Child abuse pediatrics: Who we are and where we are going

As a child protection team, we have seen some of the very worst things imaginable happen to children while simultaneously witnessing some of the best parts of humanity every day in our work. During our careers, we’ve seen professionals in child welfare and law enforcement at the bedside of children as they were removed from life support, so they were not alone in their final moments. We’ve seen nurses compassionately help children get dressed after an examination. We’ve witnessed forensic interviewers recount stories that children have told them to prevent the child from re-living their trauma over and over again. We’ve also seen family advocates work tirelessly with caregivers to make sure their needs are met when they leave our advocacy center.

Perhaps most importantly, we’ve seen the smiles of children as they are handed a new stuffed animal and blanket after their examination. All of these experiences encompass what it means to be a child abuse pediatrician.

Child maltreatment is a pervasive public health issue. Each year, an average of 4 million referrals are received by child protective services due to concerns of maltreatment. Around 700,000 of those cases are substantiated with the majority being child neglect, followed by physical abuse and sexual abuse. A fourth, and often unrecognized type of maltreatment, is psychological abuse. Each maltreatment subtype is defined within the Child Abuse Prevention and Treatment Act (CAPTA).

Child maltreatment is a phenomenon that spans across multiple disciplines’ domains and, as such, requires a coordinated multidisciplinary response. Part of this response sometimes includes children having medical exams to properly diagnose neglect, physical abuse, sexual abuse, medical abuse and psychological abuse.

In response to the growing need for formal maltreatment-related medical training, the board-certified subspeciality of child abuse pediatrics was created in 2009, followed by the creation of accredited fellowships in 2011. A key aspect of the subspecialty’s training is how to properly recognize medical aspects of maltreatment and, just as importantly, when there are non-abusive diagnoses. As mandated reporters, it is important for all medical providers to recognize the most common forms of child maltreatment to know when to make a report to the appropriate agency.

Neglect

Child neglect can most simply be defined as when a child’s basic needs are not being met. This diagnosis is one of omission, in which the caregiver fails to provide a child with basic needs such as medical care, proper supervision, a safe environment or emotional support. It is the most prevalent form of maltreatment, accounting for approximately 75% of annual cases. It is also the deadliest, with 72.9% of child maltreatment fatalities in 2019 involving neglect.

Risk factors for neglect can be viewed using Bronfenbrenner’s ecological systems theory. At the child level, risk factors include underlying developmental disorders, complex medical conditions or past trauma. At the caregiver level, risk factors include lower education levels, intimate partner violence and substance use. By far, the biggest risk factor within the family is poverty. It is important to remember that families experiencing poverty are not necessarily neglectful as poverty itself is not a crime. However, policies specifically enacted to strengthen the economic security of families have been shown to reduce the number of child neglect reports. Lastly, risk factors at the community level can include lack of community resources, food deserts and purposeful design to create unsafe neighborhoods.

Physical abuse

Child physical abuse is defined as when a child sustains an injury at the hands of a caregiver. Physical abuse can be from excessive physical discipline, with isolated bruising to severe abusive head trauma. Those at risk for physical abuse include younger children, particularly those less than three years of age, male children, children with developmental disorders and children with younger, single parents.

Recognition of physical abuse is of paramount importance to decrease associated morbidity and mortality. Previous research has found that infants often present to medical services with sentinel injuries that are oftentimes missed. Sentinel injuries are often small, non-specific injuries such as bruising on a non-mobile baby, subconjunctival hemorrhages or a frenulum injury. Being aware of sentinel injuries and reporting them appropriately can decrease the chances that an infant sustains more catastrophic injury later in life.

One pneumonic to help providers remember concerning injuries is “TEN-4-FACESp” which stands for: “torso, ear, neck (TEN), frenulum, angle of jaw, cheeks (fleshy), eyelids, subconjunctivae (FACES) and patterned (p).” A key part of the work-up includes following the American College of Radiology recommendations for obtaining imaging for suspected abuse. A common screening tool is the 22-film skeletal survey which should be completed for all children less than two years of age when abuse is suspected. The films should be repeated in 14-21 days to look for occult fractures that may have been missed on the first skeletal survey.

Additionally, there are many physical exam findings which may be mistaken for child physical abuse. Due to this, it is important to consult a child abuse pediatrician when possible so abuse can either be appropriately diagnosed or, just as importantly, ruled out.

Sexual abuse

Most experts agree that child sexual abuse is remarkably underreported. On average, one in seven females and one in ten males experience sexual abuse before the age of 18. Sexual abuse can take many forms, from child exploitation (child sexual abuse materials), fondling and sexual assault.

When concerns for sexual abuse arise, medical providers should first ensure the child’s safety by verifying that if the child leaves the office, they will not be exposed to the individual alleged to have committed the abuse. Once safety has been established, an accurate medical history should be conducted without the use of leading questions. This means allowing the child to tell their story in their own words. As mandated reporters, after gathering essential history, a referral to both child protective services and law enforcement should be made. For the purpose of these reports, providers must communicate enough details to allow for a thorough investigation.

Finally, the physician must determine if and when a medical exam should be performed. This can best be decided by contacting your local children’s advocacy center to ask what the local protocol is. In general, if the alleged contact has been less than 72 hours before the visit, a sexual assault nurse examination should be completed by someone trained to collect forensic evidence. If the contact was more than 72 hours before the visit, and the child is medically stable, the examination can be delayed until after a forensic interview has been completed and the child is ready for an exam. The vast majority of sexual abuse examinations, for males and females, have no physical exam findings.

Another consideration is testing for sexually transmitted infections (STI) if the child disclosed genital-genital, genital-oral or genital-anal contact with or without fluid exposure. Blood work for HIV, syphilis and hepatitis B should be completed at the initial examination. Urine NAAT for gonorrhea and chlamydia should also be obtained. If it was an acute assault, follow-up should be completed in two weeks and then repeat testing for bloodborne pathogens at six weeks and after three months. For non-verbal children, STI testing can also be performed.

The roles of bias and policy: What needs to change for future generations

Child protective services and maltreatment investigations in general have been marred by implicit and explicit biases, resulting in discrimination and profound harm to minority communities. For instance, the creation of the Indian Child Welfare Act (ICWA) in 1978 was in direct response to a congressional investigation which found that 25-35% of Indigenous children were being removed from their homes even when there was no evidence of maltreatment.

In addition to historical precedence, previous research has shown disparities by race and ethnicity in reporting abuse and subsequent investigations along with medical evaluations and diagnoses. Given what is known, there is a critical need for the expansion of funding and further research to better understand the experiences of minority community members in the child welfare system.

Further, the public discourse surrounding child abuse has been misused against specific populations to meet various agendas not related to child-wellbeing in the United States. These actions further deteriorate the seriousness of abusive and grooming behavior while also accusing individuals in the court of public opinion without verifiable evidence. As such, the priorities of many policymakers are misaligned, and sometimes in direct conflict with policy creation and funding needed for interventional and support services.

Personal experiences as child abuse pediatricians

Physicians are uniquely situated to care for people on the worst days of their lives. Child abuse pediatricians similarly are at the bedside when a child endures fatal or near fatal injury. We are obtaining medical history from both offending and non-offending caregivers and must check our own trauma and biases at the door to focus on the well-being of the child.

The relationships built with these children and their families may continue after the visit ends. In cases of confirmed child maltreatment, child abuse pediatricians are called on to recount the mistreatment inflicted on the child in both criminal and civil court. We view this as another form of advocacy for the child and an opportunity to educate judges, attorneys and jurors about the medicine of child abuse pediatrics and the lifetime effects of trauma.

While child abuse pediatrics is a young subspecialty, it is filling a critical need in the medical care of children. The education received by doctors of osteopathic medicine makes DOs uniquely qualified to care for these patients. While the focus of care is initially on the presenting injury, DOs’ understanding of a holistic approach to medicine ensures that we are addressing the physical, emotional and psychological needs of our patients in an attempt to stop the hurting and start the healing.

Related reading:

What medical students and other doctors should know about pediatric medicine

The DO Book Club: “On Becoming a Healer: The Journey from Patient Care to Caring about Your Patients”