Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Cindy Christian. I am a Child Abuse Pediatrician at The Children’s Hospital of Philadelphia. I also serve as the Assistant Dean for Community Engagement at the Perelman School of Medicine at the University of Pennsylvania.
Today, we will be reviewing what you need to know before you encounter your first patient who has been abused. We. will focus on physical and sexual abuse of children.
Child abuse, which is sometimes called non-accidental trauma, is a public health problem with life-long health consequences for survivors and their families. Adults who were maltreated as children have poor health outcomes, and there is accumulating evidence that early adverse childhood experiences, including being exposed to abuse, neglect and other forms of family violence, are strong contributors to many adult diseases. Regardless of your ultimate professional specialty, you will come across many pediatric and adult patients whose lives have been affected by abuse.
For some children, physical abuse results in permanent disability, affecting their lifelong health in profound ways. For example, victims of abusive head trauma (AHT) have high rates of neurologic disability, including sight and hearing impairment, epilepsy, cerebral palsy, and developmental and cognitive delay. Abused children may suffer permanently disfiguring injuries. And abused children are at risk of developing a variety of emotional and behavioral problems.
Child abuse is a highly complex phenomenon in which parent, child and environmental characteristics interact to place children at risk. Child physical abuse affects children of all ages, ethnicities and socioeconomic groups, although children of color and children from poorer families are more likely to be reported to child protective services. There are many risk factors for abuse that are important for guiding the development of prevention and intervention strategies. But these risk factors should be considered as broadly defined markers, rather than strong individual determinants of abuse. What is important for you to know is that children who live in families with no risk factors can be victims of child abuse, and most families under stress do not harm their children.
The identification of physical abuse can be difficult. Other than the perpetrator and the child, witnesses to the abuse are uncommon, perpetrators of the abuse infrequently admit to their actions, child victims are often preverbal, too severely injured or too frightened to disclose their abuse, and injuries can be non-specific. Physicians are taught to rely on parents for accurate information about the child’s history and may not be critical or skeptical of the information provided. And unconscious biases often influence evaluation and reporting practices.
Recognizing abuse and reporting reasonable suspicions to child protective services, or CPS, can be one of the most challenging and difficult responsibilities for the pediatrician. Yet early identification and intervention to protect abused children have the potential to reduce morbidity and mortality. There is evidence, however, that physicians miss opportunities for early identification and intervention. This is especially true for infants and toddlers, who are at highest risk of life-threatening and fatal injuries at the hands of their caregivers. Why would this be so challenging? There are many reasons. First, it’s difficult to distinguish an injury that is the result of abuse from other injuries. In some types of abuse, for example in sexual abuse, the child usually has no physical injury to identify. Many other abusive injuries are non-specific- a bruise is just a bruise, for example, and you cannot distinguish an accidental bruise or fracture from an inflicted bruise or fracture simply by your physical exam or looking at a radiograph. Some injuries seem so minor that they are easy to disregard, and we don’t recognize their significance.
Second, it is rare that a caregiver brings a child who has been abused to the office or emergency department for medical care and confesses to harming the child. They sometimes report a history of minor trauma, hoping it will be believed. In medicine, we have all learned that the way we make a diagnosis is to take a good history and complete a thorough physical examination, and after our thorough H & P, we often have created a short differential diagnosis. But when adults are untruthful, or omit critical information, the history is unreliable, and making the correct diagnosis can be a great challenge.
Third, the child may be brought for medical care by an unsuspecting and non-offending parent, who does not know that the child has been abused. They often present to care with a list of non-specific concerns about the child, and no history of trauma is provided.
Finally, and importantly, it is emotionally difficult for many physicians to confront parents when there are concerns of abuse. But physicians, nurses, social workers and other health care providers are sentinels. Our society expects that we will look out for children who are or have been abused and work with other professionals to protect them.
As health care providers, we are all mandated reporters. We make a diagnosis of abuse like we make other medical diagnoses. We use our powers of observation, take a thorough history, complete a careful physical examination, and use ancillary testing to generate a working diagnosis. If, after our evaluation, we have a reasonable suspicion of abuse, we are mandated – or required - to report our concerns to child protective services.
It’s also important to recognize that as individuals, we each will have a different threshold for reporting, based in part on our cultural background, religion, childhood and parenting experiences, and many other factors. There will be children whose abuse is so egregious that there is no question they need protection; but other cases can be challenging. In those situations, it is extremely helpful to consult with colleagues or those who have more experience. The best way to intervene to protect abused children is by being aware, thorough in evaluations, objective in decisions and honest in conveying concerns to parents.
AS MEDICAL STUDENTS, your responsibilities are to consider child abuse in your differential diagnosis, and to talk with your senior residents or attending physicians about any concern you may have. Even though we are all mandated reporters, the decision to report suspected abuse is best made by an experienced team only after careful medical and social work considerations with an objective and thorough medical evaluation. Like all diagnoses, there are other differential diagnoses to consider.
Traumatic injury is extremely common in children, and the vast majority of pediatric trauma is due to preventable accidental injury and not abuse. So how do we, as clinicians, distinguish children whose injuries are concerning for abuse from the vast majority of children whose injuries are accidental? There are many clues: We look for children with significant injury whose caregivers deny any history of injury; we look for children whose injuries are not congruent with the history of trauma provided- for example a history of a fall off a couch that has resulted in life-threatening injury even though the history doesn’t suggest that the injury should be this serious; we look for children who are said to have injured themselves, but are not developmentally capable of causing that specific injury – like a leg fracture in a child who is not mobile; we look for injured children in whom there is an unexpected, unreasonable and unexplained delay in seeking care; we look for families who provide notably changing histories or accounts of events; and finally, for children whose injuries are so obviously from abuse, we consider them pathognomonic. An example of this would be a “C” or “U” shaped bruise or laceration from being hit with a looped belt or cord. Or retinal hemorrhages in an infant that are indicative of shaken baby syndrome.
INJURIES:
When thinking about the kinds of injury we see in abused children, it is important to know that with very few exceptions, no single type of injury is diagnostic of abuse. There are, however, combinations of injuries that can be diagnostic. For example, children who have experienced abuse often present with new, healing, and old injuries to multiple organ systems. When you see multiple injuries of different ages, there is really no doubt that the child has been abused. But some children who have been abused will present with only bruises, others with a burn or broken bone, some with abdominal injury and some with head trauma. For any patient with any injury, recognizing abuse requires taking a thorough history, performing a complete physical examination, completing a thorough work up searching for both occult injuries and exploring alternative diagnoses, and formulating an objective conclusion about the data. Let’s talk about each of these components of the evaluation:
First, the history. As medical students, you are taught to take a complete history from patients – or their parents- which should serve you well in identifying abuse. At our hospital, and many others, there is a child protection team, which is usually comprised of a physician with experience caring for children who have experienced abuse or neglect, social workers, and others. The child protection team is consulted once a concern for child abuse or neglect has been identified. When we on the child protection team are going to talk with families about concerns of physical abuse, we ensure privacy for the family interview, and for toddlers and older children, we talk with parents away from the patient. We also ensure that at least one additional health-care provider, most often a social worker, is present when we talk with the family. These encounters can be highly stressful for the family and the medical team, and as a medical student, you should not take these interviews on independently. But you should take advantage of the opportunity to join these conversations for your patients. We introduce ourselves as members of the child protection team and explain our role and why we are there. Then we proceed with a thorough and careful history, including the events that brought the child for medical care. If there is a history of trauma, we ask for details of the event. We also take a careful social, past medical, family and developmental history. Back to basics, so to speak! If the patient is able to talk with us, we may do that with the child alone, again ensuring privacy.
As a pediatric clerkship student, your responsibility is to always be cognizant of the possibility of abuse. Before you see your patient, review the medical record for the child. Has the child been seen previously for injury? And if so, how often? Did the previous injury history make sense? Have there been previous concerns of abuse in the medical record? You should review the child’s growth chart, and look for trends that are concerning- is the child malnourished? Is the head circumference enlarging too quickly, suggesting the possibility of macrocrania from expanding chronic subdural hemorrhages? When you take a history from a family, be thorough and don’t forget to include a good social history. Who lives at home? Who cares for the child? Do the parents work outside the home, and if so, who cares for the child? If the history given doesn’t make sense, it is appropriate to ask clarifying questions. If there was an unexpected delay in seeking care, you may want to ask why they decided to bring the child for care? It is important to be thorough in the history without being accusatory.
Next, the physical exam. Our physical examinations are thorough, reviewing growth charts and growth parameters, and carefully looking for signs of subtle injury. For example, we always do a good mouth examination, assessing the frenula and tongue for injuries. We also look for bruises that are strongly associated with abuse- especially in infants and young children. We use the mnemonic TEN-4-FACESp to remind us about abuse.
TEN-4:
T- Torso bruises
E- Ear bruises
N-Neck bruises
4- In children 4 years of age and younger and ANY bruise in an infant 4 months of age or younger
And FACES-p- to describe facial injuries that are high risk:
F- injuries to the frenulum
A- Bruises to the angle of the jaw
C- Bruises to the fleshy part of the cheek
E- eyelid bruising
S- Subconjunctival bruising
P- Patterned bruises anywhere on the body
Remember 10-4-faces p as clues to physical abuse in young children with bruises. When you see bruises in young infants and toddlers, 10-4-facesp can remind you which bruises to be most concerned about. As we say, if the baby don’t cruise, the baby don’t bruise- so even minor bruising in young infants is a cause for concern.
When you are examining your pediatric patients, you should do a careful skin examination. If you see new or old injuries that are concerning, it is appropriate to ask the child or parent about the injury- how and when did that happen. Remember, most injuries are the result of accidental trauma, but our responsibility is to be mindful of the possibility of abuse. And your physical examination should be complete, assessing for any areas of pain or tenderness, looking for unusual marks or scars.
After the H & P is completed, we consider a differential diagnosis and make plans for further medical and social investigation. The differential diagnosis for children who are suspected victims of abuse is extensive. Children who present for medical care with excessive bruising or bleeding could have a bleeding disorder. Children with fractures could have rickets or metabolic bone disease. On rare occasion, children with subdural hemorrhages might have metabolic disease such as glutaric aciduria. I’ve diagnosed all these child abuse mimics during my career, and our job is to think objectively about the diagnostic possibilities and test for alternative possibilities when appropriate.
There are a number of standard tests we order in the evaluation for physical abuse. For infants and young toddlers where there is concern for physical abuse, a skeletal survey, which is a series of plain radiographs that assess the entire skeleton for acute and healing fractures, often identifies occult injuries. We screen for abdominal trauma by ordering trauma labs- liver and pancreatic function tests, and for anemia or coagulopathy that can accompany significant acute blood loss. We usually start with a CBC and PT/ PTT and for some children, we might also obtain Factor VIII and IX levels and von Willebrand screens. We also consider the differential diagnosis when we are ordering tests. There are many diseases and medical disorders that can mimic abuse. As I mentioned before, children with unusual bruising could have a bleeding disorder, and children with fractures could have rickets or an inherited bone disease. So we routinely screen for those disorders and refer patients to our specialist colleagues if we are considering an alternative diagnosis. For example, for infants and children with fractures, we screen for bone health by ordering a Ca, PO4, Alkaline Phosphatase, 25-OH Vitamin D, and PTH. Based on the child’s physical examination, family history and radiographs, we may also send genetic testing for osteogenesis imperfecta. We don’t do that in all cases, especially if the child has additional, non-skeletal injuries. As I mentioned, it is important to be thorough in our evaluations and we base our laboratory testing on the clinical situation.
Once we have the data we need, we formulate an opinion- a working diagnosis as we all refer to it. Sometimes the diagnosis of abuse is clear, and in such cases, it is important to be clear in our medical documentation. In other cases, it is clear after a complete evaluation that the child’s injury was accidental, or that the child has a medical disease. Again, it is important to be clear in our medical charting of these conclusions. Finally, in many cases, we cannot conclude based on a medical evaluation alone, whether the child has been abused. In these cases, when we have a reasonable suspicion of abuse, we are obligated to make a report to child protective services for investigation. In making a report, it is essential that the medical team try to convey with clarity the reason the report is being made, what is known and unknown, the level of concern for the child’s safety, and the plans for further medical evaluation. In some cases, a report has already been made, perhaps by a referring hospital, or in the Emergency Department, prior to the child’s hospitalization. At other times, the child protection team will make the report. Regardless of who has made the report, it is important to talk with the parents about the report, why the report is being made, and the next steps in the evaluation. Although these conversations are difficult, it is very important to be honest with families and specific about the concerns and next steps. Parents are usually upset and can be angry or frightened about the involvement of child protective services. It is usually helpful to talk with the family about their own family and social supports during this time. Once a report is made to child protective services, discharge planning for the patient needs to be coordinated with the child protection investigators. This can sometimes delay discharge for the patient – or, if this is happening in the outpatient or emergency department setting, it may mean that the patient needs to be admitted, but we must allow the investigators to come up with a safe plan for the child. The majority of children are discharged home with a family member; sometimes additional relatives are asked to help care for the child during the investigation. And on occasion, when the family resources are limited or the child is not thought to be safe at home, the child can be discharged to kinship or foster care. Kinship care refers to the care of children by relatives or, in some jurisdictions, close family friends. These decisions are not the medical teams to make. The child protection investigators will make these decisions. Our responsibility is to provide investigators with accurate medical information so that they can make the best decisions for the child’s safety. Children who have experienced physical abuse usually require medical follow up to monitor injury healing and to complete the medical evaluation for trauma and other possible diagnoses.
Now let’s talk briefly about child sexual abuse. Children who have experienced sexual abuse present for medical care in a number of ways. Unlike the diagnosis of physical abuse, which often rests on a medical provider’s ability to identify and evaluate injuries, sexual abuse is most commonly identified when a child feels safe enough to verbally disclose their abuse. This may occur after a single episode of abuse, but more characteristically only occurs after weeks, months or years of abuse. Children disclose their abuse when they feel safe to disclose- and some children never disclose. Some children present for medical evaluation with behavioral changes, including those we call internalizing- for example withdrawal from normal activities, sadness, somatic complaints, inhibition- or those we refer to as externalizing behaviors- such as physical aggression, cheating, stealing, fighting, or disobeying rules. Occasionally, children present with hypersexualized behavior, such as increased masturbation or use of sexual words, and it may be difficult to distinguish abuse from sexual exposure or even normal development. Children who have experienced sexual abuse can display many behavioral signs, including promiscuity, anxiety, sleep disturbances, bedwetting, inappropriate sexual play or drawings, and others. When children present with behavioral problems, it is important to consider whether their behaviors are caused by specific stressors, such as abuse. In all cases, it is appropriate to ask about any new stresses at home, and whether there is a concern that someone may be harming the child. Children may also be identified when a 3rd party unexpectedly walks in to find sexual activity involving a child. Less commonly, children may present with genital or anal complaints, but these are often non-specific and a differential diagnosis must always be considered. Finally, some children are recognized as having been sexually abused when they are diagnosed with a sexually transmitted infection. These children may deny their abuse initially, as they commonly are not ready to disclose their abuse, but their body has exposed their abuse when their infections were recognized. Most commonly, children who have been sexually abused come to the attention of medical providers after they have disclosed their abuse to a parent, relative, teacher or other trusted adult, and the child is brought to medical care by a non-offending parent to assess the child’s physical health.
Like other medical diagnoses, the medical evaluation of the sexually abused child begins with a history. We usually begin the evaluation alone with the parent, as they often need time to share their story and concerns without the child in the room. Some parents are distraught by a child’s disclosure; others are disbelieving, and allowing time to understand the dynamics of the situation can be very important. We also spend time alone with the child obtaining age and developmentally appropriate information. For example, we take a sexual history from an adolescent but not a young, school-aged child. If the child’s abuse has not been reported to CPS and the police for investigation, we will complete a minimum facts interview- a basic history to assess whether a report is needed, but not one that asks for all the details of the abuse. In many communities, child advocacy centers have been established to coordinate child sexual abuse investigations, and children are more formally interviewed by specially trained forensic interviewers, who work closely with child protective services and the police. If the investigation is already underway, we will still meet with the child to ensure that they know why they have been brought for medical care, and to assess their physical, behavioral and emotional health. For school aged and adolescent patients, we also screen for depression and any indicators of suicidality.
The examination of the child should be chaperoned, to protect both the child and the provider. A complete examination normalizes the experience for the child, although the genital examination is more detailed than what most children have previously experienced. The examination usually involves a careful genital inspection using colposcopy for light, magnification and photographic documentation, and is not invasive. For children with acute assault with acute, significant genital trauma, the examination is usually done in the operating room with the child under anesthesia. This is not commonly needed. Most children can complete the examination with gentle encouragement. As with all patients, we consider a differential diagnosis when children are brought to us with concerns of sexual abuse. Many medical diseases and common problems affect or include the genitals, from something as simple as a non-specific vulvovaginitis caused by poor hygiene to something as dangerous as rhabdomyosarcoma or other rare cancers of the genital tract.
The vast majority of sexually abused children have normal genital examinations at the time of the medical examination- for a number of reasons. Most sexual abuse does not involve physical injury to the child. Perpetrators may gradually escalate their abuse over time, and activities such as fondling, genital contact, and vulvar coitus do not typically leave injury to the child’s body.
Because disclosure of the abuse can be delayed for weeks, months or years, genital injuries that may have previously been present have had time to heal, as mucosal tissue has excellent healing capacity. Injuries are more commonly identified in children who present to care within 72 hours of their last contact or assault, but even in the acute period, only 25% or so of patients will have injuries identified.
Some might ask why bother examining children at all if they are asymptomatic and are unlikely to have injury. There are a number of reasons to do so:
First, we don’t know which child may have an unexpected genital injury- I have had this experience on many occasions, and the identification of an injury is powerful evidence of the abuse. We don’t know which child might have a sexually transmitted infection, or STI. The medical examination may also identify other medical problems that need addressing. But the most important reason to examine victims of sexual abuse is to provide reassurance to the child and the parents when the child’s examination is normal. We often think of the examination as being therapeutic as well as evaluative.
In cases of suspected sexual abuse, we routinely screen for sexually transmitted infections, which has become so much easier with nucleic acid amplification tests. Although some children are quite symptomatic from STIs, others are not, and we are sometimes surprised that a child is diagnosed with a chlamydia or trichomonas infection. We screen for sexually transmitted infections by sending urine and/or anogenital NAATs, and in some children, we obtain RPR, or rapid plasma reagin to screen for syphilis,and HIV testing. For children with a vesicular genital rash, we obtain a sample from the base of a vesicle for HSV, or herpes simplex virus, pcr testing. Genital warts are usually diagnosed by simple clinical inspection, although biopsy might be indicated in a few cases. Some sexually transmitted infections, such as gonorrhea and chlamydia, are virtually diagnostic of sexual activity and abuse outside of the newborn period. Other STIs, such as genital HSV or genital warts, are less diagnostic, but should always raise the consideration of sexual abuse. We collect forensic evidence, commonly referred to as a Rape Kit, if the child presents for care acutely after an assault. This is usually done in the Emergency Department and is something that you should only do with the supervision and guidance of your senior resident, attending, and/or the child protection team. We also test for pregnancy for our adolescent patients and we identify pregnant teens from time to time.
Many, but not all children and parents benefit from counseling and therapy and a referral to a mental health specialist is often helpful. Medical documentation in cases of sexual abuse should include accurate details of any disclosure by the patient, including direct quotes from the child if possible. The genital examination should be carefully described, noting any abnormal findings or signs of trauma. And once again, it is important to be clear in our medical charting of our findings and medical opinions for each child.
I specifically remember the first abused patient I ever cared for. I often say that on that night, my second night of call as an intern, I was paralyzed with ignorance. I had no experience with child abuse, had not learned anything about the problem, and had no idea what to say to the child or family members. I had no idea what to do. But I was surrounded by physicians and social workers who were experienced, and they guided me as I learned how to approach these challenging cases in a compassionate and effective way. On your clerkship, if you are concerned about a patient and the possibility of abuse, please reach out to your supervisors to discuss your concerns. These evaluations always need a team approach- one that is inter-disciplinary. In most children’s hospitals, there is a child protection team of physicians, social workers and others who can assist with next steps when unexpected concerns arise during a medical visit. I hope this session provided you with some basic understanding of the evaluation when children have been abused. There are lots of great resources available for additional learning, and I’ve included some of these in the show notes. And thanks for listening to Clerkship Ready - Pediatrics. I hope you found today’s podcast helpful. Don’t forget to subscribe below and rate the podcast!
