Section A: Abuse and Neglect

BACKGROUND

The topic of child abuse and neglect is often a source of anxiety and discomfort for even the most seasoned of pediatric medical providers. While disheartening to even consider the possibility of a child being intentionally injured by a trusted caretaker, pediatric providers are uniquely positioned to identify situations concerning for child maltreatment and intervene accordingly.

Each year, nearly one million children in the United States are abused or neglected.¹ The majority of these children are victims of neglect, with the remaining being physically or sexually abused. For the purpose of this section, we will concentrate on the various aspects of child physical abuse (Chapters 38,39,40,41), as well as the legal issues which are inherent in all cases of child maltreatment (Chapter 42).

Cutaneous injuries are the most noticeable telltale sign suggesting that a child has been physically abused.² They should be documented and carefully considered in the context of the child’s overall history and presentation. Although alone not specific for nonaccidental trauma, the presence and particular characteristics of skin findings such as bruises, lacerations, abrasions, burns/thermal injuries, and bite marks can raise suspicion for an abusive etiology.

CLINICAL PRESENTATION

The clinical presentation of the child with cutaneous lesions can vary widely. Regardless of whether the child is presenting with a stated concern for a skin injury or one is detected as an incidental finding, the medical provider should be prepared to seek additional information if the child’s injury is not consistent with the history provided.

BRUISES

Bruises are a common cutaneous finding in the ambulatory child seeking to explore his/her environment. However, when present in the nonambulatory child, bruises should raise concern for possible physical abuse or an underlying medical condition. In a population of 973 children less than 36 months of age attending well-child care visits, Sugar and colleagues found that “those who don’t cruise rarely bruise.”³ That is, bruising was more common among those children who were cruising (17.8%) and walking (51.9%). Bruises were rare (2.2%) in those who were not yet walking with support (cruising). Moreover, the location of the bruises in the ambulatory children was noteworthy. Bruises typically occurred over anterior surfaces or bony prominences. The most common sites of bruising were the anterior tibia or knee, forehead, scalp, and upper leg. It was far less common for children to have bruising over posterior surfaces, chest, face (except for forehead), buttocks, or hands.³ Hence bruising in these areas as well as protected areas such as the abdomen, genitalia, and ears in infants and toddlers is extremely worrisome for the possibility of inflicted trauma.^3,4

In addition to correlating the bruise with the developmental stage of the child, providers should pay careful attention to patterned features of bruises that may belie the device or implement used to cause the injury. Children struck with linear objects (e.g. rods, rulers, belts) may present with linear configured scars. Likewise, flexible implements which are doubled over (e.g. ropes, cords, chains) can leave a loop-configured bruise, abrasion, or scar at the site of contact. Slap marks may appear as a negative image such that an outline of the handprint is created on the skin as a result of blood extravasating from vessels into the surrounding interstitial space. Binding devices (e.g. wires, ropes, cords) may manifest as circumferentially configured bruises, lacerations, or abrasions involving the neck, wrists, ankles, or oral commissure. The combined presence of patterned cutaneous findings appearing over unusual locations (e.g. posterior surfaces, soft tissues, genitalia) should raise grave concern for child abuse.⁵

BURNS

No matter the etiology, burns of any type are particularly concerning for abuse and/or neglect. Of children who are physically abused, it has been estimated that burns account for nearly 25% of cutaneous injuries.⁶ The mere presence of a burn does not distinguish between an accidental or intentional event; rather, it is necessary to examine the features of the injury and correlate the injury with the explanation provided. In the pediatric population, the scald burn resulting from contact with a hot liquid is the most frequently encountered burn injury.⁷ In young children, the scald injury can inadvertently occur when the child overturns a hot beverage onto himself or bumps into another person carrying a hot beverage. In those situations, the most significant area of skin involvement is located at the site of initial contact with less skin involvement distally, as a result of the liquid cooling while traveling away from the central point of contact. Of course, it is entirely plausible that the caretaker intentionally threw the hot substance onto the child, as this would result in a similar pattern of injury.

The immersion burn is most closely associated with inflicted trauma. This type of burn results from a child being placed, thrown, or held in a hot substance. Characteristically, the burn will have a sharp demarcation between the burned and unburned skin (i.e. water level) and uniformity of burn severity. If the extremities were immersed into the hot liquid, the child can present with a patterned and localized stocking (i.e. feet/leg) or glove (i.e. hand/arm) distribution of burned skin. Immersion of the child in a flexed position can result in skip areas, whereby the creased skin is protected relative to the surrounding exposed areas. If the buttocks comes into contact with the cooler surface (e.g. bathtub bottom), there may be a region of spared skin over the buttocks as a result. Kicking of the extremities and other physical efforts to resist the immersion event may result in splashing of the hot substance and subsequent “splash marks” (i.e. round areas of burned skin).

Similar to bruises, burns in a patterned configuration are strong indicators of abuse. Cigarettes, automobile cigarette lighters, steam irons, radiator grids, and blow dryer gratings are only a few commonly recognized burn patterns. Children burned by cigarettes typically present with a 6- to 8-mm round burn, with the center of the burn being most heavily affected due to the hot embers. Burns from automobile cigarette lighters produce a characteristic round burn containing concentric circles. Visualization of a burn pattern depicting round holes and a triangular tip is strongly suggestive of a steam iron burn. Similarly, the parallel and perpendicular pattern created by contact with a hot radiator grid or inner blow dryer grating is easily identifiable.

Other types of burns less frequently encountered include flame, electrical, and chemical burns. Obtaining an appropriate history can be most helpful in discerning their etiology.

BITE MARKS

The identification of bite marks on a child warrants special consideration. These lesions typically appear as an interrupted ovoid-shaped lesion. There may be surrounding edema or ecchymosis. Adult bite marks can be distinguished from those made by a child by measuring the maxillary intercanine distance. In adults, the standard maxillary intercanine distance ranges from 3 to 4 cm, whereas in children it is <3 cm. A forensic odontologist can be of assistance to further examine the lesion to elucidate other noteworthy features critical in narrowing the pool of potential perpetrators.

Although bite marks may be blamed on the household pet, human bite marks are not easily confused with those made by animals. Human bite marks are characterized by superficial abrasions or contusions. They are associated with rectangular-configured imprints from the four upper and lower incisors and the triangular imprints from the canines.⁸ This is in contrast to the deep, puncture, flesh-tearing, crush injuries often created by animal bites.

DIFFERENTIAL DIAGNOSIS

Regardless of how seemingly straightforward the etiology of the skin finding may appear, it is prudent to consider a differential diagnosis for all cutaneous injuries. Hematologic disorders, cultural practices, congenital conditions, infections, and oncologic processes can all mimic the appearance of abusive injuries^9-11 (Table 39-1). Some of the mimickers may have a patterned configuration which can further contribute to them being mistaken for inflicted injuries.

DIAGNOSTIC EVALUATION

A comprehensive medical evaluation is essential for the child presenting with a cutaneous finding. An organized, systematic approach will lessen the likelihood of an inaccurate diagnosis and inappropriate involvement of the state child protective services (CPS) agency.¹² Especially in situations where there is a high suspicion for inflicted injury, providers should carefully document details obtained during the initial history, as an evolving or changing explanation for the injury can serve as a red flag for abuse and/or neglect. Providers should obtain specific information describing the circumstances surrounding the event. For example, information needed for a child presenting with a bruise after an alleged fall would include location/position of child prior to the fall, height of the fall, fall surface, landing position, and surrounding objects in the vicinity of the fall. Complete medical, developmental, and family history should also be obtained.

As intrafamilial stressors are a major contributor to child maltreatment, a complete social work assessment should be performed to identify parental and environmental risk factors which would contribute to a child’s vulnerability for being abused. Providers should understand, however, that the history, as well as any information given by the caretaker, may be flawed and not capture the entire truth. A caretaker bringing the child for medical care may intentionally omit, misrepresent, or be innocently unaware of information helpful to determine the cause of the injury; therefore it is critical to remain objective, nonjudgmental, and unbiased when correlating the reported explanation with the injury itself.

Any cutaneous injury in an unusual location or a patterned configuration should prompt further inquiry as well as additional workup for a possible underlying medical condition and abusive trauma. Brain imaging should be performed in the nonambulatory child with facial or ear bruising. In situations where brain imaging is revealing of significant intracranial hemorrhage or trauma, an ophthalmologic evaluation should be performed.¹³ However, in the absence of radiographic evidence of brain injury, the likelihood of a positive ophthalmologic examination is low; therefore it is not considered a mandatory study to obtain in all children being evaluated for suspected physical abuse.¹⁴ A skeletal survey for children less than 2 years of age is mandatory for the purpose of identifying areas of acute or healing skeletal trauma.¹⁵

Researchers have found that a significant proportion of children with abusive burns have associated occult fractures.^16,17 Therefore providers should be rigorous in their evaluation when assessing children with suspicious burns and obtain a skeletal survey so as not to miss the opportunity to identify areas of skeletal injury. For children older than 2 years of age, the physical examination becomes more reliable, making the need for a skeletal survey less crucial.

Overall, bruising involving soft tissue surfaces (e.g. abdomen, genitalia) is unusual and should trigger additional laboratory evaluation including liver transaminases (AST/ALT), urinalysis, CBC, platelets, PT/PTT, amylase, lipase, and electrolytes. Using a threshold of 80 IU/L for either AST or ALT, Lindberg and colleagues showed that an elevated AST or ALT has a high sensitivity (77%) and specificity (82%) for predicting occult intra-abdominal injury.¹⁶ Therefore abdominal imaging (i.e. abdominal CT) should be strongly considered for children presenting with liver transaminases above 80 IU/L in whom abuse is a concern.

Bite marks can be a source of forensic evidence. A dry bite mark should be swabbed with a moistened cotton swab, and the swab air dried and placed in an appropriate forensic evidence envelope for further inspection by the crime lab. Of note, if the bite mark is already moist, it should be swabbed with a dry cotton swab to be submitted for testing.

Whenever possible, photographing cutaneous lesions is highly recommended, as most skin findings will resolve or change in appearance over time. Images should be properly labeled and a measuring device should be placed near the finding. If a ruler is not available, an object of universal size (e.g. coin) may be used instead. Providers should be compliant with institutional policies governing the permission to obtain images as well as the process for safe storage and release of the images.

MANAGEMENT

Providers with a suspicion or reasonable cause to believe that a child is being abused or neglected should have a low threshold for involving their state CPS agency. This mandated reporting is required by law in all 50 states, including the District of Columbia and the US territories. Although the resources available to CPS vary from state to state, in most states, CPS has the capability of conducting an investigation which may involve visiting the home, examining the scene where the alleged incident occurred, and making outreach to other individuals known to the child (e.g. daycare providers, teachers, neighbors, family members), all in an effort to obtain a more comprehensive understanding of the child’s injury.

ADMISSION AND DISCHARGE CRITERIA

While the decision to admit may depend on the medical care needed for the child’s particular injury, often this decision is focused around the process needed to determine the etiology of the finding. Admission is usually the most efficient means to obtain additional studies to assess for other areas of trauma, while simultaneously ensuring the child’s safety. Children presenting with minor unexplained injuries, but who are otherwise very well appearing can create a particular challenge for the medical care provider. The temptation and pressure, often created by a parent’s threats or frank hostility, to discharge can be great. However, medical providers should be mindful of the problems associated with a premature discharge. While it may be feasible to obtain studies to assess for skeletal or brain injury, once discharged, there is no guarantee that the family will obtain these studies in a timely manner. In addition, the medical provider is often not well situated to follow up with the family to ensure this occurs. Moreover, even if the recommended studies are obtained, the identification of additional areas of trauma, either new or healing, poses a risk management liability for the provider as well as his/her institution. Thus it is strongly recommended that in cases of suspected abuse the child be admitted such that all required studies to establish a diagnosis can been completed.

In situations in which a mandated report has been filed with CPS, discharge may be limited by the CPS response and decision-making process needed to effectively ensure a safe placement for the child after discharge. A safe placement may include placement with a relative (kinship foster care) or an individual unrelated to the child (foster care).

CONSULTATION

Effective case management of the child suspected to have been abused is best achieved using a multidisciplinary approach. Collaboration with relevant subspecialty services may be needed to clarify the diagnosis, identify possible underlying medical conditions which may account for the finding, and further understand the mechanism contributing to the finding. Given the challenges presented by some cutaneous lesions, it is not uncommon to obtain consultation from Dermatology, Hematology, Genetics, or Dentistry. Providers should also avail themselves of the services of a trained child abuse pediatrician and/or their hospital-based child protection team, which may be multidisciplinary in nature. Frequently composed of child abuse pediatricians, nurses, social workers, psychologists, and specialists with expertise in managing individuals involved in relationships characterized by interpersonal violence, the child protection team serves as a critical asset in case formulation, communication with CPS, and as a source of continued consultation to law enforcement, attorneys, and CPS even after the child has been discharged. Opinions provided by consultation services should be formally documented in the patient’s medical record, as the views of curbside consults are not verifiable in future discussions of the case with external agencies or during legal proceedings.

SPECIAL CONSIDERATIONS

In an effort to narrow the list of possible perpetrators, providers may be asked by law enforcement or CPS to render an opinion about the age of a particular bruise or other skin finding. Armed with this information, the seekers of justice can then create a timeline to better identify individuals who may have had access to the child at that time. However, providers should refrain from dating cutaneous findings, as they cannot be reliably dated with any degree of specificity. Depth of tissue injury, location of injury, skin pigmentation, and other factors all contribute to the appearance of a bruise, thereby making attempts to consistently correlate the color of the bruise with the time of the injurious event hopelessly erroneous.¹⁸

REFERENCES

BACKGROUND

The term abusive head trauma (AHT) is used to describe the spectrum of injuries that can arise when a caregiver shakes, throws, strikes, or otherwise injures a child resulting in skull, brain, and possibly spinal cord injury. Although children of any age may be affected, typically infants and young children are at highest risk, with most cases occurring in infants less than 1 year of age with a peak incidence noted in the first few months of life. The spectrum of injury ranges from mild to fatal, with approximately 15% to 23% of children dying from their injuries.¹ The majority of children who survive have permanent disability, which may include developmental delay or intellectual disability, blindness, seizure disorder, cerebral palsy, and feeding or respiratory issues.

The nomenclature of this entity has evolved as researchers have developed a deeper understanding of the mechanisms and pathology related to AHT. This understanding is informed not only by clinical and radiologic studies and pathologic assessment of injuries, but also by direct confessions of perpetrators. Dr. John Caffey initially noted a correlation between long bone fractures and subdural hemorrhage in 1946,² and developed the language of “shaken baby/shaken whiplash syndrome” when he published a case series of these children in 1972.³ (This phenomenon was also noted by AK Guthkelch in 1971.⁴) In 1987, Duhaime and colleagues ⁵ proposed that fatal and more severe cases of inflicted brain injury were likely to involve not only shaking but also blunt force impact, leading some to coin the term “shaken impact syndrome.” In 2009, the American Academy of Pediatrics⁶ joined many experts in supporting the term “Abusive Head Trauma,” a designation which encompasses not only injury from shaking but injuries which may be sustained when a child suffers blunt trauma or crushing injury.

The incidence of AHT is estimated to be between 24 and 34 cases per 100,000 children less than 1 year of age; however, it is likely that this is an underestimate due to unrecognized cases of abuse.⁷ Milder cases may be missed if parents fail to bring children for evaluation, and more severe cases may not be recognized, but rather mistaken for meningitis or seizure disorder, accidental injury, viral gastroenteritis, or other medical disorders. The likelihood of a misdiagnosis appears to be higher if patients have mild injury or if parents are judged by providers to be “low risk”—i.e. married, white, and economically stable.⁸ Boys appear to be victimized at a slightly higher rate than girls. Male perpetrators are more common than female, with fathers, stepfathers, and boyfriends making up 60% of offenders.⁹

Brain injury seen in AHT is caused by a cascade of events. Depending on the mechanism of injury, there often is direct trauma to the brain parenchyma during violent and repetitive shaking or during the rapid acceleration/deceleration event which occurs when a child is thrown down. There may be shearing injuries, which develop as brain tissues of different densities move at different speeds. In addition, children may experience periods of apnea (possibly related to brainstem injury) contributing to poor oxygenation of parenchymal tissue. Brain edema may lead to midline shift, causing damage to the opposite hemisphere of the brain as well as possible herniation of brain tissue. Not only does this brain edema lead to compression of smaller blood vessels which provide oxygen and nutrients to brain tissue, but these shifts of brain tissue within the cranial vault may also kink or compress vessels which supply vital territories of brain tissue. As neurons die, they release excitatory amines and other chemicals, which lead to further neurologic damage.¹⁰

CLINICAL PRESENTATION

Children with AHT present with a spectrum of injuries ranging from mild to severe. Victims with mild injury might present with poor feeding, vomiting, or irritability, and may be misdiagnosed as colic or gastroenteritis. There is not always bruising or other external signs of trauma. Sometimes, caregivers do not seek care for days or weeks, and symptoms may resolve without the true cause being identified. Because presenting symptoms in mild cases can be non-specific, it is important to have a high index of suspicion when treating any young child with unexplained or repeated symptoms of vomiting, irritability, lethargy, or apnea, so as to prevent discharging patients home who may be subject to more severe abuse. A large number of patients in whom the diagnosis is missed are reinjured, sometimes more severely.⁸

More extensive injury results in clear and immediate symptoms of lethargy, apnea, seizure, and cardiopulmonary instability. These gravely injured children suffer progressive worsening of symptoms over the 24 to 48 hours following their injuries, with increasing nervous system dysfunction, which may lead to coma and death.

The mechanisms causing these injuries often lead to findings which are helpful in identifying AHT. In shaking injuries, subdural hemorrhages (usually not clinically significant) are common due to torn bridging veins; subarachnoid hemorrhage may also be present. Blunt force trauma may lead to skull fracture, and other forms of physical abuse may create additional fractures of long bones or ribs. Retinal hemorrhages are present in approximately 75% of cases, and may be unilateral or bilateral.¹¹ These retinal hemorrhages are usually in multiple layers of the retina, extend to the periphery of the retina, and are numerous. The retinal layers may also be split, leading to retinoschisis or retinal folds, a highly concerning and specific finding.

The timing of injury can be difficult to determine in children who do not sustain severe injuries; however, interviews with confessed perpetrators indicate that the onset of symptoms occurs immediately after the shaking event.⁹ An accurate history of when the child was last seen behaving normally is often the most helpful clue to determine when the injury may have occurred.

DIFFERENTIAL DIAGNOSIS

It is critical to consider other potential causes for a child’s injuries due to the huge emotional and legal impact for the caregivers of a child diagnosed with AHT. Although some of the possible medical etiologies for a child’s presentation may seem very unlikely, surprisingly, these conditions will surface as legitimate explanations for the child’s symptoms as the case moves forward in the legal system. Therefore it is important to carefully consider alternative diagnoses and document the systematic evaluation and rationale for their exclusion as a likely cause for the child’s condition.

The birth process may lead to small subdural hemorrhages (SDH) or skull fractures. Most birth-related SDH are supratentorial or in the posterior fossa. These hemorrhages are usually small and clinically insignificant; most resolve within 1 to 2 weeks, although some may be detectable within 3 months of birth.¹² More significant intracranial injury generally results in symptoms that occur within the first 36 hours of life, and is therefore detected before or shortly after newborns are discharged home. Retinal hemorrhages can also result from birth. These are most commonly associated with instrumented or vaginal delivery (20%–70%), although they can occur with caesarian sections as well (1%–12%). These retinal hemorrhages are usually not associated with intracranial injury, and the vast majority resolve within 1 to 2 weeks, although residual discrete hemorrhages may persist up to 4 to 8 weeks in very rare cases.^{13, 14}

Accidental head trauma can result in some of the findings seen in AHT. Falls from significant heights and accidents that involve a parent, a car seat, or a walker that fall with the child have a greater momentum and may include not only angular but rotational forces that can lead to greater injury. However, a fall from a modest height (e.g. bed or changing table) rarely results in significant brain injury and does not cause widespread retinal hemorrhage.¹³ Children with benign extra-axial fluid collections of infancy may be at increased risk of sustaining intracranial hemorrhage with minor trauma; however, severe brain injury and retinal hemorrhage are generally not seen in these cases.

The differential diagnosis of AHT also includes choking/aspiration, SIDS, meningitis, bleeding disorder (including vitamin K deficiency), Menkes disease, and glutaric aciduria type I. Most of these conditions have other classic findings associated with them, and further testing can rule out the presence of underlying infectious, metabolic, or hematologic abnormalities.

DIAGNOSTIC EVALUATION

As with other forms of child abuse, a detailed history of the events leading up to the child’s presentation can assist in narrowing the differential diagnosis. The initial history given by caretakers is crucial to establishing the diagnosis. In AHT there is usually either a history of no trauma or of minor trauma which in no way could explain the injuries seen. The history should be taken as soon as possible, focusing on a detailed description of the events leading up to the child’s presentation as well as the child’s appearance and activities before developing symptoms. When obtaining the past medical history, providers should inquire about the birth history, prior history of minor falls or injuries, developmental abilities, and family history, including specific questions about bleeding disorders or relatives with multiple fractures or death in childhood. Discussion with the child’s primary care physician, who can provide important growth and head circumference data, is an integral part of this history-gathering process.

Social work staff can often be extraordinarily helpful in obtaining a detailed social history, including information about substance abuse, mental health issues, family stressors, interpersonal violence, and prior child protective services (CPS) involvement. Parents should be interviewed separately to screen for interpersonal violence and to obtain their individual accounts of the events leading up to the child’s hospitalization. Involvement of a hospital-based child protection team and a child abuse pediatrician, if available, can be critical to assist with diagnosis and case management decisions.

Infants presenting with signs that might be related to abuse require a thorough physical, radiologic, and hematologic evaluation. Physical examination should look for any signs of bruising, as any bruising in a non-ambulatory infant is of significant concern for abuse. Attention should be paid to the oral cavity to detect frenum tears or trauma to the floor of the mouth. In addition, a thorough neurologic examination is critical. A dilated eye examination should be performed by ophthalmology as soon as is clinically possible to clearly document the number, size, and distribution of any retinal hemorrhages as well as to detect any accompanying ocular injury (e.g. vitreous hemorrhage, retinal detachment, retinoschisis, etc.)

Computerized tomography (CT) scan and magnetic resonance imaging (MRI) of the brain can both be helpful and are complimentary studies. CT scan can help identify acute subdural hemorrhage, and a three-dimensional reconstruction can identify skull fracture. MRI may detect very small collections of extra-axial hemorrhage which might not be seen on CT. Also, MRI can serve to identify intraparenchymal injury as well as determining the extent of ischemic areas of brain tissue by detecting areas of restricted diffusion. Magnetic resonance angiography (MRA) or magnetic resonance venography (MRV) can help rule out the possibility of arterial occlusion or superior sagittal venous thrombosis. MRI is also useful in defining the nature of fluid collections (subdural vs. subarachnoid). However, care should be taken when describing mixed-density fluid collections. At no time should mixed-density fluid collections be described as “subdural hemorrhage of differing ages,” as such findings may also represent “hyperacute” bleeding, or can be seen as a result of arachnoid tears that lead to leakage of cerebrospinal fluid into the subdural space.

High detail skeletal survey can identify occult fractures which may be seen in AHT, including posterior rib fractures, classic metaphyseal lesions, or long bone injury. Bone scan or a 2-week follow-up skeletal survey can identify fractures which are new and which may be not readily identified on the original survey.

Laboratory studies may include a complete blood count with differential, blood and cerebrospinal fluid culture (if the child is febrile), prothrombin time, partial thromboplastin time, INR, liver function tests (to rule out occult abdominal trauma), copper levels (low in Menke syndrome), urine studies for glutaric aciduria, and possibly a toxicology screen. If fractures are present, vitamin D, parathyroid hormone, calcium, phosphorus, and alkaline phosphatase should be checked, as well as testing for osteogenesis imperfecta. Although these are very rare disorders, this level of testing will be expected once cases go to adjudication and should be gathered early, as it may take several weeks before some of the results are known.

MANAGEMENT

The management of AHT requires a multidisciplinary team approach so that support to the family and assistance with complex social issues can take place while the child is being cared for medically. If a child has been placed in state custody, medical care of the child may be made more complicated by the need to seek state approval for medical interventions.

The repercussions of the traumatic brain injury dictate the medical management. Surgical intervention is rare. Occasionally, there may be either a significant subdural hemorrhage or midline shift with impending brain herniation which require surgical intervention. This may be seen in cases of direct skull trauma which lead to massive injury to one side of the brain with midline shift described by some as “big black brain”;¹⁵ in these cases, sometimes a neurosurgeon will remove a bone flap and leave it off for days to weeks so that brain swelling can continue without creating herniation.

More commonly, surgical intervention is not helpful, as significant and permanent damage to brain parenchyma leads to the majority of symptoms. Children who are severely injured may deteriorate in the first 24 to 48 hours as brain swelling increases. Caution dictates that these infants should be followed in the intensive care unit in order to provide monitoring, possible respiratory support, and skilled management of intracranial pressure. Seizures may require the use of anticonvulsant therapy. Brain injury may lead to coagulopathy or disturbance of sodium hemostasis.

Children who survive AHT often require ongoing medical management. They may have visual loss from damage to the occipital cortex. They may be unable to feed due to poorly coordinated suck and swallow, and may require placement of a feeding tube. Some children require tracheostomy for respiratory support. Physical and occupational therapy services are involved long term, and these patients may require a prolonged stay in a rehabilitation facility owing to permanent neurologic damage.¹⁶

ADMISSION AND DISCHARGE CRITERIA

Any child who is thought to have a diagnosis of AHT should be admitted for further medical evaluation, social work assessment, and a hospital-based child protection team consultation.

Once medically stable, the child may be discharged home or to a rehabilitation facility. Often, the timeline for discharge planning is dictated by the ability of the state CPS agency to locate a safe environment for the child, either in a kinship placement or foster care if the home environment is deemed unsafe.

CONSULTATION

Cases of AHT are often best managed by a multidisciplinary team. If a hospital-based child protection team is available, they should be consulted as soon as possible in order to guide further assessment. Additionally, social work staff should always be involved, as well as specialists in neurosurgery, ophthalmology, orthopedics, hematology, genetics, and endocrinology, if indicated. If intimate partner abuse is involved, interpersonal violence advocates may also be very helpful to non-offending parents.

Any case in which there is a strong suspicion of child abuse requires a mandatory report to the state CPS agency. This agency will determine whether there are other children exposed to the offending caretaker who may be at risk. Staff should be prepared to interface with outside agencies, including representatives of CPS services and law enforcement. Accurate diagnosis, consideration of all possible differential diagnoses, and excellent documentation are essential. Throughout the hospital admission, non-offending parents and guardians of the patient should be treated with respect and kept apprised of both medical management issues and necessary social work interventions.

SPECIAL CONSIDERATIONS

PREVENTION

Prevention programs are in place in many states, with varying statistics about their effectiveness. These programs focus not only on educating caretakers about the dangers of violent handling of infants but also giving skills which may help in coping with normal crying behaviors.¹⁷ Hospital-based child protection teams are becoming standard in most pediatric hospitals, thus improving early detection of child abuse and refining practice around cases of abuse. Public health agencies are encouraging a “trauma informed” approach to caring for families, which will hopefully provide services early to parents who may need more assistance caring for young infants. Research continues to refine our understanding of the complex processes which take place when an infant sustains abusive head trauma.

REFERENCES

BACKGROUND

In 1946 John Caffey described the association of subdural hematomas and skeletal fractures in infants and raised the possibility of maltreatment to explain these injuries.¹ Kempe and Silverman later coined the term “battered child syndrome” in a landmark article to the general medical community that described the characteristic radiologic features seen in abused children.² Child abuse is the second most common cause of brain injury and fractures in infants and young children.³ Diagnostic imaging is crucial in the evaluation of child abuse and its imitators.

EVALUATION OF SKELETAL TRAUMA

Skeletal injures can be classified with regard to their relative specificity for abuse based on their imaging pattern and location (Table 41-1).^4-6 Highly specific fractures are usually identified in infants and are typically clinically occult.⁴ Most of these occur with indirect forces, rather than direct blows, explaining the usual absence of bruising overlying the fracture sites.⁷ Rib fractures near the costovertebral articulations occur with anteroposterior compression of the thorax that may be associated with violent shaking (Figure 41-1). The classic metaphyseal lesion (CML) results from torsional and tractional forces applied to the extremities (Figure 41-2); it may also occur with accelerational forces associated with infant shaking. Highly specific injuries are not caused by simple falls^8-11 or by two-finger cardiopulmonary resuscitation efforts.^12,13

Skull fractures have been reported in 10% of abused children and although usually linear, they may be multiple, diastatic, complex, bilateral, and depressed.^14-16 Skull fractures can occur with short falls to firm surfaces in young infants; therefore, simple linear skull fractures have a low specificity for abuse. Although long bone shaft fractures have a strong association with abuse in non-ambulatory infants, they can occur with household and playground accidents, particularly in toddlers and older children. Thus long bone shaft fracture must be viewed in conjunction with the clinical history.

Adequate imaging is critical for the detection of subtle fractures specific for abuse. Failure to perform an adequate skeletal survey may result in returning a child to a potentially dangerous environment. Jenny et al. found that nearly one-third of cases of abusive head trauma (AHT) had been previously seen by a physician where the diagnosis was missed.¹⁷ The detection of skeletal injuries depends on the technical quality and thoroughness of the skeletal survey. Digital imaging should be performed according to the guidelines of the American College of Radiology (ACR) and the American Academy of Pediatrics (AAP), and optimized to a high detail technique.^18-20 The skeletal survey protocol is shown in Table 41-2.²⁰ The study should be reviewed before completion by an experienced radiologist, and positive sites should be imaged in at least two projections.^19-21

Skeletal surveys are recommended in all infants and toddlers <2 years of age when there is suspicion of abuse. Clinically occult trauma in children older than 2 years is less common than in infants¹⁴; therefore skeletal surveys should be reserved for those older children when there is a strong suspicion of physical abuse. There is little value to global screening for inflicted skeletal injury beyond age 5.¹⁹

Additional imaging studies may complement the skeletal survey in problematic cases. High quality skeletal scintigraphy may be performed when a skeletal survey is negative or equivocal in infants, or in the appropriate setting, as an alternative to radiography in toddlers and young children. Scintigraphy can identify acute rib fractures not apparent on radiography, but it is less sensitive in the detection of CMLs and skull fractures.^22,23 Bone scintigraphy with 18F-NaF PET has better contrast and resolution than the traditional imaging with Tc-99m-labeled methylene diphosphonate.²⁴ A follow-up skeletal survey at 2 weeks can identify fractures that are subtle initially but become evident with healing.²⁵ This approach can increase the degree of certainty of fracture, assist in dating, and also differentiate fractures from developmental variants that may simulate abuse. MRI and ultrasonography are useful in the evaluation of epiphyseal separations, and may have a role in the evaluation of soft tissue injuries. Chest CT can aid in the evaluation of rib fractures in selective cases. CT 3D skull models can complement the four skull series and help distinguish skull fractures from normal variants.²⁶

Patterns of fracture healing vary depending on patient age, injury site, fracture displacement, and motion. Infants heal faster than older children. Subperiosteal new bone formation usually occurs between 7 and 10 days, soft callus is seen at about 10 to 14 days, and hard callus forms between 14 and 21 days.^27,28 Serial examinations are useful in assigning ages to specific fractures.

VISCERAL TRAUMA

Abdominal and thoracic trauma are more common in toddlers and young children than in infants. The mechanisms of the injuries are due to direct blow or deceleration forces. Children may present with nonspecific complaints. Intra-abdominal injuries include small intestinal perforation, duodenal or jejunal hematomas, adrenal hemorrhage, pancreatic lacerations and pseudocyst formation, and liver laceration.²⁹ Gastric, renal, splenic, and bladder injuries are uncommon. Neck and chest injuries include pharyngeal perforation, pulmonary contusion, pneumothorax, and hemothorax. Many visceral injuries are unassociated with bruising, and the clinical picture may suggest a naturally occurring illness. Failure to diagnose visceral injury can result in a mortality rate up to 50%.^4,30 Multidetector CT (MDCT) with intravenous contrast is sensitive in the detection of significant thoracoabdominal injuries and can be performed in seconds, usually without sedation.

HEAD TRAUMA

Intracranial injury is the major cause of morbidity and mortality in abused infants. Subdural hematomas (SDHs) are common in severely abused infants. An SDH without impact in the presence of retinal hemorrhages raises the suspicion of the shaken baby syndrome. Infants who are shaken may also have signs of blunt force trauma, including skull fractures and subgaleal hematomas. CT is highly sensitive in the detection of interhemispheric SDHs but may miss small convexity collections. MRI is more sensitive in the detection of subacute SDHs but may miss significant acute SDHs as well as subarachnoid hemorrhage. Susceptibility-weighted sequences overcome these limitations. Other common findings in abused infants are hypoxic–ischemic injury and focal or diffuse cerebral edema. Nonhemorrhagic contusions, gross white matter tears, and diffuse axonal injury are less common.³¹ In general, these patterns of injury are better displayed with MRI than CT.^4,32 Diffusion-weighted imaging (DWI) shows hypoxic–ischemic injury earlier than conventional pulse sequences.^33,34 Susceptibility-weighted images can also show retinal hemorrhages.³⁵ MRI can also provide valuable information with respect to the age and multiplicity of injury events. Ultrasonography is useful to differentiate convexity SDHs from large extra-axial cerebrospinal fluid spaces; it is also beneficial in the detection of subcortical white matter tears.^36-38

Suspected AHT is usually evaluated with CT to exclude life-threatening injuries, although rapid MRI may play a role initially.³⁹ Abnormal findings on CT should be further assessed with MRI.⁴⁰ It may be useful to perform serial imaging to assess the evolution of the injuries and to identify additional findings that may have become more evident with time. MRI is indicated in suspicious cases even when the initial CT scan is negative, when high specificity skeletal injuries are present in infants, or when there is evidence of chronic neurologic injury.⁴¹

DIFFERENTIAL DIAGNOSIS OF ABUSE

Diagnostic imaging can identify a variety of conditions that can be confused with child abuse. Multiple fractures and/or metaphyseal irregularities simulating CMLs can be seen in osteogenesis imperfecta, rickets, syphilis, certain bone dysplasias, and as a result of traumatic vaginal and caesarian deliveries. Subperiosteal new bone formation (SPNBF) can be seen with Caffey disease, sickle cell anemia, leukemia, and osteomyelitis. Developmental variants such as physiologic SPNBF can be confused with skeletal injury. These entities can generally be distinguished from abuse by the history, physical examination, laboratory data, and careful imaging evaluation.

REFERENCES

BACKGROUND

TERMINOLOGY

Medical child abuse is a complex and controversial area that is the subject of ongoing debate among child abuse pediatricians. The American Academy of Pediatrics recently defined this clinical entity as “the harm incurred when a caregiver exaggerates, fabricates, or induces symptoms of a medical condition.”¹ Initially described in the late 1970s as Münchausen Syndrome by proxy,² medical child abuse has also been referred to as factitious disorder by proxy and pediatric condition falsification. The term used in this chapter, medical child abuse, is both more inclusive and more specific than previously used terms.³

The scholarly debate surrounding the terminology used to refer to medical child abuse is less relevant for the sleep-deprived hospitalist than the urgent issue of determining whether a patient’s presentation raises concern for maltreatment. Regardless of terminology, there is expert consensus that medical child abuse is a dangerous, even potentially fatal, form of child maltreatment that too often eludes prompt diagnosis.

In evaluating whether a patient may be the victim of medical child abuse, treating physicians must keep three important questions in the forefront. First, is the child’s clinical presentation consistent with an organic disease process? If not, are the symptoms attributable to exaggeration, falsification, or induction by a parent or caregiver? If so, have the non-organic symptoms resulted in the child receiving medical interventions that are not needed and that are potentially or actually harmful?¹ Cases of medical child abuse are rarely straightforward, and answering these questions accurately can challenge the even the most seasoned practitioner. This chapter addresses typical features that should raise concerns for medical child abuse and outlines ways in which these concerns can be systematically evaluated. The chapter also addresses the key question of how to prevent ongoing abuse once the diagnosis is made, and how hospital-based physicians can work as part of a multidisciplinary team to intervene to protect the abused or at-risk child.

EPIDEMIOLOGY

Because medical child abuse is both under-detected and under-reported, accurate epidemiologic data are difficult to obtain. The age range of affected children spans infancy to adolescence, though cases cluster in early childhood. One study of 451 published case reports estimated an average age of onset at 4 years, and the average length of time to detection of abuse at 21.8 months. Boys and girls were affected in equal proportions, and mothers perpetrated the abuse in roughly 75% of cases. The same study found a 6% mortality rate and a 7.6% rate of serious morbidity in victims. Known siblings of victims were calculated to have a 25% mortality rate, with 61.3% exhibiting symptoms that also raised concern for medical child abuse.⁴ Accurate population-based figures for incidence and prevalence of medical child abuse are lacking. Recently published data from an Italian hospital in which all pediatric inpatient admissions were reviewed to identify cases of medical child abuse found a prevalence of 0.53% among this population.⁵

PATHOPHYSIOLOGY

ABSENCE OF ORGANIC ILLNESS

The essential element of every case of medical child abuse is that the patient’s reported or observed symptoms cannot be explained by underlying organic illness alone. Yet because it is by its very nature covert, medical child abuse is often missed. Unlike an asthma exacerbation, which is easily diagnosed by recognizable clinical signs and symptoms and responds promptly to standard treatment, medical child abuse presents along a spectrum of severity and can involve a broad variety of presenting complaints. The term medical child abuse encompasses three main types of presentation, which can occur simultaneously in the same patient¹:

1. Report of exaggerated symptoms or of false symptoms. A parent reports that her infant has a large-volume emesis after every feed, but these symptoms have never been witnessed by a healthcare provider.

2. Falsification of symptoms. A parent shows a soaked spit-up cloth as proof of patient’s emesis when in fact the parent has simply poured formula directly onto the cloth.

3. Induction of symptoms. A parent adds ipecac to the infant’s formula to cause intractable vomiting.

EXAGGERATION AND FALSIFICATION OF SYMPTOMS

When symptoms are exaggerated or falsified, the criteria for diagnosis of medical child abuse are not met until the exaggerated or falsified symptoms result in medical interventions that are not needed and could cause harm to the patient. For example, the pediatrician who evaluates the well-appearing infant with parental report of frequent large-volume emesis may opt to follow clinically without performing any workup, thereby avoiding unnecessary medical care. Conversely, the same patient may see a pediatrician who takes the history at face value and orders an extensive workup. Because the history is not true, no amount of medical intervention will lead to resolution of the vomiting. The apparently intractable nature of the disorder can lead to specialty referrals and multiple studies, formula changes, trials of medication, and even invasive medical technologies such as a gastrostomy tube or a central line for TPN. It is important to remember that in the case of such a patient with reported intractable vomiting, it is likely that the infant has seen both of the above pediatricians in succession, as the parent seeks further interventions and more intensive medical care from a series of medical providers.

INDUCTION OF SYMPTOMS

In contrast to cases in which a parent or caregiver exaggerates or lies about symptoms that a patient does not have, induction of symptoms occurs when a caregiver intentionally makes a well child ill. In these cases, the patient suffers from actual illness caused by the parent or caregiver, and the harm to the child is clearly evident. The crucial distinction between simple physical abuse and medical child abuse is that in the latter, the perpetrator deceives medical providers by misrepresenting as genuine illness the symptoms that he or she caused.

The literature provides an instructive example of induced symptoms in the case of a girl whose mother beat her legs with a hammer to cause orthopedic injuries. After surgeries were performed to address the injuries, her mother introduced contaminants into the incisions, causing chronic infections. These induced medical conditions led to countless antibiotic courses and surgical procedures over the course of 8 years of treatment by puzzled medical staff.⁶ The involvement of the medical system in treating induced illness contrasts to the case of a parent who hits a child with a hammer to punish her and then attempts to conceal evidence of this abusive injury when it is detected. Both children are the victims of physical abuse; parental deception of medical providers and the resultant medical interventions make the first example a case of medical child abuse as well.

CLINICAL PRESENTATION

MEDICAL CHILD ABUSE IN THE INPATIENT SETTING

Pediatric inpatient facilities are ground zero for many cases of medical child abuse, and so awareness of this possible diagnosis in the medically complex hospitalized patient is essential. A patient may have been admitted due to concerns for medical child abuse, and hence the hospitalization may serve both a diagnostic and a therapeutic purpose. More commonly, however, awareness that the possibility of medical child abuse evolves over time as an underlying organic diagnosis remains elusive. These cases are usually highly complex; it is easy to lose sight of the larger clinical picture in the flurry of specialized tests and studies that may be recommended by a host of consultants. As the workup continues and new treatments are trialed, the patient will typically show no response or develop new symptoms. This is because, in the words of one expert, “treatment given for nonexistent illness is seldom successful.”³

The literature on medical child abuse still consists mainly of case reports and case series. Few articles have been published that present rigorously collected data in order to classify common presentations. Table 42-1 presents clinical features commonly associated with cases of medical child abuse, regardless of the reported diagnosis. Although certain characteristics recur, the possibilities are nevertheless infinitely varied. Hence Table 42-1 should be used to rule in rather than rule out suspected cases of medical child abuse. Table 42-2 presents common clinical presentations, which in the absence of verified organic etiology should raise concern for medical child abuse. While no one characteristic or diagnosis is definitive, awareness of common themes can inform the approach to these complex patients.

DIFFICULTY OF DETECTION

Medical child abuse is particularly challenging to detect because it violates a fundamental principle that grounds good medical care—that the history obtained from the parent can direct appropriate treatment. In the case of medical child abuse, the well-intentioned physician acts in good faith on incomplete, inaccurate, exaggerated, or frankly false history, resulting in provision of care that exposes the patient to harm or risk of harm.³

By the same token, it is essential to recognize that medical child abuse by its nature involves the medical system. Medical interventions may be prompted by an unreliable or false history; ultimately, however, decisions are made and orders placed by the physician caring for the patient. In this sense, physicians are the sine qua non of medical child abuse. The physician’s intense commitment to providing care and investment in finding an organic cause for the patient’s symptoms may present an additional barrier to early recognition of medical child abuse.³

Finally, it is important to note that making the diagnosis of medical child abuse hinges simply on whether maltreatment has occurred or is likely to occur. The motives of the perpetrator, as in other forms of child abuse, are not relevant to the diagnosis and can be a distraction from the primary goal of protecting the patient from further harm.¹

DIFFERENTIAL DIAGNOSIS

Simply including medical child abuse on the differential is a critical first step for the medically complex patient in whom a long list of less common conditions is likely being considered. Medical child abuse is not a diagnosis of exclusion. The workup as outlined below should take place in parallel with the medical workup so that an affirmative diagnosis may be reached and the child can be protected if necessary. It should also be kept in mind that medical child abuse may be taking place and the affected child may in fact have underlying illness; the presence of organic disease does not preclude medical child abuse.¹ Figure 42-1 presents an initial decision-making algorithm for the patient in whom medical child abuse is suspected, and is intended to compliment the diagnostic approach detailed below.

DIAGNOSTIC EVALUTION

INFORMATION GATHERING

Once medical child abuse is suspected, objective verification of the symptoms reported by the parent or caregiver must be attempted. The presence of multiple published case reports of medical child abuse available in the literature can also be of benefit in bolstering concerns if a quick search identifies a similar case or cases. Additionally, a psychosocial assessment of the patient should be performed. Depending upon the age and developmental capabilities of the patient, the assessment may be most appropriately conducted by a psychologist, psychiatrist, social worker, or experienced member of the hospital-based child protection team. Interviews of parents, family members, and other care providers should be conducted separately from the child and from one another. Observations by nursing and support staff who work on the hospital ward can also provide unique information that clarifies the clinical picture.

MEDICAL RECORDS REVIEW

A painstaking review of all medical records with close attention to detail is required in order to evaluate concerns for medical child abuse. A systematic approach has been proposed by Roesler and Jenny that involves developing a detailed chronological chart documenting the date of each visit or admission, with corresponding presenting history, testing and studies performed, and whether the clinical picture supported the medical concerns raised. This approach allows identification of patterns of care-seeking behaviors and may demonstrate a stark contrast between the presenting complaint, clinical appearance, and objective findings.³ A high index of suspicion should be maintained for “chart lore” that has been perpetuated in the medical record without verification.⁷

It is particularly important to ensure that all records from previous providers are obtained, and that providers currently caring for the patient have a real-time conversation with prior providers and the primary care pediatrician when possible. Convening a meeting of all involved providers can reveal significant discrepancies between the history offered by the parent and information substantiated in the medical record. In cases of medical child abuse, it is not uncommon for prior providers to have harbored suspicions of abuse without acting upon them. Conversely, a report may have already been filed with the state child protective services (CPS) agency, and in fact may have prompted a transition of care to a new institution. The importance of obtaining this history cannot be overemphasized, as it can support developing concerns and accelerate the investigatory process for a child or children at ongoing risk of harm.

SEEKING EXPERT CONSULTATION

Practically speaking, a thorough records review can be a challenging undertaking, as typically patients have had contact with multiple institutions and the history provided by parent or caregiver may intentionally omit important pieces of chronology. It may not be feasible for a team on a busy inpatient service to pursue an exhaustive review of all records with the level of detail required to make the diagnosis of medical child abuse. If preliminary review of available records supports a concern for medical child abuse, then prompt consultation with the hospital-based child protection team or, if not available, consultation with the state CPS agency, is of utmost importance. Investigation by state CPS may also include a review of mother’s medical record and medical records of living or deceased siblings. Findings may amplify concerns and reveal history that has been concealed from treating providers.

THE CHALLENGE OF OBJECTIVITY

The additional benefit of seeking the input of an expert outside the treating team is that objectivity can be particularly hard to maintain in cases of medical child abuse. This is partially because the perpetrating parent or caregiver may be likeable and may tend to form close relationships with physicians and staff. The presence of a parent or caregiver at the bedside whose interactions with the patient are “appropriate” should not assuage concerns for medical child abuse.

Another reason the treating team may lack objectivity is the natural inclination of physicians to become invested in diagnosing an unusual or rare condition.³ Physicians may become enmeshed with the perpetrating parent and this relationship may unintentionally spur further testing and treatment.⁷ Reframing the patient’s presentation as attributable to a non-organic cause may require providers to engage in honest self-assessment and develop a willingness to recognize and understand their role in perpetuating unnecessary and potentially harmful medical care.

COVERT VIDEO SURVEILLANCE

In the absence of a direct admission by the perpetrating parent or caregiver, it is natural to desire “proof” that a child’s symptoms are either falsified or induced prior to diagnosing medical child abuse. Covert in-hospital video surveillance in order to document suspected medical child abuse is a controversial topic that has been extensively debated in the child abuse literature.^8,9 Covert video surveillance has provided valuable insights into the behavior of perpetrators of medical child abuse but presents a host of real-world legal, ethical, and practical challenges that preclude its use.

More important than these barriers, however, is the recognition that allowing an at-risk child to undergo video surveillance in the hopes of “catching” a perpetrator in a harmful act exposes the child to unnecessary and avoidable risk. If concerns for the child’s safety are high enough to prompt desire for continuous surveillance, then the child and suspected perpetrator should never be left unattended. Simply being in the hospital setting does not protect a vulnerable child from further abuse when the perpetrator is at the bedside. A 1:1 around-the-clock sitter is possibly a safer option, though the perceived need for this level of intervention should beg the question of whether the suspected perpetrator should be allowed any contact at all with the patient as the workup continues.³

MANAGEMENT

In contrast to the complexity of diagnosing medical child abuse, treatment is straightforward and consists of halting harmful medical interventions. The diagnosis is confirmed when care is simplified and the patient remains well. De-intensifying the approach to workup and treatment can be a difficult process that may require the treating team to reverse its goals of care. A multidisciplinary approach is essential, as is agreement among involved services and providers. The hospital-based child protection team and state CPS agency can guide and facilitate this process.

Once the treating team is in agreement, a multidisciplinary family meeting should be arranged with parents or caregivers. One physician on the team should be identified as the point person for all communication with the family. The message of the meeting should be simple: to deliver the news that the workup has not identified serious underlying illness, and to inform parents or caregivers of the team’s concerns for false or induced symptoms if this has not previously taken place. The team should be prepared for denial and possible extreme emotional or physical reactions from parents or caregivers.³

DISCHARGE CRITERIA

The final decision on how to protect the medically abused child and his or her siblings is one that is outside the purview of treating providers. Nevertheless, state CPS may rely heavily on the medical team for assistance in understanding the medical aspects of the patient’s care. Providing complex information in a format that is accessible to investigators who may lack medical training is a critically important role and one that is best filled in conjunction with the hospital-based child protection team. When the perpetrator is continuously supervised at the bedside or barred from contact with the medically abused child, recovery is often quick and dramatic. Once a safe environment is assured and needless interventions have been discontinued, the patient may be discharged.

CONSULTATION

When medical child abuse is suspected, early consultation with a trained child abuse pediatrician and the hospital-based child protection team or state CPS is crucial. Medical child abuse is a diagnosis that may seem to require time and observation for certainty, but cases typically conform to patterns that are readily recognizable to experts with experience in similar cases. Input from child abuse experts can provide invaluable guidance and can help assure that the diagnosis of medical child abuse is not delayed or missed entirely.

SPECIAL CONSIDERATIONS

MANDATED REPORTING

When medical child abuse is suspected, medical providers are required to report their concerns to the state CPS agency to prevent further harm to at-risk children. As with other forms of abuse, reporting is mandated when a physician or other member of the medical team has reasonable cause to believe that medical child abuse has occurred or is occurring. Absolute proof is not required. In the case of medical child abuse, when so much depends on full access to medical records and a family’s prior history, early involvement of state CPS not only assures timely investigation in these high-risk cases but also fulfills the provider’s legal mandate to report. Reporting also allows for investigation of the safety of other siblings in the family, who may be victims of abuse too. All states offer immunity from liability to mandated reporters whose report of child abuse or neglect is made in good faith, and almost all states have established penalties for mandated reporters who fail to report in accordance with legal requirements.^10,11 Medical care providers should become familiar with the particular mandated reporting laws of their state.

RECORD KEEPING

An additional important consideration in cases of medical child abuse is creating a thorough and accurate record of the patient’s hospital course, including any events that raised concerns for exaggerated, falsified, or induced symptoms. Concerns for the possibility of medical child abuse should be made explicit in the assessment even if certainty is lacking. Records should be kept with the expectation that they may be reviewed at some point in the future by subsequent medical providers or by child abuse investigators, because a parent or caregiver who has already sought care from multiple providers in different jurisdictions is likely to continue this pattern. Parents who retain custody of the child will also have continued access to the medical record. Therefore, documentation should be comprehensive, yet objective and clear.

LEGAL CONSIDERATIONS

Finally, due to the complexity and high-risk nature of these cases, the treating team would be well served by notifying the hospital’s risk management, general counsel, or equivalent administrative entity of their concerns for medical child abuse early in the patient’s hospital course.

REFERENCES

BACKGROUND

Physicians do not learn much about child protective services and the legal system during their training, yet in pediatric practice there is an increasing need for understanding of these two areas, especially in the area of child maltreatment. Medical professionals often have questions regarding the process of mandated reporting of child abuse to state agencies, as well as the civil and criminal court actions that may result from those reports, which may require physicians to provide factual and expert testimony.

REPORTING

The Federal Child Abuse Prevention and Treatment Act (CAPTA) (Public Law 93-247), and subsequent amendments, provides definitions to inform national, state, and community efforts to prevent, identify, and treat child abuse and neglect and provides federal assistance to states to support these efforts.¹ Federal legislation defines child abuse and neglect as, at a minimum:²

• “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation”; or

• “An act or failure to act which presents an imminent risk of serious harm.”

Each state provides its own definitions of maltreatment within civil and criminal statutes.² It is important for inpatient pediatricians to be familiar with their state laws and definitions of the various types of maltreatment.

All 50 states allow anyone—but have statues that require certain professionals—to report incidents of suspected child abuse and neglect to the state child protective services (CPS) agency. Common mandated reporters are physicians, nurses, teachers, psychologists, social workers, and law enforcement personnel. Only a reasonable suspicion or belief of abuse is required to make a report to state authorities; a person does not need evidence that abuse or neglect exists to make a report.

All states have immunity provisions for mandated reporters, so that the reporter is protected from any civil or criminal liability if a report is later deemed erroneous or unsubstantiated.³ In contrast, failure of a mandated reporter to report suspected child abuse may result in a fine, malpractice suit, or criminal sanctions. Therefore a report should be filed any time there is “reasonable cause” to believe that abuse or neglect exits.

As an inpatient pediatrician, it is essential to confirm that a report has been made in all cases in which doing so is necessary. If another person or institution has filed a report about the same episode of abuse, no other professionals are required to duplicate that report.³ However, if a new indicator of abuse is observed, a new report must be filed. For example, a report is filed for a nonambulatory child with an unexplained femur fracture. He is subsequently transferred to another hospital for further treatment, where he is found to have suspicious rib fractures as well. The accepting physician must make a supplementary report about the rib fractures. As practices may vary from state to state, pediatric providers should become knowledgeable about the reporting requirements within their institution.

CHILD PROTECTIVE SERVICES

CPS is a state-administered governmental agency responsible for investigating reports of child maltreatment, determining whether child abuse or neglect has occurred, and intervening to ensure a safe environment for the child. In most cases, CPS agencies assist families in finding appropriate support services to protect and improve the well-being of their children. When it is deemed necessary, these agencies also secure alternative placements for children or pursue the termination of parental rights. Although CPS agencies vary by state and county, professional standards of practice have been widely accepted and implemented.

REPORTING MALTREATMENT

When a report is made to CPS, it is important to provide as much information as possible regarding the child and the incident or circumstances that led to the suspicion of maltreatment. State laws protect the identity of reporters if they choose to remain anonymous. However, especially in the inpatient setting, it is recommended that parents or guardians be notified when a medical professional is going to make a report to preserve (to the extent possible) an open, honest relationship with the child’s caretakers. The most effective means of notifying parents or guardians is to express concern that someone may be harming their child, rather than directly accuse them of maltreatment. When providing this information, the physician can ask whether the parents know of anyone who might be hurting their child. Although the physician–parent relationship may become strained, parents generally respond better to honesty and directness than to secretiveness. This should facilitate a more comfortable working relationship while the child remains in the hospital, and may encourage appropriate follow-up care.

Once a report is made, the CPS staff determines whether the report meets criteria to be accepted as an investigation or assessment and is thus “screened in.” Reports that do not meet the criteria may be “screened out” and referred to other services.⁴ Rules vary by state regarding whether the CPS agency must thoroughly investigate every report.¹ This remains a controversial issue as states attempt to balance their mandates for child protection with limited financial resources.

THE INVESTIGATION

The CPS investigation begins by gathering all the relevant information about the case. Many state laws and regulations outline the investigative procedure in great detail. Most require contact with the child and family within 24 hours of the most serious reports of abuse and within 2 to 5 days for other reports.^1,4 Interviews are conducted with the child, the parents, other family members, and other individuals who might have knowledge about the specific allegations or about the family’s treatment of the child in general.

Many jurisdictions have children’s advocacy centers in place to assist and guide the child interview process. Children’s advocacy centers provide a multidisciplinary team approach to investigations of child abuse, including forensic interviews, therapeutic interventions, victim support and advocacy, and case management. Such facilities provide a safe, child-friendly environment to conduct forensic interviews of a neutral, fact-finding nature. Often these agencies work in collaboration with law enforcement and CPS to minimize the number of times the child victim is interviewed.

If the alleged maltreatment constitutes criminal behavior, law enforcement personnel should be brought into the investigation to ensure that the criminal aspect of suspected maltreatment is thoroughly investigated and that the evidence necessary for criminal prosecution is adequately safeguarded.¹ The reporter may contact the police directly, or this may be done through an established mechanism within CPS. Many jurisdictions have guidelines to ensure cooperation between law enforcement and CPS.

EMERGENCY REMOVAL

One of the most important aspects of the child protection system is the ability to take a child into protective custody on an emergency basis if he or she is in imminent danger. State laws vary whether CPS or law enforcement maintain the authority for this emergency intervention. Once this is done, the CPS agency must obtain a retroactive court order granting it temporary legal custody of the child within 24 to 72 hours from the time the child was placed in protective custody.⁵

Emergency removal orders are usually entered ex parte (with the court only hearing from CPS and without notice to the parent or guardian). Immediately after the 24- to 72-hour period, the matter must be brought before the court at the initial hearing, where the parents are present and have an opportunity to be heard. The main purpose of this initial hearing is to determine whether there is enough evidence to conclude the child is at risk of harm and should remain in substitute care or be returned to the parents pending further proceedings. In addition, the court may issue other types of protective orders against individuals alleged to be responsible for the child’s maltreatment, such as orders for those individuals to vacate the home and have no contact with the child or other family members.⁵

DISPOSITION AFTER THE INVESTIGATION

State laws and regulations require that the CPS agency conclude the investigative process by arriving at a disposition or a formal finding of whether child abuse or neglect has occurred within a given time frame.¹ A number of terms, including indicated, supported, confirmed, or substantiated, are used when CPS believes that the child was a victim of maltreatment; words such as unfounded or unsubstantiated indicate that there was insufficient evidence to conclude that child maltreatment occurred. It is important to keep in mind that these CPS conclusions are not the result of a hearing.

Although an unsubstantiated report seldom involves additional action on the part of CPS, a finding that abuse or neglect has been substantiated frequently requires further action by the child welfare agency and the family, unless the perpetrator no longer has access to the child and the child is not at any additional risk. Public Law 96-272 requires that CPS make “reasonable efforts” to keep the child within his or her family home rather than placing the child in foster care.¹ Thus the next step often involves the formulation of a case plan by CPS, with the main goals of ensuring the child’s safety and stabilizing the family system. The case plan reflects the expectations and responsibilities of family members as well as the role and contributions of the CPS agency, which often involves the provision of assistance through other community agencies. CPS staff then follows the progress of the family in accomplishing the changes set forth in the case plan. If the family does not follow the plan and the child continues to be at risk, CPS can take further steps.

A minority of substantiated cases of child maltreatment result in some type of court proceeding. This occurs when the child is thought to be in imminent danger of repeated maltreatment or when it is perceived that social services will not be sufficient to effect the desired family changes. A small percentage of the cases filed in court result in the child’s removal from the home and placement with a third party. Public Law 96-272 requires the juvenile court to (1) conclude affirmatively that the CPS agency has made reasonable efforts to avoid removing a child from his or her family home before authorizing an out-of-home placement for the child, and (2) review the actions of CPS periodically to ensure that reasonable efforts are being made to return the child to his or her birth family.¹

Parents may willingly have their children placed in “kinship care” to avoid a child protective court hearing after a CPS investigation has confirmed maltreatment and deemed the child’s removal from the home is necessary. This is more likely when there is a safe placement for the child in the home of a relative, godmother, good friend, or other suitable person close to the family.⁵

Cases investigated by CPS become “closed” for a variety of reasons, ranging from the conclusion that the child is safe insofar as can be determined to the termination of parental rights and placement of the child in a permanent substitute family.¹ Infrequently, under certain circumstances, cases may be closed for less legitimate reasons.

LEGAL PROCEEDINGS

CIVIL CHILD PROTECTION COURT

Medical testimony may be used in a variety of legal proceedings in civil and criminal courts, including a civil child protection court action, criminal prosecution of alleged perpetrators of child maltreatment, and civil actions for damages from injuries. Most child abuse and neglect cases are heard in state courts. Civil child protection cases usually involve the juvenile or family court, with the CPS agency initiating the action. In juvenile court child protection proceedings, ideally, the focus is on the child—whether he or she has been subjected to abuse or neglect, and if so, what intervention is needed not only to protect the child but also, unless contraindicated, to strengthen the child’s family.⁵ It is not always necessary to prove that a specific parent or guardian injured a child.

Child protective judicial proceedings begin with the filing of a complaint or petition. The initial hearing, typically referred to as a “preliminary protective,” “shelter care,” “temporary custody,” or “detention” hearing, determines the immediate need for alternative custodial arrangements or protective orders while the investigation is underway.⁵ At this initial stage, parents may concede the allegations in the petition are true and accept the court’s jurisdiction, or contest the allegations resulting in the case being continued to another date. Afterward, there may be formal or informal attempts at negotiating a case settlement. If a settlement is not negotiated a formal hearing, or adjudicatory hearing, will ensue.

In juvenile court child protection proceedings, the child is appointed a Guardian ad Litem (GAL) at or before the initial hearing. A GAL is an attorney or a volunteer who is an independent advocate for the child’s best interest. Volunteers also may be called court-appointed special advocates (CASA). The volunteers often are professionals trained in other disciplines, such as nursing, psychology, or education. The child’s advocate assists the child and protects his or her interests throughout the proceedings or as long as the court has jurisdiction over the child.⁵ Special representation for the child is rarely arranged in criminal proceedings.

At the adjudicatory hearing, also known as the “fact-finding” or “jurisdictional” hearing, the judge determines whether the facts in the petition are true. State laws require the adjudicatory hearing begin or conclude within a set time from the date of petition or original placement of the child. Unlike criminal proceedings, during the adjudicatory hearing parents cannot refuse to be called to testify based on the Fifth Amendment. However, once on the stand they may refuse to testify, which may be weighed against them by the court.⁶ If child maltreatment is not proven, the case is dismissed. If child maltreatment is concluded the case proceeds to a disposition hearing.

At the disposition hearing (sentencing), the court decides whether the child needs help from the court and, if so, what services will be ordered to resolve the problems that led to CPS intervention.⁶ For example, the court may order mental health and rehabilitative services, out-of-home placement, or establish visitation schedules and corresponding level of supervision for parents. It also can order CPS to conduct follow-up visits with the family to ensure the child’s protection.

If the child remains in out-of-home care, or at home under the CPS agency’s protective supervision, periodic review hearings are required at set intervals. Federal law requires that a separate “dispositional hearing,” to establish a firm permanent placement plan for a child, occur no later than 18 months after the child’s entry in placement.⁵

CRIMINAL COURT

Criminal court cases are begun with the filing of an indictment or other charge. In civil actions, the standard of proof is less than that required in criminal court. The moving party usually has the burden of persuading the factfinder by a “preponderance of the evidence” or by “clear and convincing evidence,” meaning the state must prove that it is more likely than not that the allegations are true.⁷ In contrast, criminal cases require a higher degree of certainty—“beyond a reasonable doubt”—to prove guilt. Therefore, even if there is insufficient evidence to convict a perpetrator in a criminal trial, it may be sufficient to give the juvenile court protective jurisdiction over the child.⁵

Criminal cases involve the prosecution of individuals by the state or federal government to establish their guilt or innocence of particular charges and to determine appropriate sentences for those found guilty.⁷ All sexual abuse and unlawful sexual conduct as well as severe physical abuse are criminal acts. In the event the government believes that it cannot prove the suspect guilty beyond a reasonable doubt, the government may instead seek a court order adjudicating the child a dependent of the court as previously described.

DISCOVERY PROCESS

Once the civil or criminal legal process has begun, there is frequently a period of “discovery” whereby both sides exchange information regarding the case. Physicians may be involved in the discovery process by means of a subpoena. A subpoena ad testificandum is a court order requiring an individual to appear at a designated time and place to provide sworn testimony.⁷ A subpoena duces tecum requires the production of records or documents relevant to the matter being litigated.⁸

A deposition is part of the discovery process whereby the parties learn about and evaluate the other’s case through the testimony of witnesses before the trial.⁷ In a civil case, it is possible that the opposing attorney will depose the treating physician. It is an informal setting, without a presiding judge or jury. It is important for the physician to be well prepared and to confer with the patient’s attorney before the deposition. The testimony is given under oath and is recorded by a stenographer. After the deposition, the witness is advised about the procedures for either reading and signing the deposition or “waiving” the review and signature. If the witness chooses to “read” the deposition, a transcript is printed and signed by the witness, with amendments limited to corrections and clarifications.⁷

MEDICAL DOCUMENTATION

It is very important for physicians to be complete, accurate, and legible when documenting events in a patient’s medical records. In the event those records will be used as evidence in court, it is even more vital that they be comprehensive. Correct, thorough, decipherable medical records can help the treating physician recall his or her findings when preparing for a hearing or a trial, which may occur several months after the physician’s initial involvement with the patient, and they can help the lawyer have a better understanding of the medical findings. If the medical records become evidence, they will help the fact-finder (i.e. judge or jury) understand the case and render the proper resolution.

All hospital staff must clearly document a child’s statements describing the history of the illness or injury and the presenting symptoms, as they may be admissible in legal proceedings. While a child’s words typically fall under the “hearsay” rule, there are certain exceptions to the hearsay rule that pertain to medical care, including the “excited utterance exception” and the “medical diagnosis or treatment exception.” Without careful documentation of exactly what questions were asked and exactly what the child said, the professional will likely not remember months or years later when called as a witness.⁸

PROVIDING EXPERT AND NON-EXPERT TESTIMONY

The rules of evidence provide the statutory and case-law framework by which information is deemed by a judge to be relevant, material, and therefore ordinarily admissible for consideration by the fact-finder (i.e. judge or jury) at a hearing or trial.⁷ Although the rules of evidence may vary between federal and state proceedings and from state to state, most jurisdictions have evidentiary rules consistent with the federal rules of evidence as provided in Title 28 of the U.S. Code.

Evidence can be testimonial or “real” in the form of documents, pictures, or things (e.g. weapons). There are two types of witnesses. A fact witness provides factual testimony based on personal knowledge and is not allowed to express an opinion based on that knowledge.⁷ An expert witness can formulate a professional opinion on the matter at hand, assist the fact-finder in understanding the evidence, or answer a hypothetical question. The judge decides whether a witness has sufficient knowledge, education, training, skill, and experience to qualify as an expert witness.

PREPARING TO TESTIFY

Testifying in a court hearing can be stressful, even for the most experienced professionals. It is crucial to be well prepared to ease anxiety, decrease the risk of surprises, and ensure that the court is provided with the most helpful information possible.⁷ This involves reviewing all the medical records related to the case and any subsequent letters or documents generated.

It is crucial for the physician to confer with the attorney who subpoenaed him or her before the court date. This allows the physician to share knowledge or concerns that may be of interest to the lawyer, as well as any fears or past experiences.⁷ The attorney should provide the physician with the theories of the case and a list of questions he or she intends to ask. The attorney may also discuss the opposing counsel’s theories and anticipated questions. The physician should inquire whether documents will be admitted partially or entirely into evidence and whether he or she will be asked to use them as part of the testimony.⁷ It is critical that the attorney be aware of the physician’s opinion and understand the reasoning behind that opinion. The physician must be firm about the limits or scope of both his or her factual testimony and opinions. If the attorney presses for answers or opinions that the physician is uncomfortable giving, this must be expressed.⁷

TESTIFYING IN COURT

On the day of the trial, the physician should dress professionally, arrive early, and notify the attorney of his or her presence. This allows time to clarify any new issues that may have arisen since the last contact. Of note, witnesses often are sequestered, meaning that they are allowed in the courtroom only during their own testimony. In some cases, the court may permit the physician to be in the courtroom during the opposing side’s expert testimony.

While on the witness stand, it is imperative that the physician listen to and understand each question. If the question is not fully heard or comprehended, the physician must ask the attorney to repeat the question. Questions should be answered with truthfulness, precision, and clarity. It may be necessary to define unfamiliar terms and explain difficult concepts. Always attempt to answer questions in language that is understandable to laypeople. In the event the physician does not know the answer to a question or cannot remember, he or she must say so.⁷

The initial part of expert testimony involves qualifying the physician as an expert. The attorney begins by asking a series of identifying and qualifying questions regarding the physician’s professional education and experience.⁷ In some instances, the physician’s curriculum vitae will be admitted as an exhibit. The opposing counsel then has an opportunity to ask further questions to refute this qualification.

Once the physician is qualified as an expert, testimony can take one of three forms: an opinion, an answer to a hypothetical question, or a lecture that provides background information for the judge or jury.⁸ Most often the expert is asked to render an opinion based on the facts of the case. Sometimes the expert’s testimony is in the form of an answer to a hypothetical question that includes significant facts relevant to the case at hand. On occasion, an expert may testify in the form of a lecture that provides the fact-finder (i.e. judge or jury) with background information on technical, clinical, or scientific issues.⁸

Whatever the form of question and answer, it is important that the answer be well thought out, accurate, and clearly articulated. The physician should explain all conclusions and analyses in terms that are understood by the fact-finder and ensure that he or she does not exceed the bounds of his or her expertise or exaggerate in any manner. In formulating an opinion, an expert may rely on all relevant clinical, scientific, historical, and factual information. Experts are not allowed to express an opinion on legal issues such as the guilt or innocence of a defendant.

During cross-examination, the opposing counsel will attempt to show the fact-finder that the expert’s testimony is flawed in some way. This may involve trying to discredit the expert’s knowledge of the relevant evidence or posing other theories to explain the child’s condition. An expert who has thoroughly reviewed all medical documents and relies on up-to-date knowledge in the field will be well equipped for cross-examination. The expert should also be prepared to explain the nature of possible differential diagnoses, their manifestations, and why they are not a plausible explanation for the matter on which the expert has given his or her opinion.⁷

Once again, it is imperative that the physician be attentive and understands each question asked by the opposing counsel. Although attorneys are not allowed to ask “leading” questions during direct examination, such questions are allowed and are often used during cross-examination. Usually these take the form of yes or no questions, which the opposing counsel uses to control the witness and the testimony. If a question cannot be answered truthfully yes or no, the expert should say so and qualify the answer. The expert is also entitled to request to clarify a previous answer if it appears that he or she misspoke or misunderstood the question.⁷

If the expert was not allowed to fully answer a question or the expert’s testimony was undercut during cross-examination, the direct examiner will attempt to clarify the expert’s testimony during the redirect examination. This portion is usually limited to areas of inquiry pursued in or raised by cross-examination.⁷

REFERENCES