What is child abuse? It is the physical or emotional abuse of a child by a parent, guardian, or other person. Reports of child abuse, including sexual abuse, beating, and murder, have climbed in the United States and some authorities believe that the number of cases is largely under reported. Child neglect is sometimes included in legal definitions of child abuse to cover instances of malnutrition, desertion, and inadequate care of a child's safety. When reported, child abuse cases are complicated by inadequate foster care services and a legal system that has trouble accommodating the suggestible nature of children, who are often developmentally unable to distinguish fact from make-believe (Hay, 1996). In 1993, the United States Advisory Board on Child Abuse and Neglect declared a child protection emergency. Between 1985 and 1993, there was a 50 percent increase in reported cases of child abuse.

Three million cases of child abuse are reported in the United States each year. Treatment of the abuser has had only limited success and child protection agencies are overwhelmed (Lewitt, 1997). Recently, efforts have begun to focus on the primary prevention of child abuse. Primary prevention of child abuse must be implemented on many levels before it can be successful.

Prevention plans on the social level include increasing the economic self-sufficiency of families, discouraging corporal punishment and other forms of violence, making health care more accessible and affordable, expanding and improving coordination of social services, improving the identification and treatment of psychological problems, and alcohol and drug abuse, providing more affordable child care and preventing the birth of unwanted children. Prevention plans on the family level include helping parents meet their basic needs, identifying problems of substance abuse and spouse abuse, and educating parents about child behavior, discipline, safety and development. Primary prevention is both the prevention of disease before it occurs, and the reduction of its incidence. In the case of child abuse, primary prevention is defined as any intervention designed for the purpose of preventing child abuse before it occurs (Hay, 1996). Between 1985 and 1993, the number of cases of child abuse in the United States increased by 50 percent.

In 1993, three million children in the United States were reported to have been abused. Thirty-five percent of these cases of child abuse were confirmed. Data from various reporting sources, indicates that improved reporting could lead to a significant increase in the number of cases of child abuse verified by child protection agencies. The lack of verification does not indicate that abuse did not occur, only that it could not be verified.

The facts are that each year 160, 000 children suffer severe or life-threatening injury and 1, 000 to 2, 000 children die as a result of abuse. Of these deaths, 80 percent involve children younger than five years of age, and 40 percent involve children younger than one year of age. One out of every 20 murder victims is a child. Murder is the fourth leading cause of death in children from one to four years of age and the third leading cause of death in children from five to fourteen years of age. Neonaticide, which is the murder of a baby during the first 24 hours of life, accounts for 45 percent of children killed during the first year of life (Lewitt, 1997). As I stated above, deaths from abuse are under reported and some deaths classified as the result of accident and sudden infant death syndrome might be reclassified as the result of child abuse if comprehensive investigations were more routinely done.

Most child abuse takes place in the home and is started by persons are know to and trusted by the child. Even though it has been widely publicized, abuse in day-care and foster-care settings accounts for only a small number of confirmed cases of child abuse. In 1996, only two percent of all confirmed cases of child abuse occurred in these settings. Child abuse if fifteen times more likely to occur in families where spousal abuse occurs.

Children are three times more likely to be abused by their fathers than by their mothers. No differences have been found in the incidence of child abuse in rural versus urban areas. Following are the types of abuse and the percentages of the different types. Neglect - 54%Physical abuse - 25%Sexual abuse - 11%Emotional abuse - 3%Other - 7% (Davis, 1998).

Not only do children suffer from the physical and mental cruelty of child abuse, they endure many long-term consequences, including delays in reaching developmental milestones, refusal to attend school and separation anxiety disorders. Other consequences include an increased likelihood of future substance abuse, aggressive behaviors, high-risk health behaviors, criminal activity, depressive and affective disorders, personality disorders, post-traumatic stress disorder, panic attacks, schizophrenia and abuse of their own children and spouse. Research has shown that a loving, caring and stimulating environment during the first three years of a child's life is important for proper brain development (Davis, 1998). There have been some recent changes in regards to the causes of child abuse. The results of research initiated by the National Research Council's Panel on Research on Child Abuse and Neglect showed the first important step away from the simple cause and effect patterns. The panel stated that the simple cause and effect patterns have certain limitations, mostly related to their narrow focus on the parents.

These patterns are limited by asking only about the isolated set of personal characteristics that might cause parents to abuse their children. These patterns failed to account for the occurrence of different forms of abuse in one child. These patterns had very little explanatory power in weighing the value of various risk factors involved in child abuse. As a result, they were not very accurate in predicting future cases of child abuse. To replace the old static pattern, the panel has substituted what it calls an ecologic model. This model considers the origin of all forms of child abuse to be a complex interactive process.

This ecologic model views child abuse within a system of risk and protective factors interacting across four levels: (1) the individual, (2) the family, (3) the community and (4) the society. Some factors are more closely linked with some forms of abuse than others. The following are factors thought to contribute to the development of physical and emotional abuse and neglect of children: Community / society Parent-related High crime rate Personal history of physical or sexual abuse Lack of or few social services Teenage parents High poverty rate Lack of parenting skills High unemployment rate Unwanted pregnancy Emotional immaturity Child-related Poor coping skills Prematurity Low self-esteem Low birth weight Personal history of substance abuse Handicap Known history of child abuse Domestic violence Lack of preparation for extreme stress of having a new infant (Understanding Child Abuse and Neglect, 1996). Many people would argue that our society does not really value its children. This argument is highlighted by the fact that one in four children in the United States lives in poverty, and many children do not have any form of health insurance. The presence of high levels of violence in our society is also thought to contribute to child abuse.

Deadly violence is more common in the United States than in seventeen other developed countries. Seventy-five percent of violence occurring in this country is domestic violence. The United States leads developed countries in homicide rates for females older than 14 years and for children from five to fourteen years of age. Other factors that may contribute to high rates of violence include exposure to television violence and reliance on corporal punishment (McKay, 1997).

Poverty is the most frequently and persistently noted risk factor for child abuse. Physical abuse and neglect are more common among the people who are the poorest. Whether this is brought on by the stress of poverty-related conditions or results from greater scrutiny by public agencies, resulting in over reporting, is debated. Other factors include inaccessible and unaffordable health care, fragmented social services and lack of support from extended families and communities (Besharov, 1990). Parents who were abused as children are more likely than other parents to abuse their own children. Lack of parenting skills, unrealistic expectations about a child's capabilities, ignorance of ways to manage a child's behavior and of normal child development may further contribute to child abuse.

It is estimated that forty percent of confirmed cases of child abuse are related to substance abuse. It is also estimated that eleven percent of pregnant women are substance abusers, and that 300, 000 infants are born each year to mothers who abuse crack cocaine. Domestic violence also increases the risk of child abuse (Helper, 1998). Other factors that increase the risk of child abuse include emotional immaturity of the parents, which is often highly correlated to actual age, as in the case of teenage parents, poor coping skills, often related to age but also occurring in older parents, poor self-esteem and other psychologic problems experienced by either one or both parents, single parenthood and the many burdens and hardships of parenting that must be borne without the help of a partner, social isolation of the parent or parents from family and friends and the resulting lack of support that their absence implies, any situation involving a handicapped child or one that is born prematurely or at a low birth weight, any situation where a sibling younger than 18 months of age is already present in the home, any situation in which the child is the result of an unwanted pregnancy or a pregnancy that the mother denies, any situation where one sibling has been reported to the child protective services for suspected abuse, and finally, the general inherent stress of parenting which, when combined with the pressure of anyone or a combination of the factors previously mentioned, may exacerbate any difficult situation (Besharov, 1990). The United States Advisory Board on Child Abuse and Neglect has stated that only a universal system of early intervention, grounded in the creation of caring communities, could provide an effective foundation for confronting the child abuse crisis. It is believed that successful strategies for preventing child abuse require intervention at all levels of society.

No agreement has been formed concerning which programs or services should be offered to prevent child abuse. This is because research on the prevention of child abuse is limited by the complexity of the problem, the difficulty in measuring and interpreting the outcomes, and the lack of attention to the interaction among variables in determining risk status for subsequent abuse. A broad range of programs has been developed and implemented by public and private agencies at many levels, little evidence supports the effectiveness of these programs (Rushton, 1997). As 1994 look back on a review of 1, 526 studies on the primary prevention of child abuse found that only thirty studies were methodologically sound.

Of the eleven studies dealing primarily with physical abuse and neglect, only two showed a decrease in child abuse as measured by a reduction in hospital admissions, emergency department visits or reports to child protective services. Although there is a need for better designed research to evaluate the effectiveness of prevention strategies, recommendations for preventive interventions are based on what we currently know about causes of child abuse (Hay, 1996). Primary prevention strategies based on risk factors that have a low predictive value are not as likely to be effective as more broadly based social programs. In addition, programs focused on a society level rather than on the individual level prevent the stigmatization of a group or an individual. Society strategies for preventing child abuse that are proposed but unproven include increasing the value society places on children, increasing the economic self-sufficiency of families, enhancing communities and their resources, discouraging excessive use of corporal punishment and other forms of violence, making health care more accessible and affordable, expanding and improving treatment for alcohol and drug abuse, improving the identification and treatment of mental health problems, increasing the availability of affordable child care and preventing the births of unwanted children through sex education, family planning, abortion, anonymous delivery and adoption (Rushton, 1997). Common Features of Successful Child Abuse Prevention Programs Strengthen family and community connections and support.

Treat parents as vital contributors to their children's growth and development. Create opportunities for parents to feel empowered to act on their own behalf. Respect the integrity of the family. Enhance parents' capability to foster the optimal development of their children and themselves.

Establish links with community support systems. Provide settings where parents and children can gather, interact, support, learn from each other. Enhance coordination and integration of services needed by families. Enhance community awareness of the importance of healthy parenting practices. Provide emergency support for parents 24 hours a day. (Rushton, 1997).

Plans aimed at helping the individual can also be considered strategies for helping the family. In the list of features of successful child abuse prevention programs listed above, the idea is to support parents in their role of parenting. Until parents' basic needs are met, they may find it difficult to meet the needs of their children. The first thing parents need is assistance in meeting their basic requirements for food, shelter, clothing, safety and medical care. Only when these needs are met can higher needs be addressed (Rushton, 1997). The next step should be to identify and treat parents who abuse alcohol or drugs, and identify and counsel parents who suffer from spousal abuse.

Identifying and treating parents with psychologic problems is also important. Other issues that need attention include financial concerns, and employment and legal problems. Providing an empathetic ear and being a source of referral for help with these issues may take physicians a long way toward nurturing needy parents. The next higher level of need includes education about time management and budgeting skills, stress management, coping and parenting skills such as appropriate discipline, knowledge of child development, nutrition and feeding problems, and safety issues (Rushton, 1997). In the United States, some of the specific methods of delivering services to families include long-term home visitation, short-term home visitation, early and extended postpartum mother / child contact, rooming in, intensive physician contact, drop-in centers, child classroom education, parent training and free access to health care.

Of all these methods, only long-term home visitation, up to two years, has been found to be effective in reducing the incidence of child abuse as measured by hospital admissions, emergency department visits and reports to child protective services. Man organizations are now embracing the concept of home visitation as a method of preventing child abuse by identifying family needs and providing the appropriate services. Results of one study on home visitation showed benefits or improvements in several areas: parents' attitudes toward their children, interactions between parents and children, and reduction in the incidence of child abuse. Without a basic framework of support services such as health care, social services and child care, home visitors will be unable to deliver needed services (Rushton, 1997). Strategies for Preventing Child Abuse Diagnose pregnancy in unmarried mothers and explore its impact with them.

o Assess the number of stressor's on new parents, including: Social support Financial situation Martial status Level of education Number of children Identify families with problems of: Substance abuse Domestic violence Mental he altho Offer new parents: Services of a social worker Long-term home visitation Parenting classes Educate new parents regarding: Developmental tasks of childhood Age-appropriate anticipatory guidance Nutrition and feeding problems Safety Discipline Discourage corporal punishment Survey parents to identify health issues that are of interest to the mo Support universal health care for children Advocate for quality, affordable and universally available child care Advocate for community respite care for parent so Advocate for community alcohol and drug treatment, mental health, and spouse and child abuse centers (Rushton, 1997). Many of the causes of child abuse center on the needs and problems of the parents. In order to prevent child abuse, we must first help and support the parents. Parents with multiple emotional, medical, financial and social needs find it difficult to meet the needs of their children. It is imperative that physicians develop a supportive attitude toward parents to ultimately help the children. Effective prevention of child abuse and neglect can best be achieved using strategies designed to help parents protect and nurture their children.

These strategies including giving parents the necessary support, resources and skills. The physician should obtain help from social workers, home health agencies, financial counselors, psychologist, local mental health facilities, alcohol and drug treatment centers and parenting centers, as appropriate. The National Committee to Prevent Child Abuse has a nationwide network of fifty-two chapters that provide leadership in prevention of child abuse (Understanding Child Abuse and Neglect, 1996). One source I read suggested setting up group parenting classes to discuss issues such as: safety issues, nutrition and feeding concerns, discipline and normal child development. Classes should be divided into two groups: one for the parents of infants and one for the parents of toddlers, since these two groups will require a different focus. Providing child care during these classes may be necessary to ensure attendance.

Other suggestions are for a physician to help to try prevent child abuse. Spending less time examining an obviously well child and more time discussing psycho social issues with that child's parent is one suggestion. The following is a list of questions a physician can ask parents that might help assess the risk of child abuse. What is it like for you taking care of this baby? Who helps you with your children? Do you get time to yourself? What do you do when the child's behavior drives you crazy? Do you have trouble with your child at mealtime or bedtime? Are your children in day care? How are things between you and your partner? (Rushton, 1998). If psycho social problems are uncovered, the physician might schedule more frequent visits to allow for further discussions. Other strategies include inviting fathers for an office visit and encouraging the parents to rely on the support of families and friends.

It is important to address issues that are of concern to the parents. It is also important to try to give very specific and concrete suggestions to parents instead of talking in broad generalities. Physicians could suggest that parents use an egg timer to help children anticipate and be more compliant with bedtime or use time-out as an alternative to spanking a child for bad behavior. Parents should be reminded of and taught to distinguish between childish behavior and willful disobedience, and to discipline only those actions that are in the child's control according to his or her stage of development (Rushton, 1997). Many things need to happen at international, national, state and community levels to prevent child abuse.

Studies have shown that countries with the most generous social services have the lowest rate of child homicide. People should lobby for greater availability of drug and alcohol treatment programs, more shelters for the homeless, more accessible mental health care and more shelters for abused women and children. These programs and those that provide parenting skills, support groups and respite care for parents and care givers should be available in every community. Child abuse is a complex problem with many causes, it is important that people not take a defeatist attitude toward its prevention. Despite the absence of strong evidence to guide preventive efforts, society can do things to try to prevent abuse. Showing increased concern for the parents or care givers and increasing attempts to enhance their skills as parents or care givers may help save the most vulnerable people, our children, from the nightmare of abuse and neglect..