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Child Abuse: Recognition and Reporting

Child Abuse: Recognition and Reporting. Maria D. McColgan, MD, MSEd Assistant Professor Director, Child Protection Program St. Christopher’s Hospital for Children. Agenda. History Definitions Epidemiology Etiology Recognition of abuse Medical Evaluation Reporting and Documenting.

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Child Abuse: Recognition and Reporting

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  1. Child Abuse: Recognition and Reporting Maria D. McColgan, MD, MSEd Assistant Professor Director, Child Protection Program St. Christopher’s Hospital for Children

  2. Agenda • History • Definitions • Epidemiology • Etiology • Recognition of abuse • Medical Evaluation • Reporting and Documenting

  3. History • 1860 - Ambroise Tardieu • French physician • Medical, psychiatric, social and demographic features of child abuse as a syndrome • 1874 – Mary Ellen Wilson 10 y/o • Removed from home • Provided protection by NY courts • Founding of NY society for Prevention of Cruelty to Children • 1899 – First juvenile court in Illinois

  4. History • 1912 – FDR helped create US children’s Bureau • 1944 – Supreme court confirms state authority to intervene to protect children • 1946 – Dr. Caffey (pediatric radiologist) • SDH and long bone fractures inconsistent with accidental injury • 1962 – Dr. C. Henry Kempe • “The battered child syndrome” in JAMA • 447 abuse cases reported in 1962 • (2.9 million cases reported in 1992) • In response the US children’s Bureau recommends child abuse reporting laws • 1967 – 44 states adopted mandatory reporting laws

  5. Nomenclature • Terms in National Library of Medicine • Syndrome of Ambroise Tardieu • 1964 – “Child abuse” • 1975 – SIDS • 1981 – PTSD • 1987 – “Child abuse, Sexual” • 1991 – Battered child syndrome • 1992 – Munchausen syndrome by Proxy • 1992 – Head injuries, closed • 2003 – shaken baby syndrome • 1993 – AAP noted term

  6. PA State Law Definition Of Child Abuse • A victim is under 18 years of age who has sustained… • A serious physical, mental, or sexual injury or serious physical neglect as a result of the acts or omissions by… • A parent, paramour of the parent, person residing in the same home as the child or person responsible for the child’s welfare (at least 14 years of age). • Any recent (within 2 years) act or failure to act by a perpetrator that creates an imminent risk of serious physical injury to, or sexual abuse or sexual exploitation of a child.

  7. Pennsylvania State Law: Statutory Rape • Consensual intercourse between children within 3 years of age is not illegal • 15 y/o can consent to sexual intercourse with an 18 y/o • Statutory rape : victim is less than 16 years of age, there is 4 year difference in ages and they are not married to each other • Sexual intercourse with a child less than 13 is rape • A child less than 13 years old cannot consent to having intercourse • If one of the children is older than 12 and greater than 2 years difference from the age of the other child, then it can be considered rape • It is not illegal if both children are less than 12

  8. Other State Statutes • National Clearinghouse on Child Abuse and Neglect http://nccanch.acf.hhs.gov/general/legal/statutes/define.cfm • National District Attorney’s Office http://www.ndaa.org/apri/programs/vawa/statutes.html#

  9. Mandated Reporters of AbusePennsylvania Consolidated StatuesTitle 23 § § 6301-6319 • “Persons who…come into contact with children shall report …when they have reasonable cause to suspect that any child, on the basis of their training and experience… is an abused child.” • While at work, physicians and other health care workers, teachers, pastors

  10. Mandated Reporters of Abuse • May be prosecuted for failure to report • Legal immunity is granted to the reporter • Identity of the reporter is confidential. • Informing the parent • Not required by law • St. Chris advocates informing the family of the DHS • If there is a flight risk, involve police and DHS

  11. Epidemiology • Child Maltreatment 2006 USDHHS • ~ 3 million reports involving 5.5 million children • ~ 902,000 confirmed cases • 12.1/1000 children • 18% Physical Abuse • 64% Neglect • 9% Sexual Abuse • Medical personnel - ~8% of reports http://www.acf.hhs.gov/programs/cb/pubs/cm04/index.htm

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

  13. Why doctors do not report Flaherty, Sege 2005 • Physician recognition of child abuse • Lack of knowledge • Psychological barrier to recognition • Family, racial, economic factors • 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. Age and Child Abuse

  15. Perpetrators • Parents 80% • Other relatives 6.7%

  16. Fatalities • Nearly 1530 fatalities • 2.04/1,000 children • 78% < 4 years old • Infants 18/1,000

  17. Risk of Abuse for Children with Special Needs Type of Incidence of Incidence of Ratio Maltreatment Children w/ Children w/o Disabilities Disabilities (per 1,000) (per 1,000) _____________________________________________________ Any Maltreatment 35.5 21.3 1.67 Physical abuse 9.4 4.5 2.09 Sexual abuse 3.5 2.0 1.75 Source: From A Report on the Maltreatment of Children w/Disabilities, U.S. Department of Health and Human Services, James Bell Associates, Inc., No. 105-89-16300, Westat, Inc., 1993.

  18. Etiology • Multi-factorial • Child Characteristics • Parental Characteristics • Family/Environmental Factors • Triggering Situations

  19. DV and Child Maltreatment • Child maltreatment • occurs in 33-77% of families in which there is abuse of an adult (Garbarino 1992, Wright 1997, Zuckerman 1995) • Children of battered mothers • 6 to 15 times more likely to be abused

  20. DV and Child Maltreatment Physical Injuries to Children May Be: • Accidentally caught in the crossfire • Intentionally injured while protecting their mother • Over-disciplined or abused by stressed, anxious, and depressed parent

  21. AAP Committee on Child Abuse and Neglect - 1998 • The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women • Intervention is crucial because children are also likely to be victims • Questions about family violence should become part of anticipatory guidance • Identifying and intervening on behalf of battered women may be one of the most effective means of preventing child abuse

  22. Medical Evaluation of Victim of Suspected Abuse • History • Physical Examination • Laboratory and Radiologic Studies • Differential Diagnosis • Documentation

  23. Taking a history from the caretaker/parent • Children should not be present!! • Interview adults who are present separately • Triage history often plays a critical role

  24. Taking a history from the caretaker/parent • Who? • What? • When? • Where? • Why? • How?

  25. Suspicious Behavioral Complaint • Depressed, angry, withdrawn, other changes • School performance • Aggressive behavior, temper tantrums • Behavior with family pets/animals • Detailed information about adult sexual behavior • Explicit demonstration of sexual play • Compulsive masturbation • Excessive sexual curiosity • Bedwetting • New risk taking behaviors

  26. History from the child • It is OK not to take a history from the child • Is the information necessary to make medical decisions? • Has the child been interviewed already and disclosed? • Is the child ready to disclose? • Would this child be better served by a forensic interview?

  27. SuspiciousHistory • History inconsistent w/physical • Magical injury • Sibling blamed • History changes with time or varies between caregivers • Delay in seeking care • Self-inflicted injury incompatible w/development • Poor Parent Child Interaction

  28. Physical Examination • 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

  29. Physical Exam “Red Flags” • 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

  30. Location

  31. Location

  32. What’s wrongwith thispicture?

  33. Donut diagram

  34. WF 7 month old • Mom found him at bottom of stairs with excersaucer on top of him

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