medical aspects of child abuse evaluations
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
Medical Aspects of Medical Aspects of Child Abuse Child Abuse EvaluationsEvaluations
Nisha AbdulCader, M.D., F.A.A.P.Nisha AbdulCader, M.D., F.A.A.P.Medical Director, Suspected Abuse Response Medical Director, Suspected Abuse Response
TeamTeamPediatrician, Martha’s Place Children’s Pediatrician, Martha’s Place Children’s
Assessment CenterAssessment CenterSupervising Physician, Juvenile Service CenterSupervising Physician, Juvenile Service Center
CDC: Cost of Child Abuse CDC: Cost of Child Abuse Higher than Cost of Diabetes Higher than Cost of Diabetes
or Stroke or Stroke (Fang, Feb 2012)(Fang, Feb 2012) 2008 data suggests 579,000 to 2.8 2008 data suggests 579,000 to 2.8
million new cases of child abuse million new cases of child abuse nationally each yearnationally each year
Annual cost is between $124 and $585 Annual cost is between $124 and $585 billionbillion
Lifetime cost (low end) is $212,012Lifetime cost (low end) is $212,012 Using 2008 confirmed case data, Using 2008 confirmed case data,
study added up lifetime cost in 2010 study added up lifetime cost in 2010 dollars: health care, productivity loss, dollars: health care, productivity loss, child welfare cost, criminal justice child welfare cost, criminal justice cost, and special education costcost, and special education cost
Unable to determine: impact of Unable to determine: impact of psychosocial abuse, impact of psychosocial abuse, impact of reduced life expectancy, poor reduced life expectancy, poor quality of life, and future negative quality of life, and future negative parenting behaviorsparenting behaviors
Child Abuse must be Suspected for Evaluation…
Reliant on mandated Reliant on mandated reporters to be well reporters to be well
trained and programs trained and programs that support children to that support children to
disclose safelydisclose safely
Multidisciplinary Multidisciplinary ResponseResponse
Law enforcement and CWSLaw enforcement and CWS
MedicalMedical Mental HealthMental Health LegalLegal
SART ProgramSART Program(Suspected Abuse Response Team)(Suspected Abuse Response Team)
Child Focused ServicesChild Focused Services SART- Suspected Sexual SART- Suspected Sexual
AssaultAssault DEC- Drug Endangered ChildDEC- Drug Endangered Child SCAN- Suspected Child AbuseSCAN- Suspected Child Abuse Coroner’s SupportCoroner’s Support Part of Multi-Agency, Part of Multi-Agency,
Multidisciplinary ResponseMultidisciplinary Response
Components of Medical Components of Medical EvaluationEvaluation
Requires Specialized Requires Specialized Training and ExpertiseTraining and Expertise Identify, document, and Identify, document, and
interpret physical findingsinterpret physical findings Treat medical problems, refer as Treat medical problems, refer as
neededneeded Provide counseling referralProvide counseling referral Answer questionsAnswer questions Provide expert witness testimony (up Provide expert witness testimony (up
to date on literature and studies)to date on literature and studies)
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
Sexual Abuse:Sexual Abuse:Medical Exam Medical Exam ConsiderationsConsiderations Majority of children with a history of sexual Majority of children with a history of sexual
abuse will have a normal physical examabuse will have a normal physical exam Injuries heal often without abnormalitiesInjuries heal often without abnormalities Many physical findings are normal variantsMany physical findings are normal variants Many conditions mimic abuseMany conditions mimic abuse Genital injuries in boys more often related Genital injuries in boys more often related
to physical abuseto physical abuse Increasing information and studies for most Increasing information and studies for most
current interpretationcurrent interpretation
Genital Exam of ChildGenital Exam of Child
Acute vs. Non-Acute evaluationsAcute vs. Non-Acute evaluations Not invasive, not painfulNot invasive, not painful No stirrups/speculum/Pap smearNo stirrups/speculum/Pap smear Flexibility of exam order and Flexibility of exam order and
locationlocation Supportive caregiverSupportive caregiver Findings discussed after examFindings discussed after exam
Drug Endangered Drug Endangered ChildrenChildren
Toxic exposure from processingToxic exposure from processing Toxic exposure from useToxic exposure from use Sales and use environmentSales and use environment
High level of violenceHigh level of violence NeglectNeglect Physical abusePhysical abuse Sexual abuseSexual abuse
Medical DEC ProtocolsSymptomatic –Immediate 1. 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.
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 evaluation5. 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
Evaluation of Injuries
Historical Information Pain Tenderness Skin Findings Re-creation of Event
Physics of Trauma
Soft Tissue Injury
“If they don’t cruise, they don’t bruise.”
Location of Injury:Toddler and Child
Pattern of Injury
Physics of Trauma
Skeletal trauma
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
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?