with a complete pat-down search including our groin area. Why are these intrusive measures required, why do we allow this loss of privacy? In order to protect air travel.
So let us assess the threat:
How many deaths from terrorism on airplanes occurred in the United States in 2010?
In contrast: How many deaths from child maltreatment occurred in the United States in 2010?
That is the equivalent of 8 jets each with 250 passengers crashing and leaving no survivors, each year. Can you imagine what intrusive measures we would accept if that were the case for air travel? And yet, we hesitate to intrude on our privacy in the face of 2,000 deaths of children. Will we allow intrusive questions to be asked, in order to protect our children?
So great is the discomfort over the idea of asking children if they are being abused, that even health professionals avoid it. Consider the standard of care of the American Academy of Pediatrics, who are taught to assess for child abuse by identifying the following signs:
Sprains or fractures
Discomfort with physical contact
At home with no caretaker
Does not want to go home
Begs or steals money or food
Running away from home
If child reports abuse
Pain or itching in genital area
Unattended medical needs
Torn, stained, or bloody clothing
Lags in development
Overly compliant, passive, withdrawn
Shrinks at approach of adults
Nightmares or bedwetting
Note this last one: “if the child reports abuse.” If. The pediatrician carefully notes the child’s behavior and looks for physical signs. He or she does everything but the one thing that is much more likely to result in the identification of child maltreatment. Missing from this list is the most reliable, most obvious, most effective way of assessing whether the child has been neglected or abused: Ask the child.
Pediatricians are currently not required to ask the child if they are being hit, neglected, or sexually molested by their parents, siblings, or anyone else. Only if there is a sign of such abuse might they ask. But how often are these signs ambiguous? Often. How often are there no overt signs of abuse? Often. That this reluctance to ask is not due to prissiness on the part of the Academy is shown by the fact that they advocate that pediatricians teach children age 5 and above the names for their genitalia. Indeed, doctors are obligated to actually touch the private parts of our children as part of the physical exam, but hesitate to ask the child whether they have been touched inappropriately by others!
How about the Boy Scouts of America? In 1995, the BSA implemented a mandatory program on child abuse for every Cub Scout and Boy Scout in this country, which includes going through a pamphlet on child abuse with their parents, who are required to sign that they did this with their child, and then watching an explicit video about child abuse, each year. 6 to 9 year olds watch “It Happened to Me,” and 10 to 14 year olds watch, “A Time to Tell.” The materials emphasize that the most likely abuser is going to be someone close to them, a teacher, a coach, a family member, even a scout leader. They are told to report any such act to the appropriate person immediately and to not be intimidated by the abuser to remain silent. The videos are explicit, uncomfortable, and accurate.
1.6 million young boys, from the age of 6 to 10, and 1.2 million boys age 11-16, or 10% of all boys in the country, are receiving this training. This may be one of the most comprehensive public health interventions in the nation, and thus is a tremendous advance, but again, the program instructs the children to Recognize, Resist, and Report the abuse once it has happened. Nowhere in the educational materials does it instruct the adult leaders or parents to Ask their children if any abuse is occurring. The act of courage that reporting abuse requires is left up to the child, and not us.
I have found that oftentimes it is mental health professionals that are the most hesitant or concerned about asking children directly! All of us bear the responsibility of sustaining the cultural norm of silence and privacy and protection. We walk by each other, alone in our histories, protected in our private suffering by a norm that crushes the children we work with into silence. We drive to work past silent houses within which our future patients are being harmed. In these ways, we are inadvertently contributing to the conditions that are sustaining the problem.
Indeed, there can be only one conclusion: We are the problem.