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Medical Aspects of Child Abuse Evaluations

Medical Aspects of Child Abuse Evaluations. Nisha AbdulCader, M.D., F.A.A.P. Medical Director, Suspected Abuse Response Team Pediatrician, Martha’s Place Children’s Assessment Center Supervising Physician, Juvenile Service Center.

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Medical Aspects of Child Abuse Evaluations

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  1. Medical Aspects of Child Abuse Evaluations Nisha AbdulCader, M.D., F.A.A.P. Medical Director, Suspected Abuse Response Team Pediatrician, Martha’s Place Children’s Assessment Center Supervising Physician, Juvenile Service Center

  2. CDC: Cost of Child Abuse Higher than Cost of Diabetes or Stroke (Fang, Feb 2012) • 2008 data suggests 579,000 to 2.8 million new cases of child abuse nationally each year • Annual cost is between $124 and $585 billion • Lifetime cost (low end) is $212,012 • Using 2008 confirmed case data, study added up lifetime cost in 2010 dollars: health care, productivity loss, child welfare cost, criminal justice cost, and special education cost • Unable to determine: impact of psychosocial abuse, impact of reduced life expectancy, poor quality of life, and future negative parenting behaviors

  3. Child Abuse must be Suspected for Evaluation…Reliant on mandated reporters to be well trained and programs that support children to disclose safely

  4. Multidisciplinary Response • Law enforcement and CWS • Medical • Mental Health • Legal

  5. SART Program(Suspected Abuse Response Team)Child Focused Services SART- Suspected Sexual Assault DEC- Drug Endangered Child SCAN- Suspected Child Abuse Coroner’s Support Part of Multi-Agency, Multidisciplinary Response

  6. Components of Medical EvaluationRequires Specialized Training and Expertise • Identify, document, and interpret physical findings • Treat medical problems, refer as needed • Provide counseling referral • Answer questions • Provide expert witness testimony (up to date on literature and studies)

  7. Medical Evaluation: SCAN • Physical exam • Complete exam • Vital signs • Growth chart • Dental • Document and evaluate any injuries • Location, size, type • Tenderness. Loss of function • Pattern (bruise, bite, burn) • Laboratory Studies • Blood Studies • Urinalysis/Urine toxicology • Imaging studies • Skeletal survey • Under two years of age • CT/MRI

  8. Sexual Abuse:Medical Exam Considerations • Majority of children with a history of sexual abuse will have a normal physical exam • Injuries heal often without abnormalities • Many physical findings are normal variants • Many conditions mimic abuse • Genital injuries in boys more often related to physical abuse • Increasing information and studies for most current interpretation

  9. Genital Exam of Child • Acute vs. Non-Acute evaluations • Not invasive, not painful • No stirrups/speculum/Pap smear • Flexibility of exam order and location • Supportive caregiver • Findings discussed after exam

  10. Drug Endangered Children • Toxic exposure from processing • Toxic exposure from use • Sales and use environment • High level of violence • Neglect • Physical abuse • Sexual abuse

  11. Medical DEC Protocols Symptomatic –Immediate Head to toe exam within 2 to 4 hours to ensure medical stability and document any acute findings that might need treatment or change over time 2. Collect urine for toxicology. This should happen as soon as possible but must occur within 12 hours * for optimal results. 3. Blood tests. Can be done acutely or within 24 to 72 hours: a CBC (anemia, cancers, thrombocytopenias), Chemistry Panel (BUN/Cr and LFT’s ), Hepatitis B and C panels.

  12. Medical DEC Protocols Asymptomatic -Within 24 to 72 hours 1. A complete medical evaluation. 2. If seen within 12 hours*, collect urine for toxicology 3. Blood tests as above 4. Developmental evaluation 5. Mental health evaluation. 6. Dental evaluation. Follow-Up 1. Repeat medical evaluation in 30 days, 6 mos & 1 year 2. Follow up developmental evaluations as needed 3. Follow up mental health interventions and assessments

  13. Evaluation of Injuries • Historical Information • Pain • Tenderness • Skin Findings • Re-creation of Event

  14. Physics of Trauma Soft Tissue Injury “If they don’t cruise, they don’t bruise.”

  15. Location of Injury:Toddler and Child

  16. Pattern of Injury

  17. Physics of Trauma Skeletal trauma

  18. Summary of Child Abuse Emergencies Physical abuse of a child less than 2 years Significant injury without explanation Abdominal injury Head injury Circumferential, deep, or extensive burn Sexual assault less than 72 hours Risks associated with Domestic Violence

  19. Ask Yourself… Is the injury typical? Is it developmentally appropriate? Is the location typical? Is there a pattern? Is there a history given? Is the history plausible? Is the child in a high-risk environment? Am I still concerned about this child?

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