Recognizing and Responding to Child Abuse & Neglect

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1 Recognizing and Responding to Child Abuse & Neglect Maria D. McColgan, MD Associate Professor Drexel University College of Medicine Director, Child Protection Program St. Christopher s Hospital for Children

2 Disclosures I provide expert opinion in cases of child abuse and neglect.

3 Goals Describe your role as a mandated reporter of Child Abuse and Neglect Identify risk factors and indicators of suspected child abuse and neglect Know how to: Report a case of suspected child abuse Communicate your concerns with caregivers/others involved in the investigation Provide appropriate medical treatment to the child

4 Agenda Definitions Epidemiology Etiology Evaluation Reporting Prevention Resources

5 One day last November, we had four battered children in our pediatrics ward. Two died in the hospital and one died at home four weeks later. For every child who enters the hospital this badly beaten, there must be hundreds treated by unsuspecting doctors. The battered child syndrome isn't a reportable disease, but it damn well ought to be. Dr. Henry Kempe, Newsweek, April 1962

6 How far have we come? 1874 Rescue of Mary Ellen Wilson 1875 New York Society for Prevention of Cruelty to Children 1935 Social Security Act with obscure provision for protection and care of homeless, dependent and neglected children 1946 Article by pediatric radiologist John Caffey 1962 The Battered Child Syndrome Henry Kempe 1967 All states have reporting laws 1974 Child Abuse Prevention and Treatment Act (CAPTA) 2009 First Child Abuse Pediatrics Board Examination

7 Facts at a Glance 4 million abuse & neglect referrals on 7.2 million children 683,000 child victims 77% - neglect (includes medical neglect) 1,670 deaths average of 5 per day 75% of fatalities under age 3 National Center for Injury Prevention and Control, 2015 Child Maltreatment Report

8 NJ State Law Definition Of Child Abuse "Abused child" means a child under the age of 18 years whose parent, guardian, or other person having his custody and control: Inflicts or allows to be inflicted upon such child physical injury by other than accidental means which causes or creates a substantial risk of death, or serious or protracted disfigurement, or protracted impairment of physical or emotional health or protracted loss or impairment of the function of any bodily organ; Creates or allows to be created a substantial or ongoing risk of physical injury to such child by other than accidental means which would be likely to cause death or serious or protracted disfigurement, or protracted loss or impairment of the function of any bodily organ; or Commits or allows to be committed an act of sexual abuse against the child; Or a child who has been willfully abandoned by his parent or guardian, or such other person having his custody and control.

9 Mandated Reporters of Abuse New Jersey Any person having reasonable cause to believe that a child has been subjected to child abuse or acts of child abuse shall report the same immediately to the Division of Youth and Family Services by telephone or otherwise. Granted legal immunity Penalties Disorderly person

11 If maltreatment is suspected Referral to Department of Children and Families Call NJ ABUSE ( ) Call 911 if child in immediate danger Referral Appropriate mental health therapy for age/abilities Counseling for the family

12 Why doctors do not report Physician recognition of child abuse Lack of knowledge Psychological barrier to recognition Family, racial, economic factors Flaherty, Sege 2005 Barriers to reporting Do not report all cases Lack of training on how to report Report will harm child Poor experience with Child Protective Services Poor experience with legal system Misunderstanding of MD role

14 Categories of Adverse Childhood Experiences Abuse Psychological 11% Physical (parent) 11% Sexual (anyone) 22% Household Dysfunction Substance abuse 26% Mental Illness 19% Domestic Violence 13% Imprisoned household member 3%

16 Etiology Multi-factorial Child Characteristics Parental Characteristics Family/Environmental Factors Triggering Situations

22 Medical Evaluation Performing the H&P

23 Chief Complaint Diagnosis Differential Goal: Correct diagnosis Prevent misdiagnosis of abuse

24 Medical Evaluation of Victim of Suspected Abuse History Physical Examination Collect Forensic Evidence; photographs Laboratory Evaluation? Radiologic Studies? Subspecialist Consults/Child Abuse Pediatrician/SW? Refine Differential Diagnosis & Plan Documentation

26 Thorough Medical History HPI, PMH Birth history, previous trauma Developmental Milestones Family History Bleeding disorders, easy bruising, collagen vascular disease, easy fractures, bone disease, dental or hearing abnormalities Small children, early death Thorough Review of Systems

27 Sentinel injuries Previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible.

28 Sentinel injuries missed opportunities OBJECTIVES: primary objective of this study was to determine how frequently abusive fractures were missed by physicians during previous examinations. A secondary objective was to determine clinical predictors that are associated with unrecognized abuse. METHODS: Children who were younger than 3 years and presented to a large academic children's hospital from January 1993 to December 2007 and received a diagnosis of abusive fractures by a multidisciplinary child protective team RESULTS: Of 258 patients with abusive fractures, 54 (20.9%) had at least 1 previous physician visit at which abuse was missed. ~ 17% of missed abuse cases, children sustained repeat injuries. CONCLUSION: 20.9% of cases missed; 17% of missed cases sustained repeat injuries Ravichandiran, Schuh, Beiuk, Al-Harthy, Shouldice, Au, Boutis.Delayed identification of pediatric abuse-related fractures.pediatrics Jan;125(1):60-6. Epub 2009 Nov 30

29 Thorough Physical Exam Emergent care first Complete head to toe evaluation Must look at all skin surfaces Remove ALL clothing Ears, Neck, Mouth, Genitalia Description of all skin findings

30 What are we looking for? Physical Exam Red Flags Bruises most common indication of physical abuse Occurs in >50% of abused children Bruises are uncommon in infants < 6 months. Those who don t cruise rarely bruise. Two characteristics separate abusive from accidental bruises: LOCATION & PATTERN

31 Location ACCIDENTAL ABUSIVE Shins Anterior thigh Lower arms Upper arms Under chin Neck Forehead Face Hips Buttocks Elbows Trunk Ankles Ears Bony prominences Genitalia

32 TEN-4 Bruising Rule Be aware of any bruising to the: Torso Ears Neck or bruising anywhere on a child 4 months old or younger. This is significant for abuse. Bruising on babies is not normal! Pierce MC, Kaczor K, Aldridge S, O Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125(1): Epub Dec. 7, Erratum in Pediatrics. 2010;125(4):861.

34 Aging of Bruises Swelling resolves over the first 2-3 days Color changes occur as bruises age Colors vary widely with age of bruises Dependent upon Depth of bruise Location Vascularity of underlying tissue Age and complexion of child

35 Aging of Bruises Visual aging of bruises inexact Bruise with yellow is > 18 hours Red color can be present anytime Blue, purple present 1 hour to resolution Bruises of same age on same person can vary in color Document findings; Photographs Langlois, NEI, Gresham GA. The aging of bruises: a review and study of the color changes with time. Forensic Sci Int 1999;50:

37 Bruises and Other Skin Findings If you don t cruise, you don t bruise. Those Who Don t Cruise Rarely Bruise. Sugar NF, Taylor JA, Feldman KW. Arch Pediatr Adolesc Med. 1999;153: Used by permission from AAP

39 Protective Custody Any physician, director of a hospital or his designee involved in the examination or treatment of a child may take the child into protective custody for a period not to exceed three (3) court days when the child has suffered serious injury, the probable inference from the available information is that the injury was caused by other than accidental means, and the child would normally be returned to the custody of the person suspected of inflicting or allowing the infliction of the injury N.J.S.A. 9: See CP&P-II-B for a description of CP&P role in protective custody (hospital hold) situations

41 Discipline or abuse? Used by permission from AAP

45 Differential Diagnosis of Bruises Must consider Bleeding disorders, ITP or other coagulopathies Erythema multiforme Henoch-Schönlein purpura Secondary syphilis Allergic shiners Phytophotodermatitis Cultural practices

50 Evaluation for Bleeding Disorders in Suspected Child Abuse Prevent misdiagnosis of abuse Bruises CBC, PT/PTT VWP Factor 8 & Factor 9 American Academy of Pediatrics Clinical Report Evaluation for Bleeding Disorders in Suspected Child Abuse, Pediatrics Subdural Hemorrhage/ICH CBC, PT/PTT DIC panel (d-dimer and fibrinogen) Factor 8 &9 Hematology Consult?

51 What else should we look for? Occult Trauma Skeletal findings/fractures 2nd most common manifestation of abuse 80% cases in children < 18 months of age 43% unsuspected at time of evaluation Rib Fractures/Classic Metaphyseal Lesions (CML s) Imaging Skeletal survey and repeat skeletal survey All children < 2 years of age 2-5 years: selective survey Bone scan Labs Ca, Phos, Alk Phos, Vitamin D 25 OH, Vitamin D 1,25 OH, PTH and Copper

52 The Skeletal Survey Skull: frontal and lateral views Spine: frontal, lateral thoracolumbar spine (including sternum) Chest: frontal, obliques Extremities: Upper - frontal to include shoulders and hands Lower - frontal to include lower lumbar spine, pelvis, feet

53 Repeat skeletal survey Stage Time Characteristics Induction 3-7 days Inflammation, pain, swelling Soft callus Infants 7-10 days Children Periosteal new bone formation Hard callus days Union at fx site Remodelling 3 months-1 year Woven to lamellar bone

56 Femur fracture Used by permission from AAP

57 Case study Used by permission from AAP

$fractures 90% of abusive rib fractures seen < 2$

58 Rib Fractures Nearly 25% of all abusive fractures 90% of abusive rib fractures seen < 2 yrs of age

59 Differential Diagnosis Must consider/rule out medical diagnosis other than abuse Accidental Trauma Studies show very low incidence of fractures from short falls Obstetrical/birth trauma Usually only humeral and clavicular fractures, no rib fractures

60 DDX: Skeletal Fractures Congenital Osteogenesis imperfecta Menke s syndrome Nutritional / Metabolic Copper deficiency Rickets Scurvy Renal osteodystrophy Osteopenia Thompson 2005 Infectious Congenital syphilis Osteomyelitis Neoplasm Leukemia Langerhans cell histiocytosis Bony metastases Normal variant Physiologic periosteal new bone Neuromuscular disease Cerebral palsy Congenital insensitivity to pain

61 What else should we look for? Head Trauma

62 Inflicted Traumatic Brain Injury Shaken Baby Syndrome Leading cause of death from child abuse The cause of up to 95% of severe TBI in children <1yr Leading cause of death from brain injury in children less than 4 yrs of age At least 1,500 cases/year in the United States For children < 1 year of age: incidence of severe or fatal itbi is about 1 in 3,300 Incidence of less severe itbi may be 150 times greater

63 Abusive Head trauma misdiagnosed as Accidental trauma Viral gastroenteritis Reflux Apnea, ALTE, SIDS Seizure disorder Sepsis Otitis media Analysis of missed cases of abusive head trauma. Jenny, Hymel, Titzen, Reinert, Hay. JAMA 1999;281:

64 itbi work-up Ct Head with 3-D reconstruction Ophthalmology consult MRI Head and Neck Labs

65 Eye Exam Subconjunctival Hemorrhages Retinal Hemorrhages

66 Retinal Hemorrhages Few Hemorrhages Multiple Multilayer Hemorrhages

67 2 year old present to ED at 6:30 AM Fell from bottom bunk bed about 5 AM Multiple episodes of vomiting

68 2 year old present to ED at 6;30 AM Fell from bottom bunk bed about 5 AM Multiple episodes of vomiting PE: Ill Appearing, Bruises on Abdomen

69 Abdominal Trauma 2 nd Leading Cause Of Abuse Fatalities Average age is months More common as children become more mobile Shift from fatal site of injury from brain to the abdomen May Have Delayed Presentation Injury May Mimic Common Surgical Illnesses Liver & Spleen & Duodenum Most Commonly Injured

70 Monteleone, ed. Child Maltreatment 1994

71 Differential Diagnosis Labs Trauma labs Include LFT and Amylase Lipase Radiology Studies Skeletal survey All children < 2 years of age 2-5 years: selective survey CT / MRI Ophthalmology Medical photography

73 Evidence collection Photographs DO NOT need consent for forensic photographs Photographs DO NOT take the place of documentation, they support visual cues to the documented description Used to appropriately visualize described lesions/marks Have a marker, (ruler or coin) within the photograph that can assist with determining size of lesion Put the child s name, date of birth, medical record number, and date of ED visit on the photograph/ diskette

74 Bites ADULT BITE CHILD BITE Canine to canine To second molar Involves 1 arch Both arches cm. between canines < 2.5 cm.

75 Bite Mark Evaluation Photography of bite marks Ruler and patient ID in photograph Multiple views Swabs for forensic evaluation Forensic Dentistry/Wax impressions for matching

76 Burns What s wrong with this picture?

78 Burns in children

79 Arrow down

87 Documentation Carefully Documented In A Stepwise Approach History Verbatim Documentation/Quotes Physical Exam Pictures Are Helpful Lab & Radiographic Studies Impression Instructions for follow up

89 Communicate Effectively Communicate empathetically with families Be available to help law enforcement or CPS understand the child/adolescent s special needs (health care, meds, communication, developmental processes, abilities) Be available for follow up and/ or testimony Suny Upstate Medical University. Children and Adolescents with Disabilities. ChildAbuseMD.com. 17 Feb <

90 Statement of Concern be specific Name, age, sex of child; date seen, reason for presentation. Then, These injuries are (circle one): Concerning for physical abuse Highly concerning for physical abuse Diagnostic of physical abuse The injuries caused (circle if applicable): Substantial pain Impairment of function Current Status (discharged/admitted; siblings to be evaluated) Injury consistent with history provided by caretaker? Yes/No/Possibly/Unknown

91 An ounce of Prevention

92 Pediatrician s Role in Prevention Maintain a high index of suspicion for child maltreatment Discuss child abuse prevention, anticipatory guidance of developmental milestones, and indicators of abuse, with parents and caregivers Advocate for policy reform American Academy of Pediatrics, Committee on Child Abuse and Neglect & Committee on Children with Disabilities. Assessment of Maltreatment of Children with Disabilities. Pediatrics, Vol. 108, No. 2. Aug. 2001

93 Resources Department of Children & Families Child Welfare Information Gateway disabilities.cfm

94 Conclusions Child abuse is very common Often missed by clinicians Must have high index of suspicion, yet avoid the misdiagnosis of abuse Mandated reporters must report suspicion of abuse Complete careful histories and examinations Document, document, document! Communicate effectively and empathetically with parents and investigators

95 Maria McColgan, MD, MSEd, FAAP Phone: Thank you!

Suspected Physical Abuse Clinical Practice Guideline

Suspected Physical Abuse Clinical Practice Guideline WHEN TO CONSIDER ABUSE Consider abuse on the differential Injuries to multiple organ systems Injuries in different stages of healing Patterned injuries