Addressing Potential Maltreatment in Pediatric Patients
Laura M. Cascella, MA
Child abuse is an abhorrent, but not uncommon, problem in society. Stories abound in the media about children who have suffered maltreatment at the hands of parents, family members, caregivers, or strangers. Maltreatment might involve physical abuse, sexual abuse, emotional/psychological abuse, or neglect — and children often are victims of more than one type of abuse.
Determining the specific number of children who are abused is difficult because the legal definitions of abuse vary by state/region, as do methods for collecting information about abused children. Further, many cases of abuse are likely never reported.1 Nevertheless, the National Children’s Alliance estimates that nearly 700,000 children are abused in the United States each year, with children in their first year of life being the most vulnerable.2
Although child abuse is concerning for many reasons, it is particularly worrisome from a public health perspective. A 2015 clinical report in Pediatrics notes that maltreatment can have lifelong health consequences and may contribute to physical and mental conditions and substance abuse problems in adolescence and adulthood. Additionally, victims of maltreatment can suffer short- and long-term injuries as a result of abuse (e.g., broken bones, sexual trauma, head injuries, epilepsy, cognitive impairment, etc.).3 In the worst cases, these injuries are fatal.
From a patient safety, risk management, and legal perspective, healthcare providers — especially pediatricians, family medicine physicians, emergency medicine physicians, and other healthcare professionals in these specialties — should be aware of risk factors for and signs/symptoms of maltreatment. Although healthcare providers are not responsible for definitively diagnosing abuse or determining the identity of the abuser(s), they are legally and ethically obligated to report suspicious injuries to Child Protective Services (CPS) or other appropriate authorities as mandated by state law.4 Failure to do so can expose the provider to liability risk — but, more importantly, it may result in further patient harm.
Consider the following malpractice case example that examines a missed opportunity to report abuse and a subsequent tragic outcome:
The patient was an 11-month-old female who lived with her biological mother and her mother’s boyfriend (not the biological father of the patient). The patient was taken to her pediatrician following what her mother described as a fall from the crib onto a wooden toy chest. The infant was sent to the local emergency department (ED), where testing was done and a pediatric neurosurgeon examined her.
Because she had a skull fracture that could be consistent with the fall her mother described, possible child abuse was not reported. However, the patient also had deep bruises on the inside of both of her thighs, and the paternal grandmother (who was present at the hospital) told the neurosurgeon that she suspected abuse. In response to this statement, the neurosurgeon replied that if the grandmother suspected child abuse, she should report it to CPS and gave her the number.
The patient was hospitalized for 2 days, during which time she recovered, and she was released to the custody of her mother. Approximately 1 month later, the patient was brought back to the ED with several more severe skull fractures. After transfer to another facility and an emergency craniotomy, she was declared brain dead and subsequently died.
Charges were brought against the mother’s boyfriend, who pled guilty to manslaughter and received a prison sentence. The child’s estate commenced a malpractice suit against the pediatrician, the original pediatric neurosurgeon, and the hospital for failing to properly identify and report suspected child abuse.
This case highlights the ambiguity that often is involved in cases of suspected child abuse. The child’s injuries were consistent with the accident described by the mother; yet, the infant’s paternal grandmother voiced concerns about abuse. In other cases, it might be difficult to discern between potential abuse and common childhood injuries (e.g., bruises or broken bones). Various other barriers also might prevent or delay healthcare providers from reporting suspicions of maltreatment, such as fear of severing the parent–provider relationship or lack of confidence in CPS.
Although dealing with potential abuse is “is one of the most challenging and unsettling responsibilities in pediatric practice,” it nonetheless is a responsibility for which healthcare providers should prepare. The following strategies can help pediatricians and other pediatric providers proactively address management of potential child maltreatment:
- Fully understand laws and reporting requirements related to child maltreatment and abuse in the state(s) in which you practice. Maintain and keep updated contact information for CPS and other designated reporting agencies.
- Know whether state laws permit healthcare providers who suspect child maltreatment to examine the child, conduct tests, and/or photograph injuries without parental consent.
- Develop organizational protocols in accordance with state laws and professional guidance to assist providers and staff in responding consistently to situations in which maltreatment is suspected. Emphasize the importance of stabilizing the patient as a first step in cases involving severe injuries.
- Be aware of community resources for preventing and managing child abuse, including local pediatricians who specialize in abuse and can provide consultation and support for difficult or uncertain cases.
- Be knowledgeable of child, parent, and environmental risk factors that put children at risk of maltreatment, such as child behavioral issues, parental substance abuse, parental mental health disorders, a history of familial abuse, poverty, and social isolation.
- Learn about medical/family history and physical factors that might be red flags for maltreatment, such as behavioral changes in the child or obvious fear or anxiety, vague explanations related to trauma, changing accounts of injuries, explanations that are not consistent with the actual injuries, delays in seeking treatment, trauma to multiple organ systems, multiple injuries in various phases of healing, patterned injuries, and signs of neglect (e.g., poor hygiene and malnutrition).
- When discussing a pediatric patient’s injuries with his/her parents or guardian, ask open-ended questions to prompt more detailed responses. Let parents or the patient provide information without interrupting. Ask questions as necessary to clarify details about the injury or the event leading up to it.
- Thoroughly document patients’ medical and family histories, the results from physical evaluations, and specific details related to injuries. Thorough documentation is an essential component of patient care, and, in cases of suspected child maltreatment, detailed documentation can assist during subsequent investigations of the injuries.5
In all cases in which child maltreatment is suspected, healthcare providers should follow the appropriate reporting protocol per state law and organization policy. The aforementioned clinical report in Pediatrics also advocates for disclosing the intent to report to the patient’s parents or guardian. The authors acknowledge that this conversation might be difficult for the provider, but ultimately it might improve communication before and after the investigation. They also advise that “it can be helpful to raise concern about an injury, while not apportioning blame, and inform the parent that because of the nature and circumstances of the injury, a report for further investigation is mandated by law.”6 When considering whether to disclose intent to report, providers should use their best judgment and consider the specific patient and circumstances.
Beyond devising strategies for identifying and managing suspected child maltreatment, pediatric providers can work with local healthcare organizations, advocacy groups, and CPS to better understand abuses prevention efforts and community support as well as resources available to patients and their families. Additionally, healthcare providers can take advantage of the information available on the American Academy of Pediatrics' Child Abuse and Neglect webpage.
1 Stanly, J. R., Shropshire, D., & Bonner, B. L. (2009). To report or not report: A physician's dilemma. Virtual Mentor, 11(2), 141-145. doi: 10.1001/virtualmentor.2009.11.2.cprl1-0902
2 National Children’s Alliance. (n.d.). National statistics on child abuse. Retrieved from www.nationalchildrensalliance.org/media-room/nca-digital-media-kit/national-statistics-on-child-abuse/
3 Christian, C. W., Committee on Child Abuse and Neglect. (2015, May). The evaluation of suspected child physical abuse. Pediatrics, 135(5), e1337-e1354; DOI: 10.1542/peds.2015-0356
4 Stanly, To report on not report; Christian, The evaluation of suspected child physical abuse
5 Christian, The evaluation of suspected child physical abuse
6 Ibid.
