Providers Assessing Child Abuse and Neglect

Abstract

Child abuse is widespread and often unrecognized in our communities. Child abuse and neglect, also more generally referred to as child maltreatment, is defined as an act by a parent or caregiver that results in harm or threat of harm to a child. The 4 types of child maltreatment are physical abuse, emotional abuse, neglect, and sexual abuse. The Centers for Disease Control and Prevention (CDC) estimates that 1 in 7 children are victims of maltreatment during childhood, and 5 children die in the United States every day as a direct result of abuse or neglect. Herein we discuss the 4 main types of child abuse and the role of the pediatrician in child abuse cases.Pediatricians must become well versed on child abuse and neglect to screen for abuse, provide anticipatory guidance to families, identify child victims, and report maltreatment concerns to appropriate child welfare agencies. A medically focused, patient-centered approach to cases that prioritizes the safety of the child is critical because pediatricians are often the first, or only, medical professional to evaluate child abuse victims. Although referrals to child protective services come mostly from teachers, social workers, and law enforcement, the scarcity of child abuse specialists nationwide necessitates that pediatricians be prepared to assess child abuse cases with confidence. Identifying these at-risk children, providing appropriate management, and consulting with child welfare agencies may prevent further abuse and link families to needed services. Education on normal infant and child behaviors, interventions, and parenting supports and community resources can all be provided by the pediatrician and may help prevent some incidents of maltreatment. Pediatricians should obtain and periodically update a child’s social history, including home environment, routines, and caregivers. Child abuse and neglect is more common when caregivers have untreated mental health disorders, including postpartum depression, or illicit substance use/substance abuse or in homes with adult intimate partner violence. Furthermore, physicians must be aware of their implicit bias and the influence of socioeconomic factors on their clinical judgment concerning child maltreatment cases because wide variations in reporting and screening for child abuse persist based on race and ethnicity. Minority children from low-income households are up to 4 times more likely to be evaluated and reported for suspected child maltreatment than white children. Although child abuse can affect children from all demographic groups, there are risk factors that predispose children to abuse and neglect that include low household income (<$15,000 per year), living in a household with unrelated adults, disability of the child, and the presence of multiple siblings.Identifying physical abuse can be challenging to providers because abused children may present with nonspecific symptoms. Minor injuries are common in childhood, and most are not the result of abuse or neglect. Thus, a careful history and physical examination are crucial in the correct identification of child abuse. A well-documented, detailed history should be obtained in an objective, neutral approach. The provider should obtain details regarding the mechanism of injury, onset, progression of symptoms, and developmental status of the patient to assess whether the injury is plausible from the history/information that is given. If the child is verbal and able to provide a history on his or her own, it may be useful to obtain the child and parent histories separately. Creating a safe environment for disclosure is key. Components that are concerning for abuse include vague explanations for a significant injury, delays in seeking medical attention, and inconsistencies in the history as the investigation progresses.A comprehensive physical examination is imperative to accurately identify and document abuse. When there are provider concerns for physical abuse, an unclothed, detailed examination of all areas of the body should be completed. Injuries that are generally more concerning are numerous injuries in multiple areas of the body, in various stages of healing, or that have specific patterns of an implement. Whereas accidental injuries often occur over bony prominences, inflicted injuries tend to occur in protected areas such as the neck, buttocks, trunk, and upper arms. The TEN-4 rule is a helpful mnemonic to help providers remember that bruising to the torso, ear, or neck (TEN) in a child 4 years or younger, or bruising anywhere in a child younger than 4 months, is concerning for abuse and should be immediately investigated. It is critical to thoroughly describe and photo document any cutaneous injuries because formal child welfare evaluations and child abuse subspecialty examinations may be delayed by several hours or even days. Injuries can change in appearance or heal during this time, so it is crucial to have a detailed medical record documenting any injuries found on initial presentation. Although skin and soft tissue injuries may appear clinically insignificant, they could represent a sentinel event and be predictive of future, more serious injury or death if not recognized and reported.Diagnostic radiologic evaluations can help identify occult injuries not apparent on physical examination. Infants and children younger than 2 years with provider concern for abusive head trauma should be referred to a pediatric trauma center to complete imaging, laboratory tests, and consultation with pediatric surgical subspecialists. Most infants with concern for abusive head trauma should be admitted to the hospital at least overnight for observation. Nonaccidental trauma evaluation in these children includes head computed tomography, skeletal survey, and dilated eye examination by pediatric ophthalmology to assess for retinal hemorrhage. Skeletal surveys are an important part of the tertiary examination and are recommended in any child younger than 2 years with suspicious injuries, and up to age 5 years based on the developmental abilities of the child or clinical suspicion. Laboratory testing for bleeding disorders may be warranted based on physical examination findings or family history, and abdominal imaging may be warranted based on clinical concern with abnormal liver function tests or signs/symptoms of abdominal injury on physical examination.Neglect is the most common type of child abuse in this country, and child maltreatment deaths are most attributed to caregiver negligence rather than to physical abuse. Neglect occurs when a caregiver fails to provide care, supervision, or services necessary to ensure a child’s physical and mental health. Neglect may manifest as medical negligence, physical neglect of basic needs, educational neglect, inadequate supervision, illicit substance exposure, or emotional/psychological neglect. Concerns of neglect should be noted by the pediatrician during interactions with a family. Signs of neglect on physical examination, for example, poor hygiene, dental caries, poor weight gain or weight loss, severe diaper dermatitis, or neglected wound care, should be well documented and addressed. Children with complex medical needs or chronic conditions are more at risk for neglect, so compliance with medications and medical appointments and recommendations should be reviewed by the pediatrician. Truancy concerns, emotional stressors, or untreated mental health needs of the child and injuries because of negligence should all be addressed. When the pediatrician has concerns for acts of negligence that jeopardize a child’s health or well-being, the family should be referred to child protective services for further investigation and services.Estimates of sexual abuse of children indicate that it is significantly underreported and underinvestigated. One in 4 girls and 1 in 6 boys are sexually abused during childhood. Most confirmed child sexual abuse cases have normal or nonspecific genital findings on examination. Understanding normal prepubertal genital anatomy and anatomical variants can help identify unexplained genital injuries. Any child disclosures of sexual abuse or caregiver concerns for abuse warrant referral to child protective services for evaluation. When no genital pain or trauma is reported, a detailed genital examination should be deferred to the local child abuse pediatrician or forensic nursing team, if available. However, recent sexual contact with the perpetrator may warrant forensic evidence collection, which necessitates an immediate referral to law enforcement so that a forensic examination can be arranged with a specialized clinic or pediatric provider with expertise in sexual abuse and assault examinations. If an act of abuse occurred within 72 hours of examination, and in some instances up to 120 hours for older adolescent victims, forensic evidence collection should be completed for law enforcement. Sexually transmitted infection testing is not indicated for sexual abuse concerns in asymptomatic prepubertal children, unless at high risk for infection based on history. Adolescent victims of sexual abuse or assault should be offered sexually transmitted infection testing and prophylaxis.Emotional abuse, also referred to as psychological abuse, can occur in conjunction with other types of maltreatment and may be difficult for people outside of the home to recognize. Patterns of behavior by the caregiver that damage a child’s emotional development and sense of self-worth can have long-term behavioral, social, and mental health implications for the child victim. A child who is being emotionally abused may demonstrate a wide range of behaviors, including anxiety or depression, poor school performance, developmental regression, and frequent somatic symptoms or complaints without a clear underlying cause.Pediatricians are mandatory reporters, required by law to report suspected abuse to child protective services. Notably, mandatory reporting laws require only reasonable suspicion by the reporter, and physicians are protected from liability for reporting good-faith suspicions of abuse. A child’s safety should be an essential part of the immediate assessment. If the provider has concerns that a child will be a victim of repeated or continued abuse if they remain with current caregivers or go home to a nonprotective environment, then an immediate referral to child protective services and local law enforcement is warranted. If there is no perceived imminent risk to the child, no contact with the alleged perpetrator of abuse, and the current caregiver is protective, a nonemergency report to child protective services can be placed for community follow-up and a possible specialized child abuse pediatric referral, if available, depending on each state’s child welfare processes. Pediatricians should familiarize themselves with local and state child welfare laws and services that will allow them access to available resources for families, prevent delays in services, and prevent children from receiving unnecessary, and potentially redundant, medical evaluations. Given the importance of primary intervention by pediatric providers to prevent and identify abuse, pediatricians need specialized information to effectively screen, identify, and refer suspected child abuse or neglect.Reading this In Brief reminded me of many patients who I have cared for during my career. Addressing child abuse and neglect is perhaps one of the most emotionally challenging aspects of care we provide as pediatric providers, yet also one of the most important. It can be emotionally challenging because we are confronted with harm that has occurred to an innocent child and the injustice of that concept. So it is likely for us as pediatric providers to have a heightened emotion to the circumstances, to want to prevent it from recurring, and inadvertently “judging” those who care for the child. Yet I want to share 2 experiences that have modified how I approach child abuse. Important advice that my mentors provided me was that it was my job to assess and advocate for the safety of the child, but figuring out who the perpetrator was should be left to child protective services and the legal system. This was important because I needed to obtain the information in a nonjudgmental and neutral way. And there were multiple occasions when I “thought I secretly knew who the perpetrator was” yet further investigation revealed that assumption was incorrect. I also remember a case where a mother brought in her 5-year-old son stating that a boy of the same age had touched her son’s genitalia. Yet, when doing a complete skin examination, both the nurse practitioner who was seeing him and I discovered that he had multiple bruises on his back in the shape of shoe prints. When we asked the mother what happened, she then disclosed that she had hit him repeatedly to discipline him. We needed to report this to child protective services, yet this particular mother welcomed that report because she knew she had lost control and needed strategies to deal with her frustration and anger. Although not every case is like that, it taught me important lessons: that we as providers must again advocate for the safety of the child, and child protective services can be an important resource for parents who understand that they are not parenting effectively and are seeking help for new and better parenting strategies.–Janet Serwint, MDAssociate Editor, In Brief