Unexplained Gastrointestinal Symptoms After Abuse in a Prospective Study of Children at Risk for Abuse and Neglect

The association between exposure to child maltreatment and gastrointestinal symptoms in adults has been recognized for almost two decades; the results of the prospective cohort study by van Tilburg and colleagues now show a similar relationship in children.[1] These findings are particularly important, given its longitudinal design and use of both child protective services narratives, as well as parent and youth self-report to measure exposure. This study adds to the increasing evidence for the influence of child maltreatment on physical health in children – the topic of a forthcoming issue in the Journal of Pediatric Psychology.[2]

These adverse outcomes have led some to advocate screening for trauma exposure at well-child visits.[3] Similar to the identification of intimate partner violence exposure in adults, there seems to be a focus on "screening" – defined as "a standardized assessment of patients, regardless of their reasons for seeking medical attention" [4] – rather than selective integration of questions about violence exposure during diagnostic assessments. The US Preventive Services Task Force and the Canadian Task Force on Preventive Health Care recommend prevention strategies on the basis of scientific evidence for effectiveness; for screening, there must be accurate identification, and evidence that implementing such an approach can reduce adverse health outcomes.[4] Screening for child maltreatment does not meet either of these criteria.[5] Rather than moving prematurely to implement universal screening, why not enhance recognition of child maltreatment and enhance skills in asking about such experiences within the context of case-finding or diagnostic assessments?

With the emphasis on universal screening in family violence, we seem to have neglected the development of questions that pediatricians can include as part of history-taking during assessment of conditions that show an association with child maltreatment, including specific types of injuries, emotional and behavioral disorders, and now – with the evidence from the study by van Tilburg and colleagues – gastrointestinal symptoms. This is not to suggest that general pediatricians or their specialist colleagues be expected to conduct forensic assessments of all pediatric patients presenting with symptoms associated with child maltreatment. Rather, that we determine the best questions to ask about exposure to child maltreatment during history-taking, and develop general principles about how they should be administered (for example, not asking a child about abuse in the presence of parents). This type of research coupled with appropriate training could assist substantially in the recognition of child maltreatment.

References
1. van Tilburg MA, Runyan DK, Zolotor AJ, Graham JC, Dubowitz H, Litrownik AJ et al. Unexplained gastrointestinal symptoms after abuse in a prospective study of children at risk for abuse and neglect. Ann Fam Med 2010;8(2):134-140.
2. Noll JG, Shenk CE. Introduction to the special issue: the physical health consequences of childhood maltreatment - implications for public health. J Pediatr Psychol in press.
3. Cohen JA, Kelleher KJ, Mannarino AP. Identifying, treating, and referring traumatized children: the role of pediatric providers. Arch Pediatr Adolesc Med. 2008;162(5):447-452.
4. Cole TB. Is domestic violence screening helpful? JAMA. 2000 2;284(5):551-553.
5. Nygren P, Nelson HD, Klein J. Screening children for family violence: a review of the evidence for the US Preventive Services Task Force. Ann Fam Med 2004;2(2):161-169.

Competing interests:   None declared