Child Neglect— Medical and Legal Implications April 18, 2019 Jeffrey Bomze, MD, FAAP

1. Child Neglect— Medical and Legal Implications April 18, 2019 Jeffrey Bomze, MD, FAAP 200 N. Wynnewood Ave.--# B417 Wynnewood, PA 19096 jeffrey.bomze@craftech.net

2. Most preventable form of child abuse: --Greater than 1500 fatalities/yr in US --Victims commonly under age 3 years --Victims commonly live in poverty

3. Definition of Child Neglect: Any action or failure to act which causes serious physical or emotional harm or puts the child at imminent risk for such harm --Multiple forms of abuse and maltreatment can coexist

4. Many forms of neglect: --Physical --Supervisory --Emotional --Educational --

5. Forms of neglect: --Nutritional --Medical --Dental

6. Physical neglect: --failure to provide adequate food, clothing, shelter or hygiene Supervisory neglect: --inadequate supervision placing child at risk of physical, emotional and/or psychological harm

7. Emotional neglect: --failure to provide love, security, emotional support, psychological care when needed --failure to protect from exposure to domestic violence

8. Nutritional neglect: --failure to provide adequate nutrition to maintain physical growth and development --failure to prevent overnutrition-obesity and complications

9. Medical neglect: --failure to prescribed medical care or treatment --failure to seek appropriate medical care in a timely manner Dental neglect: --failure to provide adequate dental care or treatment despite access to care

10. Educational neglect: --failure to enroll in school and ensure regular attendance --address special education needs

11. Factors impacting neglect: --accepted standards of care for children --role of communities --harm to child

12. Factors impacting neglect: --parents’ ability or intent --family’s resources—community resources --community norms

13. Family risk factors: --poverty, domestic violence --family stress, mental health/substance abuse --decreased social support, lack of knowledge

14. Evaluation: --Types of neglect --pattern of events --possible harm to child or potential harm --risk of imminent harm

15. Clinical presentations of neglect: --depends on type of neglect and any other types of abuse --occurs on a continuum

16. Physical neglect: --hygiene, lack of adequate clothing --injuries from lack of shelter—heat illness or frostbite

17. Supervisory neglect: --repeated burns, lacerations, fractures --serious injuries-MVAs, drownings, falls --burns, poisonings—“accidental trauma”

18. Emotional neglect: --lack of emotional security --lack of follow up with psychological care Educational neglect: --truancy, poor attendance, homeschooling

19. Nutritional neglect: --malnutrition—undernutrition-failure to thrive --overnutrition—obesity with medical complications

20. Medical neglect: --serious illness and not signs not recognized or care sought --serious or life-threatening health conditions with lack of compliance with treatment plan or follow up --lack of primary care visits for at risk/complex children

21. Evaluation of neglect: --comprehensive history --social history: financial, education --psychosocial history: mental health, substance abuse --family history: domestic violence, criminal

22. Medical neglect: --most complex --continuum based on risk of harm and role of caregiver in neglect --? repeat neglect or risk to recur

23. Physical exam: --hygiene, clothing --nutritional status-hunger, diet-caution --height, weight, BMI, head circumference(< 2yo) --skin, muscle mass, hair, edema

24. Physical exam: --hair—infection, malnutrition, intentional --mouth—dental caries, abscesses --skin and nails—multiple scars and past injuries, ulcers, cracked or thin nails --unmanaged infections-scabies, lice

25. Additional studies-based on history, exam and concern --underweight-failure to thrive --obesity-complications-lipids, diabetes, liver --look for signs of physical abuse

26. Key factors in diagnosing neglect: --harm or imminent harm by caretaker’s action or inaction --type, severity, and frequency the neglect-minor injury from brief distraction --suspicion for physical, sexual and emotional abuse --? Continued deterioration despite education and family engagement in care

27. Differential diagnosis: --social factors versus physical or supervisory neglect --failure to thrive-can lead to cognitive bias preventing identification of medical illnesses --look for medical causes-undiagnosed conditions

28. Management-Report suspected abuse: --consult with child abuse team --multidisciplinary approach --report if suspicious for abuse, harm is done, interventions have failed, concern for other types of abuse

29. Management: --ensure patient safety-voluntary interventions or report to child protective services --hospitalization may be needed-dehydration, malnutrition/starvation, poisoning, burns, exacerbation of chronic disease, safety and discharge planning --hospitalize-chronic neglect, further evaluation, observe caregiver-child relationship

30. Education and documentation: --simple and clear treatment plan --family education-engage caregiver --follow up appointments --provide resources-insurance, transportation, nutritional assistance

31. Report to Child Protection: --child at risk of imminent harm --serious injury or serious medical illness caused by caretaker neglect --continued neglect despite resources --gross failure to provide adequate food, shelter, clothing, protection or education

32. Photo-documentation: --injuries, appearance, hygiene --nutritional status, skin condition --condition of any indwelling medical equipment

33. Religious objections to medical care: --most states with exemptions because of religious beliefs --respect parental religious beliefs and their role in child rearing --collaborative decisions

34. Religious objections to medical care: --legal issues when beliefs or practices interfere with appropriate medical care likely to prevent death or substantial harm or suffering --may need legal consultation for court authorization to override parental authority --may need to intervene if imminent threat to child’s life

35. Legal considerations: --need medical evidence of risk to minor’s life or health and consent requirements would delay care --need to report to child protective services --may need to consider referral to child protective services as temporary custody and/or court orders for treatment if not immediate need to treat

36. Religious exemptions: --American Academy of Pediatrics opposes religious exemptions when treatment is likely to prevent harm, suffering or death --Review of fatalities associated with religion-motivated medical neglect—over 80% would have had over 90% chance of survival with medical care

37. Sequelae of Neglect: --serious consequences in all domains of child development—physical, cognitive, emotional and social --post-traumatic stress disorder --effects in childhood on learning, parent-child interaction, high risk behavior, criminality --negative adult outcomes (heart disease, cancer, obesity, depression)