Family violence: implications for the pediatrician.

There is no escape from violence in America, even for children. Public health leaders have identified violence as a problem of epidemic proportions. Family violence has been described as endemic; its existence is a constant feature of many American families, with the home as its major setting. Family violence accounts for at least 21,000 hospitalizations, 99,800 hospital days, 28,700 emergency department (ED) visits, and 39,000 physician visits each year. The United States Department of Justice estimates that from 1987 to 1990, the aggregate cost of domestic violence amounted to $67 billion per year. Losses due to violence against children exceed $164 billion annually. In 1962, Dr Henry Kempe raised the consciousness of the nation and pediatricians to the problem of child abuse with the publication of his paper “The Battered Child Syndrome.” Over the subsequent decades, pediatricians have become well educated and familiar with the problems of child abuse, sexual assault, and neglect. Yet, overwhelming evidence indicates that violence in childhood is much more complex than abuse and neglect. Children are exposed to violence in their communities and in their homes. Children suffer from witnessing violence in a variety of ways, including the development of posttraumatic stress disorder (PTSD). Children also are the perpetrators of violence. For pediatricians, this realization means that to have a significant effect on both the short-term and long-term consequences of violence, we cannot view the child in isolation—rather, the child is part of a family in a community. There is also the sobering responsibility of nurturing the child to become an adult who will be neither the victim nor the perpetrator of violence. Key skills for pediatricians are the recognition, diagnosis, treatment, and referral of victims of family violence. Important factors are recognition of: 1) maternal circumstances that may indicate domestic violence, 2) effects of domestic violence on children, and 3) common characteristics of violent children and adolescents. The pediatrician also has a central role as an advocate for effectively evaluating community-based violence prevention policies and programs.