child abuse

Monday, September 15, 2014

Football is supposed to be about great catches, amazing runs, open field tackles and your favorite team winning in the last minute. It is supposed to be about joy and community, the celebration of individual performance and team accomplishment. It is not supposed to be about injuries and Robert Griffin’s dislocated ankle, Knowshon Moreno’s dislocated elbow, Ryan Matthews sprained knee or DeSean Jackson’s separated shoulder. But football is a violent sport and behavior on the field should not expected to be acceptable away from the stadium and for that reason, it is difficult to read about Adrian Peterson’s indictment on child abuse for disciplining his son with a switch.

The facts are not in dispute. Peterson used a switch or tree branch to hit his son and leave cuts and bruises on his back, legs, buttocks, scrotum and hands. The child was hit between 10 and 15 times but Mr. Peterson could not remember the exact number and it was not the first time that the child and his siblings had been punished in that way. CBS Houston has summarized the police reports. However, what is in dispute, and what is frustrating for those who care for beaten children, is the pretense that a parent bestowing corporal punishment on a child is a legally accepted form of child abuse.

Celebrity athletes have come to the defense of Mr. Peterson, describing their upbringing where “whooping” a child was an accepted form of behavior. Charles Barkley felt that his beatings as a child did not affect his personal development and had no trouble admitting in a CBS interview that he continued the tradition saying that his daughter was “spanked pretty good”. I’m from the South. Whipping — we do that all the time.” He tried to distinguish between using a switch and beating or child abuse, but also admitted that perhaps his grandmother had sometimes crossed the line. During a radio interview, Tony Dungy, former NFL coach and now NBC analyst, wanted to wait to see what the courts had to say whether, the whooping with a switch was child abuse. He talked about getting the same disciplinary beatings as a child.

The issue is not one of action but presumably of intent. Abuse is rage against the child, while corporal punishment that inflicts the same physical and emotional damage is somehow different. Because one generation felt it appropriate to beat children does not make it the norm. Physical violence is not acceptable, except perhaps on the football field, and on the field there are referees to enforce the rules. It is unacceptable to hit a defenseless receiver or an exposed quarterback. Players who attempt to injure are thrown out of the game. The same protections are not in place in a home where a large adult has chosen to beat a defenseless child.

What is child abuse? For most people, it’s like pornography, and paraphrasing Justice Potter Stewart: it’s hard to define but they know it when they see it. The Child Welfare Information Gateway  has a summary of signs and symptoms and how to recognize abuse and neglect, and explains the different forms that child abuse can take. But the legislature and legal system give wide latitude to parental discretion and each state has its own acceptable forms of behavior that are allowed when beating a child in name of parental discipline. From a legal paper on where and how to draw the line between reasonable corporal punishment and abuse:

Twenty-one states, along with the District of Columbia, except reasonable physical discipline from their statutory definitions of physical abuse. Theseprovisions typically use the term “reasonable” to describe legally acceptable corporal punishment, although some employ the term “excessive” to describe corporal punishment that has crossed the line of acceptability. For example, the District of Columbia’s statute provides that abuse “does not include discipline administered by a parent, guardian, or custodian to his or her child;provided, that the discipline is reasonable in manner and moderate in degreeand otherwise does not constitute cruelty. ”The statute then provides an illustrative list of specific acts that are unacceptable forms of discipline for purposes of the exception. Among these acts are “burning, biting, or cutting a child” and “nonaccidental injury to a child under the age of 18 months.” Similarly, in Florida, physical discipline can be considered excessive when it results in “significant bruises or welts,” among other enumerated injuries.

Whatever the NFL and Adrian Peterson decide must happen with his playing career matters little. He is but one player out of many in the league who have been accused of violent crimes. They are in the minority of the millions of people who have played on high school, college and pro teams, but they are also representative of what happens when star athletes are not held accountable because their performance on the field counts more than in real life.

Mr. Peterson got caught and because of his indictment, there is an opportunity to discuss openly, a subject that most of us want to pretend does not exist. In 2012, there were more than3.1 million reports of child abuse. 1,593 children died of their injuries. The NFL is the number one program on television and we celebrate, as a nation, the holiday that is Super Bowl Sunday. Perhaps if we concentrated more on our neighborhood children we wouldn’t have to be silent spectators to the child abuse that surrounds us. Adrian Peterson, Charles Barkley, and Tony Dungy have given us a wake-up call, but I refuse to thank them.

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NFL Concussions

Tuesday, September 9, 2014

Packers’ Eddie Lacy: concussion.

Bengals’ Vontaze Burfilt: concussion.

49ers’ Chris Culliver: concussion.

Jaguars’ Johnathan Cyprien: concussion.

 

The first week of the NFL season had its share of hard hits and at least four players were identified as having sustained a concussion. The good news is that the league policy makes certain that the injured player is evaluated, removed from the game and not to return until there is healing of the brain. The bad news is that even with all the awareness about head injury, the diagnosis of concussion is difficult at best, and especially when there is a delay in presentation of symptoms. Coaches, trainers and doctors are good at looking after players on the sideline if a concussion is documented or diagnosed, but what happens to the player who doesn’t realize that he is injured.

No matter what the high tech world of medicine says, there is as yet, no test to confirm or deny the presence of a concussion. The diagnosis is one that is made clinically, based on history. There may be subtle neurologic findings on physical exam (for example nystagmus, abnormal eye movements that can signal problems with the balance system of the brain) but the physical exam in a concussed patient is almost always normal. Imaging the brain with CT scan or MRI is not always necessary based on the situation. To make things more challenging, players may not appreciate that they have been hit or have their head shaken enough to even consider that the potential for concussion exists.

It’s easy to make the diagnosis is the patient is knocked unconscious or gets up after  getting hit and is dazed and confused.  Vomiting, unsteady walking, slurred speech and slow response to questions are symptoms that can be observed, but the rest of the brain injury symptom spectrum may more subjective and requires the player and family and friends to appreciate those subtleties and report them. There may be hours or days delay between the head a hit and the recognition of symptoms that cannot be measured or found on physical exam. A few include the following:

  • Difficulty concentrating
  • Short term memory issues. In students this can lead to problems studying and significant affect grades to the downside
  • Increased light and noise sensitivity
  • Change in sleep patterns, either sleeping too much or inability to get to sleep
  • Changing personality including irritability and depression

The goal of a concussion protocol is to protect the player from sustaining a second injury and allowing the brain time to heal. The ability to meet this goal requires close attention to detail but it’s hard to evaluate all the players after every down. The NFL has an independent physician trained in concussion assessment on the sideline for each team. There is a spotter for each team in the booth to look for potential head injury victims. Only obvious symptoms, that can be observed, trigger the rule that removes the player from the field for further testing. Subtle is not easy to observe. While the NFL is has the resources to surround their players with medical personnel, those same resources are not available to most amateur players from peewee to college.

And while the NFL has spelled out a protocol to decide when the brain has healed completely, every brain responds differently to being concussed. Every timeline needs to be customized to the specific person and their situation. Believing that there is a reliable road map for return to play that is the same for every player and situation is not reasonable. The return to play guidelines depend on the patient progressing from one milestone to another and there may be roadblocks that delay moving to the next checkpoint.

The bottom line about concussions is that while research is making strides in understanding the brain, the medical community continues to struggle in managing head injury patients. While the patient and public expect precision, doctors can only deliver a best guess opinion.

 

 

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