The woman in front of me is 19 years old. Her face is tight, and her eyes are tired; there are no smiles in this room. It is 2 a.m., and she says she has been up for the last three nights, comforting her 18-month-old son, who just can't stop coughing. She has just spent another four hours in our emergency department waiting to see a doctor.

In response to my questions, she rather defensively tells me that, no, she doesn't have a partner at home; it is just her and her child. They live in a basement apartment in an old, renovated house. She is receiving social assistance. And yes, she does smoke in the house. Her eyes tell me that she isn't about to take any crap over that, either.

I don't even get into the topic of alcohol and street drugs. I don't ask about boyfriends. I carefully poke around the past medical history, looking for unexplained injuries, strange presentations or previous concerns raised by other health care workers. Then I examine the child.

He is clean, happy, well fed and dressed in clothes that cost more than those his mother is wearing. There isn't a single mark of concern on his body. He is obviously used to being held and has a well-loved peek-a-boo ritual that I can use to get to know him. He doesn't want to get off his mother's knee, but as long as she is there to comfort him, I can feel his belly, listen to his chest and check out his ears. His protests when I gag him to look in his throat are quickly ended by a hug and a little shushing from his mom.

When I became a father, I was in my early 30s. I had a stable, comfortable income, a wonderful, strong partner, the support of my family, and, of course, I didn't actually have to get pregnant first. I still think that fatherhood is the toughest job I have ever done.

This young woman humbles me.

Does that sound paternalistic, a middle-aged, male doctor with an upper middle class income judging a young, single mother fighting poverty? I guess it does, and is. Part of my role as an advocate for that child, though, requires me to judge the parenting provided to him. To assess whether his mother is capable. To recognize and evaluate the risks involved. To screen him for child abuse and neglect.

Emotion, not logic, characterizes approach to abuse

If Canadians consider child abuse at all, it is almost always in the context of a story in the media. We hear about a child gone missing, or the conviction of a parent, or a survivor coming forward to tell his or her story, and we feel a rush of disgust and anger at the perpetrators of acts that most of us find incomprehensible. We fear for our kids, and for our neighbours, and even the most liberal of us find ourselves hoping for the harshest of punishments for those involved. There is a lot of emotion, and precious little logic, in our approach.

That is unfortunate, because child maltreatment is a big problem and could use a little rational thought. Just over 2 per 100 children in Canada are investigated for signs of possible child abuse or neglect each year, according to the Canadian Incidence Study published in 2005. About one-third of those investigations are completely unsubstantiated, but that still leaves us with a rate of known or suspected maltreatment of more than 1.4 per 100 children per year.

How many children do you come in contact with on a daily basis? How many children are in your child's class at school, or daycare, or sports team or community group? More than 1.4 per 100 children. Think about it.

Worse, there is a valid argument that the number of investigations tends to underestimate the problem. How many episodes of abuse go unreported? What about neglect, which is identifiable only in the most extreme cases? What about emotional abuse, which is powerful and has long-lasting effects but no characteristic bruises or x-ray findings that can stand up in court?

We tend to think of child maltreatment as being an act carried out by males, but in about one-third of all cases, the perpetrators are female. The patterns of abuse are different between genders: females tend to abuse younger children, often infants, while older victims tend to be assaulted by males. Men may be more likely to act suddenly, impulsively, and tend to inflict more hazardous injuries. Sexual abusers are overwhelmingly male.

Women may be more likely to abuse quietly and for a longer period of time. Women, for example, are far more likely to engage in Munchausen syndrome by proxy, the relatively rare and bizarre condition in which children are injured in some covert manner, then presented to medical professionals by their abuser as a diagnostic dilemma. The abuser often comes across as a distressed, caring parent desperate to find an answer to the puzzling symptoms that result.

Scary? You bet. As parents, we hate these people.

Availability of child care correlates with abuse rates

Hate is not too strong a term; we hate child abusers with a depth of feeling that we just can't find for other criminals. We love our children, and the act of harming them is so alien that, to most of us, parents who abuse their children almost cease to be human. We know that we would do anything to protect our own children, and we feel a deep sorrow that no one was there to protect the victims we hear about.

Yet, that deep emotional resonance doesn't translate into any meaningful action. We could move to dramatically decrease the number of children hurt in this country, but we don't. And one has to wonder why not.

There is a link, you see, between social environment and the risk of child abuse. Studies clearly show that poorer neighbourhoods have higher rates of child maltreatment and that residential stability and parenting stress are parts of this pathology. The amount of community support available to individual parents directly correlates with the number of shaken babies, broken limbs and raped toddlers that show up in our emergency departments. We know this, and so does our government, but we don't do much about it. Take daycare as an example. The term "child care burden" can be conceptualized as being the number of child care resources available to a parent; the more resources, the lower the burden. Studies have shown that in neighbourhoods where child care resources are low, child abuse rates are high. Further, when mothers choose to become employed, child abuse rates fall, presumably at least partly because someone else is sharing the load of parenthood.

Young, single mothers battle poverty, often in relative isolation, often without much social support. They have toddlers who do all of the wonderful and incredibly frustrating things that all toddlers do. They parent without a partner, no one with whom to discuss the raising of their child, the minor illnesses, parenting fears and uncertainties. They often experience periods of profound loneliness. And they feel the same anger any parent feels when his or her child just won't stop crying in the middle of the night or draws on the wall with the crayons yet again.

Never felt the urge to hit your child? Then you haven't been a parent very long. How stable would you be if your social circumstances suddenly changed, if you were younger, less experienced and alone? Perhaps in that light, the act of child abuse becomes imaginable. Not defensible. Maybe not even forgivable. But, perhaps, understandable. That's why these young, exhausted single parents with their clean, happy, well-fed children are, well, heroes. We should honour them. As a nation, we should be doing more to support them.

Canada's daycare system inadequate, chronically underfunded

In 2004, after more than a decade of dithering, the Liberal government announced a $5 billion plan to provide 250,000 new daycare spaces across Canada. Conservative leader Stephen Harper, however, crushed that plan shortly after taking office in 2006, announcing instead the infamous $100-per-child plan that was supposed to (somehow) create 125,000 new daycare spaces nationally. These spaces never materialized, and the plan is now seen as a failure.

In 2004, the Organization for Economic Co-operation and Development (OECD) described Canada's day care system as "a chronically underfunded patchwork of programs with no overarching goals" and said that there were daycare spaces in this country for less than 20 per cent of children age six and younger whose parents both worked. In 2006, the OECD found that Canada had the worst funding for daycare and early-childhood learning of any of the developed nations studied.

Juxtapose this with the costs of abuse. In the United States, a study in 2001 found that child abuse and maltreatment costs as much as $258 million per day — per day. That includes direct costs such as hospitalization, chronic health problems, increased burden on child welfare systems and indirect costs such as juvenile delinquency and adult criminality.

Adjusting for population and the differences in abuse rates, abuse must be costing Canadian taxpayers millions of dollars per day. Yet for some reason, funding child care is not something we are particularly interested in.

Clearly, child abuse does not occur exclusively among the poor or socially stressed, but it is these groups that are overwhelmingly affected by it. Similarly, daycare isn't the only factor amenable to social policy; attention spent on sustainable housing, drug and alcohol rehabilitation and poverty itself will also make our children safer. However, study after study relates the delivery of sound, accessible daycare to a decrease in the child abuse rate.

Why aren't we funding daycare?

We would, it seems, rather get tough on crime than prevent it. The recently adopted omnibus crime bill, for example, will increase mandatory sentences for some offences and make it easier to keep chronic criminals in jail. Other initiatives, involving the Youth Criminal Justice Act, are intended to make it easier to identify youth criminals and keep them in jail longer. The only "prevention" aspect to these initiatives is deterrence — the idea is that tougher sentences and a more aggressive approach will make potential criminals think twice.

But is this the case? If the possibility of permanently crippling or killing a child won't deter your actions, is it likely that you are the sort of person who worries about a theoretical increase in your jail time?

And how many happy, well-cared-for youth end up committing serious crimes, anyway? What if these youth didn't grow up amid poverty and violence? What if positive parenting and role modelling were available from an early age?

Why aren't we funding daycare? Whatever happened to an ounce of prevention?

It seems that we are surrounded by government officials who want to appear to be moving on these issues but are unwilling to act — either because they don't want to spend the money or because of some bizarre ideological dogma. These officials are, it seems, perfectly prepared to spend money funding jail cells but not daycare spaces.

We have to recognize that we, through our government, are partners in the assaults that take place on children every single day in this country. We can shift the blame and vent our disgust, but by choosing leaders and agendas that don't prioritize stable social environments, we choose to set the stage for the abuse that occurs in our communities. As long as we refuse to address the social basis for child abuse, we have to recognize that it's not just the perpetrators of the abuse who hurt children in this country. We hurt them, too.

Wouldn't you agree, Mr. Harper?

Brett Taylor is an associate professor of pediatrics and emergency medicine at Dalhousie University. He works as an emergency paediatrician and researcher at the IWK Health Centre in Halifax. He is in the process of obtaining a Masters in Health Informatics, also through Dalhousie. His website for parents is available at www.thevirtualpediatrician.com.

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