Child Abuse: Recognition and Reporting

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

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

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

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

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

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

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

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

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

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

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

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

13. Why doctors do not report Flaherty, Sege 2005 • Physician recognition of child abuse • Lack of knowledge • Psychological barrier to recognition • Family, racial, economic factors • Barriers to reporting • Do not report all cases • Lack of training on how to report • Report will harm child • Poor experience with Child Protective Services • Poor experience with legal system • Misunderstanding of MD role

14. Age and Child Abuse

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

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

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

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

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

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

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

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

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

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

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

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

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

32. Physical Examination • Emergent care first • Complete head to toe evaluation • Must look at all skin surfaces • Remove ALL clothing • Ears, Neck, Mouth, Genitalia • Description of all skin findings

33. Physical Exam “Red Flags” • Most common indication of physical abuse • Occurs in >50% of abused children • Bruises are uncommon in infants < 6 months. • “Those who don’t cruise rarely bruise.” • Two characteristics separate abusive from accidental bruises: LOCATION PATTERN

34. Location

35. Location

41. What’s wrongwith thispicture?

42. Donut diagram

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