Clinical Evaluation for Possible Child Abuse

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chapter 21 Clinical Evaluation for Possible Child Abuse

Steven Bellemare

Be gentle with the young.

JUVENAL 55 AD–127 AD

Child maltreatment is common but often unrecognized in pediatric practice. Though larger centers typically benefit from having a hospital-based child protection team, smaller communities rely on community physicians to assess children suspected of having been abused. This chapter outlines examination and documentation techniques to help you perform a competent assessment of a child who may have been abused.

The goal of this chapter is not to help you determine the significance of injuries in children, and it is not to provide an in-depth review of forensic issues. When in doubt about the significance of a finding, it is always best to consult a colleague experienced in the field of child abuse.

Because the issues vary greatly based on whether you are being asked to see a child for sexual abuse, physical abuse, or neglect, this chapter will first present general principles and revisit each section of the assessment individually, with emphasis on sexual abuse, physical abuse, and neglect.

Mandated Reporting

First and foremost, recognize your duty to report all cases of suspected maltreatment. Become familiar with your local child protection laws, and understand your professional duty in relation to those laws.

Although legislation varies from state to state and province to province, the United States and all Canadian jurisdictions have legislation mandating that suspected child maltreatment be reported to a child welfare authority or other body, or both, as dictated by local legislation. (For simplicity, child welfare authority will be used in this chapter to encompass any body to which you are mandated to report.) Definitions of child and of reportable circumstances vary. In some jurisdictions, health professionals are held to a higher standard of duty than lay persons, and the failure of health professionals to report suspicions of maltreatment can lead to fines, charges, or even imprisonment.

Topics typically addressed by child welfare legislation usually include:

• Physical abuse

• Sexual abuse

• Emotional abuse

• Exposure to domestic violence

• Exposure to drugs

Not all jurisdictions recognize all of these categories, hence the need to be familiar with local laws.

When children make a disclosure, they rarely lie about abuse. Although a few may try to manipulate others by making false allegations, it is not your role to judge the facts being presented. Believe children when they make disclosures, and act accordingly.

If a child discloses abuse to you, it is a sign of trust. One of the most therapeutic interventions you can undertake is to believe the child, be nonjudgmental, and ensure the child’s safety by reporting your concerns to a child welfare authority. To help that agency determine its course of action, ask about the relationship of the alleged perpetrator to the victim, and find out what access he or she currently has to the victim or to other children.

When a child discloses abuse, believe the child.

Sometimes when parents or caregivers report a suspicion of abuse, they may be unwilling to contact the appropriate authorities to report their concern. They may give many reasons for their refusal, but once you believe a child is in need of protection, you are mandated to report your concerns, regardless of patient confidentiality or parent/patient wishes about confidentiality. Sometimes, older children/youth may disclose abuse to you but ask you not to report it. Again, your duty is to report the concerns, despite the request. Explain the reasons behind your duty to report, and explain to the child that you are making the concerns known to help the child. Find out why the child does not want you to report and address these concerns. For example, a patient may feel that reporting the abuse may be risking harm upon the return home. In such cases, your report to the agency should address this concern, and a plan should be put in place to ensure the child’s safety after your report.

Because it is important to maintain a relationship of trust with older patients, make sure they understand early in your clinical meeting the limits of patient-doctor confidentiality. Make them aware that any disclosure of harm or potential harm by someone else can mandate a report of suspected maltreatment.

The limits of confidentiality should always be explained to any older child or youth, so as to avoid harming the patient-doctor therapeutic alliance should a disclosure of abuse be made.

If you’re unsure about whether a situation is reportable, call your local child welfare authority. You can present the scenario anonymously and ask whether or not the situation is reportable.

Sometimes families raise concerns of maltreatment, which may not, in your view, be well founded. Unfortunately, such situations often occur repeatedly when disputes over custody and access arise in the course of a parental separation. Although you may be tempted to distance yourself from such difficult situations, you must always act in the best interest of the child and facilitate a report of suspected abuse if the parent seeks help.

Even though you may feel that you are being asked to take sides in a parental dispute, remember, you are not a mediator, investigator, counselor, or arbiter. Your role is simply to identify and report suspected child maltreatment and to ensure the family is supported during this time. Others will determine whether the concerns are well founded. If, after listening to a parent’s concern and examining the child, you are unable to rule out abuse, it is best to make sure that a child welfare agency is made aware of your concerns. If your assessment does not support an abusive situation, and you have no concerns about abuse, you can still be helpful to the family by offering to help support the concerned parent in his or her reporting of the situation. Provide the parent with the telephone number to the local child welfare authority and offer to refer the family to a professional who can help them cope.

Unless a child is referred to you for examination by a child welfare agency, never assume that another party (i.e., a parent, teacher, or police officer) has already reported the situation. You cannot discharge your duty to report by assuming that someone else has already reported similar concerns.

If you have a reasonable suspicion that a child is in need of protection, it is your duty to report your concerns, regardless of whether the alleged event has already been reported by someone else.

Preparing for the Assessment

Preparing the patient and the family

Just as you will need to prepare yourself for the assessment, make sure that the child and family are also prepared for their visit with you. Knowing that a physical examination has been scheduled can be very difficult for a child and his or her family. Often, patients and parents do not know what to expect, as they have simply been required by child welfare officials to present to the clinic for an examination, without further information as to the reasons behind the assessment. In cases of sexual abuse of young girls, the parents may expect an internal gynecologic examination of their young daughter, which may raise anxiety levels tremendously. As well, they may have unrealistic expectations of what a medical examination can achieve. Take time to chat with them when scheduling the appointment, to explain your role, why an examination has been requested, and what can reasonably be expected as an outcome. Preparing the child and parents for the examination is likely to decrease the amount of stress and anxiety everyone feels.

The First Few Moments of the Meeting

As part of the informed consent process, advise caregivers that your notes, photographs, and any reports generated as part of your assessment are likely to be requested or subpoenaed by the involved child welfare agency. If a caregiver refuses any of the above aspects, you must respect his or her choice. If you believe that your assessment is incomplete because of, for example, a parent’s refusal to have blood work performed, report such information to the involved child welfare agency as part of your concern about the child’s safety. They may be able to intervene and find a way to ensure that a complete assessment is done.

Not all caregivers are comfortable discussing their concerns in front of their children. Conversely, some are too eager to talk and may voice concerns inappropriately in front of their young children. For this reason, a colleague such as a nurse or social worker should ideally be available to stay and build rapport with the child while you document the history. This serves three purposes: It prepares the child for the examination and helps ease tension while allowing parents to speak more freely about their concerns. While awaiting the examination, the nurse or social worker can also familiarize the child with the process by discussing it, looking at medical instruments, and showing diagrams of the various positions the child may be asked to assume during the exam. They can also stay during the child’s examination, should the child and family allow it, and ease the transition from play to examination.

First do no harm. Even though a child welfare agency may have requested an assessment, if the caregiver remains the legal guardian of the child, he or she can refuse any part of the assessment. Never force or coerce a family into agreeing to an assessment that they do not want for their child.

Obtaining the History

Child protection cases often make for difficult history-taking. Communicating with potentially abusive or neglectful parents may be one of the most difficult tasks you will undertake. You may feel angry, frustrated, or may lack empathy for “people who do such things to their children.” But remember, you are seeing only part of the picture, and that there often is more to the situation than meets the eye. Communication with abusive or neglectful parents may be very difficult, for various reasons. But once you break through the surface, you may discover that they are not the terrible people you may have imagined. In fact, they are often desperate people with poor coping skills and resources.

Our traditional teaching emphasizes that we should always believe caregivers because they know their child so well. This is not always the case in suspected child abuse, where caregivers commonly fabricate, amplify, alter or omit details—a critical issue when you want to provide an objective assessment.

Parents or caregivers may have hidden agendas—for example, custody and access battles, secondary financial gain, or mental illness that can lead to false histories. In addition, although you may be unaware of it, the historian on whom you are relying for information may, in fact, turn out to be the perpetrator and may therefore fabricate a history to conceal the nature of the injuries he or she has caused. In pediatric condition falsification (usually seen as part of Munchausen syndrome by proxy), caregivers may induce or fabricate symptoms to intentionally mislead you. Although it is difficult and counterintuitive to do, remember that the historian may be lying—sometimes quite convincingly.

Caregivers may falsify histories, sometimes quite convincingly, in cases of suspected abuse.

The history may be provided by the patient, a parent, a caregiver, a child protection worker, or some combination. While some children prefer to have a parent or caregiver present during history taking, others may prefer to be alone with you. Always give the older child or youth a choice of who will be present during the interview. Remember, situations may arise which are not conducive to the child being open and comfortable during the interview. For instance, the adult accompanying the child for examination may be the perpetrator of the abuse or may choose to protect the alleged perpetrator and, therefore, not be supportive of the child.

Do not assume that the child’s parent(s) or accompanying adult is the best person to be present with the child during a history-taking process.

At times, especially in cases of injuries, the person alleged to have been present at the time of injury may not be present during the assessment. Make reasonable efforts to obtain the information from direct witnesses and to avoid obtaining potentially invalid or partially correct information from people providing it on a third-hand basis. Making telephone calls or inviting the person who was there when the events occurred to attend the assessment are two ways through which you can exercise due diligence, as long as you have the child’s guardian’s permission to do so.

An alleged perpetrator may decline your invitation to talk, especially if he or she has been advised by a lawyer not to discuss the case with anyone. Although it is not ideal, if you believe that a third party to whom you do not have access is likely to have information that could be useful to your assessment, you can ask the involved child welfare worker to ask some questions for you. Provide a list of your questions, so that the child welfare worker can address them while interviewing the involved person. The information can then be relayed back to you for assessment.

Abuse investigators are very concerned about the validity of disclosures. Ideally they do not want anyone to speak to children about the abuse allegations before a professional forensic interviewer does so. This helps ensure that the child does not become confused and that no one has an opportunity to coach or be seen as possibly having coached a child to make statements that might otherwise not have been made. Deferring an examination until after the child has been interviewed by professionals will prevent someone from later claiming that elements of the patient’s disclosure were introduced or modified by the medical history or physical examination. Exceptions can be made to this rule of thumb, depending on the situation. When symptoms are present or when there is a high likelihood of pregnancy or sexually transmitted infection (STI), the examination should be done more urgently, even if the child has not been interviewed by forensic interviewers. Calling the involved child welfare authority and explaining the urgency can help expedite the interview and allow for prompt medical care. Inability to schedule a timely interview should not detract from your duty to provide prompt medically-indicated care.

Formulating questions

At the time of your examination, especially when the child has not yet been formally interviewed by a forensic interviewer, use open-ended questions only. Avoid making references to possible mechanisms of injury or perpetrators. If you ask only the questions required for medical care, you will avoid the trap of asking what could be misconstrued as leading questions. Although it feels natural to do so, you must remember that your role is to treat injuries and document them, not to investigate the details and circumstances of their occurrence. It takes practice to use such non-leading questioning and if you can’t get good information, don’t worry. Focus on identifying and treating injuries. Someone else, namely the forensic interviewer, will get historical details from the child at a later time.

It is not your role to investigate the circumstances surrounding a child’s injuries.

If a child makes a spontaneous disclosure during your assessment, document the context in which this occurred. Record both your own and the child’s statements, verbatim. This will minimize any future dispute over the validity of the history. For instance, such documentation could take the following form:

After lowering Daniel’s pull-up to feel his pulses, I said, “I can feel your heart there!” He immediately replied, touching his penis, “Susan hit me on there.” I replied, “Really?” Daniel responded “Hmm hmm, with the spoon.” I then asked, “What spoon?” Daniel answered, “The wood one for when I pee my pants.” Daniel stated this matter of factly, and then proceeded to ask me what my otoscope was for.

The timely, verbatim documentation of conversations and their context has invaluable credibility. In this example, without knowing any details of the case, anyone will realize that the disclosure was not sought out or coerced and that it came about spontaneously during the physical examination. Besides, given that even the most vivid memories fade, such documentation will be invaluable a few years later, in case you need to attend legal proceedings about the case.

Physical Examination

Details of the physical examination for each situation will be covered individually in the Examination for Sexual Abuse and Physical Abuse and Neglect sections of this chapter.

Documentation

For all situations, however, to document physical examination findings accurately, the following equipment is useful:

1. A camera capable of taking good-quality close-up pictures (see notes on photography)

2. A good light source or flash

3. A ruler, preferably one approved by the American Board of Forensic Odontologists (ABFO) (Fig. 21–1). These display a circle upon their surface, to allow for adequate assessment of picture distortion as a result of the angle at which the picture was taken. Alternatively, you can use a measuring tape.

4. A color chart (Fig. 21–2) to allow for assessment of the color quality of the image. (See the color version on Student Consult).

5. A detailed body map showing anterior, posterior, medial, and lateral surfaces of all areas of the body (Fig. 21–3 and a full-page version on Student Consult).

FIGURE 21–1 ABFO ruler.

FIGURE 21–2 Color chart (a color version of this figure can be seen on Student Consult).

FIGURE 21–3 A sample body map.

(Modified from http://www.pain-initiative.com/e1833/e5688/e5887/diagram_eng.gif)

Careful documentation of the findings on a body map is required. A body map, accompanied by a careful written description and photographs, is the most efficient and accurate way to document injury shapes and locations and is much more convenient to use. Include notes on the color, size, and shape of the lesions and their overall appearance and pattern.

Obtaining Pertinent History

The Student Consult Web site offers an important section on the triage of referrals, the need for a physical examination, and issues to consider in the scheduling of an assessment.

Formulating questions for history of present illness

For several reasons, many families do not use proper terminology for genitalia with their children. This can lead to misunderstandings. Therefore, you must find out whether the child uses special terms to describe their genitalia (e.g., “bird,” “flower,” “wiener”). You can ask a parent or caregiver at an appropriate time in the history process. If however, the child is not accompanied by someone who would know such details, you can ask the child. Never assume a child knows the proper terminology to describe their genitalia and, similarly, do not assume that you know what the child means when he or she makes a statement such as “He touched my noonoo.” Whereas going along with a child or parent’s euphemism for genitalia may be reasonable in a routine office visit, it is not acceptable when child abuse is suspected. There must be no confusion about what is being discussed. If you encounter a vague euphemism, ask the child to clarify it. Your conversation can be as follows:

Child:	“He hurt my noonoo.”
Physician:	“Hmmm, I’m not sure I know exactly what you mean when you say noonoo, do you know another word for it?”
Child:	“You know, my privates!”
Physician:	“Oh, I see. Just to be sure I’m thinking of the right privates, “Can you show me where your noonoo is?”
Child:	“There, silly!”

If a child protection agency has already interviewed the child, you should be able to obtain a relevant history to guide the physical examination from the child protection worker or the child’s parent or caregiver. When this is not possible, be very careful about how you ask questions to a child, so as not to be perceived to have led the child to disclose what he or she said. Take scrupulous notes. The following conversation illustrates an inappropriate questioning technique. The doctor is leading the child to make statements that might otherwise not have been made:

Child:	“He put his stick in my bird.”
Physician:	“Do you mean his penis?”
Child:	“Yes.”
Physician:	“Is your bird your vagina?”
Child:	“Uh-huh”
Physician:	“Did it hurt?”
Child:	“Yeah.”
Physician:	“Did he put it in your mouth?”
Child:	“Yes.”
Physician:	“How about your bum?”

A better way is simply to indicate your willingness to hear more. Do your best not to look or sound shocked or distressed; it may discourage the child from telling you more. Just be interested in what the child has to say. A child who is ready and willing to disclose will give you information without your needing to ask many questions. The following example illustrates a better way to encourage the child to talk more:

Child:	“He put his stick in my mouth.”
Physician:	“In your mouth?”
Child:	“Yeah and sometimes my bird too.”
Physician:	“Hmmm. What’s that like?”
Child:	“Kinda funny ’cause it gets all big and it stands up.”
Physician:	“And how does that feel when that happens?”
Child:	“Goodish badish.”
Physician:	“Really… anything else?”
Child:	“Kinda wet and goopy too.”
Physician:	“I see…”
Child:	“But that’s okay—we use Kleenex on the night table to clean up.”

Though the child’s disclosure is not clear (we don’t know what the stick or the bird are), you have enough information to suspect inappropriate sexual contact with ejaculation. Without having led the child, there is now enough reason to consider testing for STIs and to look for sequelae of penetrating genital trauma. If you have not already done so, or if you have not succeeded in doing so, clarification of the terms stick and bird will be done by child welfare workers when they interview the child.

Remember, young children often use terminology to which they can relate to describe acts that are developmentally beyond their understanding and for which they lack the proper terminology. A 6-year-old child who discloses that his cousin “peed in (his) mouth” may in fact be describing ejaculation. At this age, peeing may be the only function a boy knows for a penis. Not knowing how to describe semen, the child may use the word pee because it represents the only experiential knowledge he possesses for a liquid substance coming from a penis. It is important to realize that the child is not lying about what happened but rather is explaining it, in his own words. Your knowledge of child development can be most important in explaining this concept to investigators who may have no experience with young children or knowledge of child development.

Past medical history

To fully assess all possibilities, review any history of genital trauma (such as straddle injuries or past surgeries) that may have caused injuries or left scars, which you may identify during the examination. As well, find out about the patient’s pubertal development, noting age at thelarche and menarche, date of the last menstrual period, past sexual activity (whether or not it was consensual), use of birth control methods and contraception, and the type of feminine hygiene products used (pads versus tampons), as appropriate.

Functional inquiry

As with all other conditions, a differential diagnosis must be considered. Anal fissures and perianal pain or bleeding may be secondary to constipation. Similarly, vulvovaginitis can lead to vulvar redness, pain, discharge, and odor. Pinworms may cause itching and discomfort. All of these symptoms could be misconstrued as symptoms of sexual abuse, and you can play a vital role in identifying a condition that mimics abuse.

Family and social history

Take a moment to find out about prior abuse in the family. Ask about domestic violence and determine how supportive the family environment is. Ask specifically whether the parent(s) have their own history of sexual abuse and how they have dealt with it. This information will be extremely informative and may well predict the ability of the child’s caregivers to be supportive and protective in the future. A parent who has not dealt with or denies his or her own abuse may not be able to support the child’s healing or will likely need significant counseling services to do so. Such information will be critical with child welfare workers and will help them make placement decisions.

Physical Examination

Many children referred for evaluation of possible abuse are, understandably, reluctant to be examined. This is particularly true in the case of older female sexual abuse victims who may be asked to undergo an examination by a male physician.

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