Navigating Suspected Child Abuse

You have just evaluated a child in the ED and are concerned for abuse. You know you must make a report, but how? And who should be involved? The process of filing a child abuse report can be daunting.

With this article we hope to provide a simple framework for the evaluation of suspected abuse, and the role of social workers, child protective services, and forensic pediatricians in cases of suspected maltreatment.

Identifying Potential Abuse
In cases of suspected abuse, the importance of a detailed history cannot be overstated. Not only will a detailed history provide you, as the clinician, with the information you need to make a proper assessment, but it will also provide you with the details necessary for filing the report and preparing documentation that may later be used in legal proceedings.

Data from the Children’s Bureau Annual Maltreatment Report revealed that in 2019, 45.4 % of child fatalities occurred in children less than 1 year of age.¹ Obtaining a history in non-verbal children, such as infants, children with special health care needs, and children with disabilities is challenging, therefore any injury should prompt the consideration of possible abuse.²

When obtaining history from a verbal child, be mindful of what information a child is capable of conveying. Children from ages 3 to 5 are unlikely to be able to chronologically order events or accurately describe the number of abuse occurrences, but it is likely that they will be able to identify an alleged perpetrator, where they were injured, and if they were injured once or multiple times.³ Children ages 6 to 11 will be able to provide more detailed answers but will struggle to give accurate dates and times of events.³ Above the age of 12, children are able to provide detailed histories with complexity. Challenges in this age group are helping the child to feel comfortable sharing with you, overcoming embarrassment, and addressing their concerns regarding consequences of disclosure.³

It is imperative to speak with a child separate from their parent, particularly if the parent may have caused injury to the child.^3,6 When talking with a child, be mindful to not ask leading or yes or no questions as children, especially younger children, are likely to guess the answer or provide information that is difficult to verify.³ When in doubt, it is safest to ask questions beginning with “who,” “what,” “when,” and “where” and allow the child to speak uninterrupted with only short interruptions for clarification (ie, “When you said ‘she hurt me,’ who is ‘she?’”).³

When speaking with the guardian of a suspected victim, it is equally important to obtain a detailed history and refrain from the use of leading questions. While obtaining this history, be mindful of red flags such as injuries not consistent with the age and development of the child, a history that is unclear or frequently changing, a denial of trauma when trauma is clearly observed, blaming the child or a sibling for injuries, and lack of acknowledgment of the seriousness of an injury.^3-6

Lastly, before making a report, obtain demographic details about the family and alleged perpetrator, as this information will be asked on your reporting documentation. This information would include such things as: names and ages of all people living in the home of the suspected victim, address, and contact information of the guardian; name, relationship, age, and address of alleged perpetrator; and presence of weapons or potentially violent animals in the home of the victim or alleged perpetrator. If there is information that you do not know, then simply state that when you are making your report. Not knowing the name or address of the alleged perpetrator is not a reason for not filing a report.

Photo Documentation
After obtaining a detailed history, it is important to begin the documentation process. One sometimes overlooked aspect of this documentation is photo evidence. As ED physicians, you are often the first to evaluate a suspected inflicted injury. This is especially important considering that many injuries will heal within days making future documentation difficult or impossible.

When taking photos, it is important to ensure that the images are clearly shown to be that of the child.^3,5,7,8 This may be done by including patient identification in each individual image or before and after an image sequence. When taking pictures be sure to take several images of each injury. A good technique is to take several perspectives (ie, overview and close-up).^3,5,7-9 If the child is moving and difficult to settle, another option is to take a video that later can be split up into still images.³ Images should be captured at a perpendicular angle from the injury.^5,7 If you have access to a ruler, such as an ABFO forensic ruler, these are great to place in the same plane of an injury for scale.^3,5,7-9 The most common errors in photo documentation are not properly focusing the camera, excessive blurring of images, and over and underexposure of the images.^3,9 Therefore, it is crucial to be mindful to keep the camera in focus, ensure proper lighting, and double-check your images after taking them to be certain that there is an adequate number of clear images. Lastly, keep in mind that most digital cameras number each image. Be careful not to delete any photos as this will be evident later on and make it appear that there are gaps in evidence.

ED Social Workers
Social Workers (SWs) provide invaluable assistance during child abuse evaluations. SWs are trained to obtain social histories and uncover details regarding social stressors and home dynamics. Many SWs also have experience working closely with Child Protective Services (CPS) and local law enforcement.

Some ways in which SWs can provide assistance are remaining with the patient and family after your initial assessment to acquire further details while you begin the workup, communicating with CPS, and updating you and the family regarding the patient’s disposition. SWs can also serve as important observers during an evaluation making note of the behaviors of the child and caretaker¹⁰ and their documentation can prove useful in the CPS investigation. Discussion of abuse is often very distressing to children and may make the child uncomfortable to discuss openly, or the parent may be unwilling to discuss the case with you in the presence of the child.³ SWs can help address this by speaking with the parents while you talk with the child. Be mindful of repetitively questioning children about what may have happened to them as children may become fatigued with repeat questions or may even feel as if you are questioning the validity of their story. Therefore, it is preferred that the physician, nurse, and social worker obtain the history together. It is most important to be mindful that your role as the physician is to address the medical concerns of the child and to not function as that of the investigator.

Child Protective Services
When making a child abuse report, you are most often reporting to your statewide hotline. After this report, the case is referred to the local children and youth agency of the city or county where the child lives. This local agency decides whether or not the case meets the state’s definition of abuse or neglect. If the case is accepted, a supervisor will be assigned to the case who will then identify a caseworker. The caseworker will work closely with you and SWs to determine patient disposition and a safety plan. A common misconception regarding CPS is that its primary function is to remove children from their homes. This may cause many medical providers to be hesitant to file a report. In reality, the role of CPS is to assess the safety of a child and other children that may be in the home and provide resources for families in need for those children who may be at risk.^11,12 The supervisor and caseworker accomplish this through scene investigation, scene reenactments, home evaluations, and interviews of family and friends. The investigation process will take place in the weeks that follow the filing of your report.¹²

Forensic Pediatrics
Many hospitals have a forensic pediatrics department specializing in child abuse and neglect, especially hospitals with pediatric residency programs. In all cases of suspicion for abuse, it is wise to alert your hospital’s forensic pediatrician regardless of whether or not you need an in-person consultation. CPS almost always prefers this consultant to be involved.

TAKE-HOME POINTS

• A common question that many practitioners ask is, “Am I seeing or being told enough to warrant filing a child abuse report?” I there is doubt as to whether or not you should file, it is likely that there is enough concern in your mind to warrant a report.
• The reporter does not need to know or have proof that abuse occurred but should have a reasonable cause to suspect abuse.
• It is better to err on the side of caution and request the intervention of CPS to conduct an investigation. A child’s life may depend on it.

References

1. US Department of Health and Human Services, Administration on Children, Youth, and Families. Child Maltreatment 2019. Washington, DC: US Government Printing Office; pg xi-xii.
2. American Academy of Pediatrics: Committee on Child Abuse and Neglect and Committee on Children With Disabilities. Assessment of maltreatment of children with disabilities. Pediatrics. 2001;108(2):508-512.
3. Jenny C. Child Abuse And Neglect. 1st ed. St. Louis: Saunders/Elsevier; 2011:39-59, 215-221.
4. Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241. doi:10.1542/peds.2007-0883
5. Letson, M.M., Tscholl, J.J. Bruises, Burns, and Other Blemishes: Diagnostic Considerations of Physical Abuse. Clin Pediatr Emerg Med. 2012;13 (3): 155-165. doi: 10.1016/j.cpem.2012.06.007
6. Hornor G. Physical abuse: Recognition and reporting. J Pediatr Health Care. 2005;19(1):4-11. doi:10.1016/j.pedhc.2004.06.009
7. Bloemen EM, Rosen T, Cline Schiroo JA, et al. Photographing Injuries in the Acute Care Setting: Development and Evaluation of a Standardized Protocol for Research, Forensics, and Clinical Practice. Acad Emerg Med. 2016;23(5):653-659. doi:10.1111/acem.12955
8. Gouse S, Karnam S, Girish HC, Murgod S. Forensic photography: Prospect through the lens. J Forensic Dent Sci. 2018;10(1):2-4. doi:10.4103/jfo.jfds_2_16
9. Verhoff MA, Kettner M, Lászik A, Ramsthaler F. Digital photo documentation of forensically relevant injuries as part of the clinical first response protocol. Dtsch Arztebl Int. 2012;109(39):638-642. doi:10.3238/arztebl.2012.0638
10. Asnes AG, Pavlovic L, Moller B, Schaeffer P, Leventhal JM. Consultation for child physical abuse: Beyond the history and physical examination. Child Abuse Negl. 2021;111:104792. doi:10.1016/j.chiabu.2020.104792
11. Fuller T, Zhang S. The Impact of Family Engagement and Child Welfare Services on Maltreatment Re-reports and Substantiated Re-reports. Child Maltreat. 2017;22(3):183-193. doi:10.1177/1077559517709996
12. Kellogg ND. Working with child protective services and law enforcement: what to expect. Pediatr Clin North Am. 2014;61(5):1037-1047. doi:10.1016/j.pcl.2014.06.013