"The battered-child syndrome" 50 years later: much accomplished, much left to do.

A HALF CENTURY AGO, KEMPE AND COLLEAGUES 1 published in JAMA “The Battered-Child Syndrome,” an article that would change the way physicians and others care for children with injuries. Although this article was not the first in the medical literature to address the problem of physical abuse of children, the authors did report the first epidemiologic study and highlighted important aspects of the evaluation of suspected abuse: (1) the discrepancy between the stated history and clinical findings, (2) questions that can be asked of parents when physicians are concerned about possible abuse, (3) some of the key physical examination and radiographic findings in abused children, (4) associated findings such as poor hygiene and failure to thrive, and (5) reasons physicians might have difficulty believing that parents can hurt their children. Since 1962, several major developments have occurred regarding maltreated children in the United States, including the development of state-mandated reporting laws; the establishment of countyor state-based child protective services (CPS) agencies, which are responsible for the investigation of suspected maltreatment, decisions about whether a child has been maltreated, placement of children in foster care when necessary, and services for the families when maltreatment has occurred; the broadening of the term “child abuse” to “child maltreatment,” which now includes physical abuse, neglect, sexual abuse, and emotional maltreatment; and the establishment in 2009 of a new pediatrics subspecialty, child abuse pediatrics. The 50th anniversary of the article by Kempe et al is an opportunity to reflect on 3 salient lessons learned over the past 5 decades about the care of maltreated children: (1) many children and families are affected; (2) the consequences can be lifelong and intergenerational; and (3) treatment and prevention can work but need to be expanded. Many Are Affected Maltreatment is far more common than first reported by Kempe et al. Data about the scope of the problem have been obtained from CPS agencies, mortality statistics, hospital discharge data, and national surveys of adults, parents, and older children and adolescents. In 2010, 3.3 million reports affecting 5.9 million US children were filed with CPS agencies; 695 000 children (0.9% of all children in the country) were substantiated as having experienced maltreatment. Approximately 78% were substantiated for neglect, 18% for physical abuse, and 9% for sexual abuse, and 1560—most younger than 5 years—died from maltreatment, although this number is likely an underestimate. Based on data from CPS agencies, the incidence of substantiated cases of child physical abuse and sexual abuse has decreased since 1990 by more than 50%. These declines are believed to be attributable, in part, to increased services for children and families, including prevention programs; widespread use of psychiatric medications; and jailing offenders. Data from other sources have not provided as optimistic a picture about a decrease in the occurrence of specific kinds of maltreatment. For example, the national incidence of hospitalization of children for serious injuries attributable to physical abuse has remained stable at about 6 cases per 100 000 children from 1997 to 2009. These cases represent less than 4% of all physically abused children, but the marked difference in the results comparing these rates of hospitalizations with the CPS data suggests that different aspects of the phenomenon of physical abuse are being measured. Research has clearly shown that children who have experienced one type of maltreatment often have experienced other types of maltreatment and often other types of violence, such as exposure to domestic violence.