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Child Abuse Evaluation & Treatment for Medical Providers Textbook

Introduction

• About this Revised Edition
• Acknowledgments
  • The Authors
  • Collaborative Support
  • Project Management and Sustained Support
  • Grant Support

Child Sexual Abuse Triage

• Suspected Sexual Abuse Overview
  • Local Child Abuse Resources
  • Child Abuse Medical Providers
  • Principles of Triage in Child/Adolescent Sexual Abuse Cases
  • Indications for a Medical Evaluation for Sexual Abuse
• Triage Steps
  • Step 1. Gather and Document Pertinent Information
  • Step 2.  Determine the Safety and Welfare of the Child/Adolescent Is this child/adolescent safe?
  • Step 3. Determine Who Should Examine the Child/Adolescent and When
  • Step 4. Determine if You are Mandated to Report this Situation
• Appropriate Level of Care
  • Emergent Evaluation
  • Urgent Evaluation
  • Evaluation Scheduled for a Later Date
• Referral to a Child Abuse Expert
  • Making a Referral to a CAC
  • The Thought Process When Considering a Referral
  • Making a Referral to a Child Abuse Expert
  • Suggested Communication to the Child Abuse Expert
  • Additional Considerations for Hospitals
  • Additional Considerations for CACs
• References and Resources
  • References
  • Resources

History

• History Fundamentals
  • Building Rapport
  • Taking a history from the non-offending parent/caregiver without the child/adolescent present 
  • Taking a history directly from the child/adolescent 
• Communication Challenges
  • Cultural
  • Asking Appropriate Questions
• Taking a History from the Parent/Caregiver
  • The Social History
  • The Medical History
  • Understanding the Uncooperative, Non-Offending Parent
• Taking the History from the Child/Adolescent
  • If the Parent/Caregiver Must Be Present
  • Questioning the Child/Adolescent
  • Ending the History Taking
  • If No History Is Given
• Responding to the Disclosure of Abuse
• References and Resources
  • References
  • Resources

Physical Examination

• Considerations
  • Telemedicine for child abuse evaluations
  • Consent and assent
  • Personnel During the Examination
  • Preparing the child/adolescent for the examination
  • Sedation and Anesthesia 
• The General Physical Examination
  • General Examination Outline
• The Perineum and Genital Examinations
  • Using a Colposcope
  • Positioning
  • Inspection/Palpation of the Genitalia
  • Female Genital Examination
  • Male Genital Examination
  • Anal/Rectal Examination
• Evidence Collection
  • Preparation
  • Consent
  • Preserving the Integrity of Evidence
  • Swabs
  • Bite Mark Evidence Collection
  • Evaluating for Drug Facilitated Sexual Assault
  • Release of Evidence
• Reassuring the Child/Adolescent and Parent/Caregiver
• References and Resources
  • References
  • Resources

Laboratory

• Testing for Sexually Transmitted Infections in Children and Adolescents
  • Symptoms of STIs 
  • Recommended Tests
  • Who Should Be Tested
  • Collecting Specimens
  • Diagnostic Testing
  • Human Immunodeficiency Virus (HIV)
  • Follow-up for an Acute Assault
• Testing for Pregnancy
• Toxicology Testing
  • Drug Facilitated Sexual Assault (DFSA)
• Evaluation for Suspected Physical Injuries
  • Evaluation for a Bleeding Disorder
  • Evaluation for Visceral Injury 
  • Evaluation for Skeletal Injuries 
• Failure to Thrive
• References and Resources
  • References
  • Resources

Radiology

• Recommended Radiological Studies Overview
• Abusive Head Trauma
  • Skull Fractures
  • Intracranial Injury
  • Intracranial Manifestations of Trauma
  • Magnetic Resonance Imaging (MRI) versus Computed Tomography (CT) for Evaluation of Intracranial Injuries
• Extremity Fractures and Skeletal Survey
  • Diaphyseal Fractures
  • Skeletal Survey
  • Complete Skeletal Survey Imaging
  • Cervical Spine Concerns
  • Specificity of Fractures for Abuse
• Thoracic Trauma Imaging
  • Skeletal Trauma
  • Spinal Injuries
  • Rib Fractures
  • Intrathoracic Trauma
• Abdominal Trauma Imaging
• Radiologic Evaluation of Siblings and Other Contact Children
• Imaging in Other Maltreatment Situations
• References and Resources
  • References
  • Additional Reading
  • Resources

Diagnosis

• Sexual Abuse
  • The Normal Examination
  • Interpretation of Genital Findings
  • Genital Bleeding
  • Spermatozoa
  • Sexually Transmitted Infections
• Physical Abuse
  • Findings Suggestive of Physical Abuse
  • Culture-Based Practices that May Be Interpreted as Abuse
  • Female Circumcision or Female Genital Mutilation
  • Bruises
• Neglect
• Emotional and Psychological Abuse
• References and Resources
  • References
  • Resources

Treatment and Follow-up

• Sexual Abuse
  • Treatment of Injuries
  • STI Prophylaxis/Empiric Treatment
    • Presumptive Antibiotics
    • Treatment Of Viruses
  • STI Treatment
  • Reporting to the State Central Register
  • New York State Communicable Diseases Reporting Requirements
  • Pregnancy Prevention
  • Follow-Up Care After Acute Sexual Assault in Children and Adolescents
    • Emotional and Psychological Support
    • Settings for Ongoing Follow-Up Care
• Physical Abuse
  • Hospitalization
  • Head Injury Treatment
  • Burn Treatment
  • Treatment of Bruises and Fractures
  • Excessive Corporal Punishment
  • Follow-Up of Physical Abuse
  • Support for Families and Caregivers
  • Prevention of Recurrence
  • Advocacy and Collaboration
• Child Neglect
  • Management of Child Neglect
• Emotional Abuse
• Siblings, Other Family Members, and At-Risk Contact Children
  • Risk Factors
  • Medical Evaluation
• Communicating with Non-Offending Caregivers After Suspected Abuse
  • Goals and Best Practices
  • Handling Sensitive Conversations
• Trauma Informed Care
  • Trauma Informed Guidelines
• References and Resources
  • References
  • Resources

Documentation

• Documenting the History
  • Documenting the Social History
• Documenting the Findings
  • Documenting the Physical Examination
  • Documenting Laboratory Results and Imaging 
• Documenting the Diagnosis
  • Suggested Wording for Documentation of a Diagnosis 
• Documenting Other Information
• Photographic Documentation
  • Reasons for Photo Documentation of Evidence
  • Photographic Equipment
  • Digital Photography
  • Consent and Cooperation
  • Release of Photographs
  • Taking Good Photographs
• Coding for Billing
• References and Resources
  • References
  • Resources

Reporting

• When to Report
  • Definitions of Abuse
  • Need to Report Cause of Death
• How to Make a Report
  • How to Make a Report in a Hospital Setting 
  • If the Report Is Not Accepted 
• Confidentiality and Disclosure of Information
  • To Whom Information Is Disclosed 
  • Limits of Privileged Information 
  • Confidentiality of Source and Report
• Liability
  • Immunity from Liability and Penalties for Failure to Report and False Reporting  
• References and Resources
  • References
  • Resources

Children and Adolescents with Disabilities

• Myths
• Risk Factors
• Responding to Abuse
• References and Resources
  • References
  • Resources

Sexual and Sexualized Behavior in Children

• Overview
  • Key Concept
  • Childhood Sexual Development: Normative, Cautionary or Problematic Behavior?
  • Physician’s roles:
    • When a parent/caregiver reports problematic sexualized behaviors
    • When offering anticipatory guidance to help parents/caregivers understand and promote healthy sexual development
    • When a family believes sexual abuse may have occurred
    • When a family believes their child or teen may be sexually attracted to children
• Risky Behaviors in Relationships
  • Beyond pedophilia
    • Adult perpetrators
    • Peer-to-peer abuse
  • Risky Behaviors Online
    • Exposure to Pornography
    • Sextortion
• Sexual Behaviors That Can Lead to Legal Problems
  • Creating and sharing sexual images
  • Sexual interaction with a younger partner
• References and Resources
  • References
  • Additional Articles and Resources
  • Organizations
  • To Share with Parents

Foster Care

• The Foster Care System
  • The History of Foster Care
  • Consent and Legal Considerations
  • The Medical Home Model for Foster Children
• Health Concerns of Children in Foster Care
  • Common Medical and Psychosocial Concerns
  • Medical Evaluation Guidelines
  • Ongoing Care
• Supporting Child Health
  • The Role of Foster Parents
  • Kinship Care
  • The Role of Caseworkers
  • Questions for Caseworkers and Foster Parents
• Supporting Reunification and Transition Care
  • Including Biological Parents in Visits
  • Discharge and Reunification Planning
• References and Resources
  • References
  • Resources

Interdisciplinary and Multidisciplinary Teams

• Roles of Key Medical Professionals
• Multidisciplinary and Interdisciplinary Teams
  • Multidisciplinary Teams
  • Interdisciplinary Teams
  • Interagency Agreements
• Child Advocacy Centers (CACs)
• Case Reviews
• References and Resources
  • References
  • Resources

Legal Issues

• Consent by Mature or Emancipated Minors
  • Emancipated Minors
  • Mature Minors
  • Emergency Situations
• Protective Custody
  • Who Takes Protective Custody in New York State
  • Consent to Treat
  • Notification
• Release of Medical Records
• Confidential and Privileged Communication
• Subpoenas
• The Judicial System
  • Criminal Court
  • Family Court
  • Civil Court
• Testifying as a Fact Witness
  • Hearsay Evidence
  • Statements for Purpose of Medical Diagnosis and Treatment

  • Excited Utterance or Spontaneous Disclosure
• Testifying as an Expert
  • Qualifications of an Expert Witness
  • Purpose and Scope of Expert Testimony
  • Forms of Expert Testimony
  • Preparing to Go to Court
• References and Resources

Appendices

• Appendix A
  • A Sample Continuum of Medical History Questions
• Appendix B
  • Burn Assessment Rule of Nines for a Child
  • Burn Assessment Rule of Nines for an Infant
• Appendix C
  • Common Types of Diaphyseal Fractures Seen in Childhood
• Appendix D
  • Findings That May Be Confused with Abuse
• Appendix E
  • Differential Diagnosis Table
• Appendix F
  • TEN-4-FACESp - Bruising Clinical Decision Rule for Children <4 Years of Age
• Appendix G
  • List of New York State Community Services

Directory of Child Abuse Agencies and Organizations

Full Reference List

Full Resource List

Curbside Consults

Abusive Head Trauma

Vincent J. Palusci, MD, MS

Introduction Page
Cover Slide

Presentation

• Objectives
• Definitions
• Introduction to Abusive Head Trauma (AHT)
• Abusive Head Trauma (AHT)
• Mechanism of Injury
• Preventing AHT
• Case
• Physical Exam
• Evaluation
• Neuroimaging
• Retinal Findings
• Post-Mortem Case
• Additional Medical History
• Reporting to Authorities
• Specific Reasons for Reporting 
this Case
• Non-Accidental Trauma Work-up
• Potential Biases
• Data
• Mimics
• Myths
• Additional Information (Investigative)
• Case Documentation
• Curbside Key Points

References

Physical Abuse and Neglect in Childhood Burns

Heather Ross, MD

Introduction Page
Cover Slide

Presentation

• Objectives
• Types of Pediatric Burns
• Epidemiology
• Case
• Case Physical Exam
• Case Physical Exam
• Scald Burns Time/Temperature Graph
• Rule of Nines
• Red Flags vs Normal
• Is this Neglect?
• Case Management
• Medical Photography Tips
• Reporting to Authorities
• Specific Reasons for Reporting This Case
• Immersion Scald Burn: Non-Accidental Trauma
• Non-Accidental Trauma Work-up
• Scene Investigation
• Concerns for Non-Accidental Scald Burns/Burns Due to Neglect
• Potential Biases
• Key Points
• Special

References

Evaluating for Abuse in a Child with a Disability


Lori Legano, M.D.

Introduction Page
Cover Slide

Presentation

• Objectives
• Background: Children with Disability
• Case
• Children With Disabilities Are at Increased Risk of Child Maltreatment
• Potential Reasons for Increased Risk of Abuse in Children With Disabilities
• Potential Reasons for Increased Risk of Abuse in Children With Disabilities
• Risk of Sexual Abuse in 
Children with Disabilities (CWD)
• Sexual Assault in Adolescents with a Disability
• Factors to Consider in Diagnosing Child Abuse in Children with Disabilities
• Case History
• Preparing to See the Patient
• Case
• Case - The Exam
• The Genital Exam
• The Exam
• Photographic Documentation
• Summary

References

Femoral Fractures in Infants and Young Children – When Should Abuse Be Considered?

Jamie Hoffman-Rosenfeld, MD

Introduction Page
Cover Slide

Presentation

• Objectives
• Skeletal Injury Facts
• Abuse is the second leading cause of fractures in children < 36 months
• Other Diagnoses for Fractures
• Epidemiology of femur fractures
• Research on femur fractures
• Fracture Morphology
• Fracture Morphology
• Fracture Morphology
• Fracture Morphology
• Fracture Morphology
• Fracture Morphology
• Case
• Case: Spiral Femoral shaft fracture in a two-year-old
• The History and Physical Exam to Support an Accurate Diagnosis of Skeletal Abuse  
• When is a fracture suspicious for abuse?
• Reporting to Authorities
• Specific reasons for reporting this case
• Potential Biases
• Initial Work-up
• Non-Accidental Trauma Work-up
• Additional details of the History
• Re-enactment:  The older brother demonstrated the two-year-old’s position when he landed on the floor.
• Curbside Key Points

References

Intimate Partner Violence (IPV)

Ingrid Walker-Descartes, MD, MPH, MBA, FAAP

Introduction Page
Cover Slide

Presentation

• Objectives
• Definition of Intimate Partner Violence (IPV)
• IPV and Child Maltreatment
• Exposure to IPV
• Case: “Trust but Always Verify”
• Reporting to Authorities
• Specific Reasons for Reporting This Case
• Potential Biases
• Additional Medical History
• Additional Information
• The Importance of Interdisciplinary & Interprofessional Approach to Child Abuse
• Interprofessional Collaboration
• Next Steps
• What Not to Miss in the Physical Exam
• Non-Accidental Trauma Work-up
• Case Physical Exams & Assessment Findings
• Documentation
• Case Documentation: EMR
• Case Documentation: Other details
• Medical Photography: Tips
• Facilitating Interdisciplinary Communication With an Impact Statement
• Final Case Disposition
• Curbside Key Points

References

Sentinel Injuries

Alicia Pekarsky, MD, FAAP

Introduction Page
Cover Slide

Presentation

• Objectives
• Definitions
• Definition of a Sentinel Injury
• Data
• Data
• TEN-4-FACESp
• Identification of a Sentinel Injury 
• Case
• Additional Medical History
• 
What Not to Miss
• Case Findings
• Case Documentation
• Case Documentation
• An Impact Statement
• Reporting to Authorities
• Additional Information (Investigative)
• Interprofessional Collaboration
• Potential Biases
• Curbside Key Points

References

When Its Just a Bump on the Head: Interpreting Skull Fractures in the Context of Child Maltreatment

James Metz, MD MPH

Introduction Page
Cover Slide

Presentation

• Objectives
• Case
• Reporting to Authorities
• Potential Reasons for Reporting This Case
• What Is the Conundrum?
• Biases in Diagnosis of AHT
• Normal Infant Skull
• Complex Skull Fractures & Abuse

• Extra-Axial Blood & Fractures 
from Accidents
• Soft Tissue Swelling (STS) & Skull Fractures

• Occult Injuries with Skull Fractures

• Occult Injuries with Skull Fractures

• Delay in Care

• Ways to Ensure We Are Not Missing Something
• Key Points
• Non-Accidental Trauma Work-up

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