The young couple was frantic. Their toddler’s feet and ankles were covered with ulcers that looked like cigarette burns. Had he been abused?
That was Angela Golden’s first thought when the family arrived at the emergency department (ED) in which she worked. But the father insisted she look at the dead fire ants he had brought with him in a plastic bag. Besides, the little boy was relaxed around his parents and didn’t seem to be afraid of them. He didn’t look at one or the other for approval.
A nurse practitioner in Flagstaff, Ariz., Golden had never seen ant bites like that, so she called the local board of health and went online for more information. As it turned out, the little boy had been playing outside and had been attacked by an army of red fire ants.
“There were other clues that this was not child abuse,” Golden says. “The parents never missed a follow-up appointment to have the little boy’s feet checked. They had kept all his well-baby appointments, and his immunizations were up to date. These parents didn’t have a lot of money, but they had two other children who were also well cared for.”
Although this incident had a happy ending, Golden was right to be skeptical. Abuse should be part of the differential diagnosis every time a child presents with an injury, experts say.
“If you’re not attuned to the possibility, you won’t think about it and you’ll miss it,” says Theresa Guins, MD, an assistant professor of pediatrics at Eastern Virginia Medical School and an attending ED physician at Children’s Hospital of the King’s Daughters, both in Norfolk. “When you miss a case, you risk further injury, or even death, of the child.”
Similarity to MIs
David Paulk, EdD, PA-C, draws an analogy to chest pains and MI in adults. “When a patient comes into the ED with chest pain, we always assume an MI until we rule it out,” says the associate professor at Arcadia University in Glenside, Pa. “The same rules should apply to child abuse: When an injured child comes in, it is incumbent upon us to suspect and rule out—or rule in—child abuse. If we miss it, the child could die.”
About 899,000 children were maltreated in 2005 in the United States and Puerto Rico, according to the most recent statistics available from the federal Administration for Children and Families. Most of those children (63%) were neglected, and 25.8% were physically or sexually abused (Table 1).Federal and state laws require health-care providers to report suspected cases. Procedures vary from state to state. Most have a 24-hour hotline number that anyone can call. Hospitals and group practices often have a social worker or designated staff member who makes the report on a clinician’s behalf.
The key to identifying abuse is to determine whether the injury was inflicted or accidental. Clinicians should take a careful history and ask a lot of questions, especially about how the injury occurred. Follow up when the history and clinical findings are inconsistent.
“The law talks about ‘reasonable causes,’ ” says Golden, “but I prefer to talk about ‘red flags.’ Does the story fit the developmental age of the child? You’d be surprised at what I hear. If he can only crawl, it’s unlikely the child fell out of a tree.”
Similarly, an infant who is not yet walking can’t fracture her femur by tripping, says Dr. Guins, a pediatric emergency physician for 12 years. “That kind of injury can happen if a child falls from a significant height. I’d feel more comfortable if the parents admitted the child was accidentally dropped,” she says.
Children who present with burns in a stocking or glove distribution on their feet or hands should also raise questions. “Those burns are typical of immersion in hot water,” says Dr. Guins. “Kids may put the tips of their fingers or toes in hot water but usually will not immerse the whole hand or foot.”Bruises in unexpected places, like the buttocks, back, axillae, genitalia, ears, and neck can be worrisome. “Children often have bruises over bony areas but rarely on the abdomen,” notes Golden. “If they fall, they curl up to protect themselves.”
Histories are very important when bruises are apparent. “You have to ask the right questions,” says Golden. “How long has it been there? Has it always been that shape? Family practices have a real advantage over EDs because we have charts; we can see if the bruise was noted on a previous well visit.”
But an unusual or unexpected bruise does not necessarily indicate abuse. It may signal a low platelet count or other blood disorder. “If there are many bruises with petechiae, consider ordering a blood count,” Dr. Guins counsels.
Many red flags are not directly related to the injury. Communication cues and delays in seeking treatment can be just as significant signs of abuse or neglect.
Why is Dad present?
Another red flag is a second adult, especially the father, accompanying a mother to the clinic or ED. “That’s not to say that every time a father comes in, it’s suspicious,” Golden adds. “It’s just that that is often the case with abusers, especially when he’s abusing his wife as well as the kids.” She routinely separates the adults to make sure they tell the same story about how the injury was incurred.
Be alert to how the adults and children act and interact. According to information from the Child Welfare Information Gateway (www.childwelfare.gov), an abused child may seem frightened of the parents, shrink at the approach of adults, and be overly compliant, passive, or withdrawn. Parents may appear indifferent to the child or depressed; see the child as bad, worthless, or “evil,” and offer conflicting, unconvincing, or no explanations at all for the injury. When they’re together, the adult and child will rarely touch or look at each other.
Paulk also suggests clinicians look for evidence of neglect, drug or alcohol abuse, and behavioral or regressive changes, such as bedwetting. Does the child give a direct response to a direct question?
Parents often feel defensive when they think the clinician suspects abuse. Questioning requires tact.
“I always teach to approach the discussion in a nonthreatening and caring manner,” says Paulk. “This means we treat suspected abusers with the same respect we treat anyone.”
He suggests this script as a model: “There are some injuries here that we are required by law to ask about. We are not accusing you of anything, but I could lose my license if I don’t check into this. I know you care about your child and want us to do everything possible for his or her health.”
Clinicians are legally protected if they file a report that turns out to be mistaken. In fact, state and federal regulations mandate reporting when there is “reasonable cause to suspect” abuse. Deliberate failure to report can result in lost licenses—and, in some states, criminal charges.
Child-abuse cases pose unique emotional risks for clinicians who make a mistake because child protective services (CPS) can remove children from their homes. When a family is innocent, the disruption can be traumatic for parents and children alike, and the clinician’s report may cause actual harm.
“If the signs and symptoms point toward a suspicion of child abuse, then the practitioner must report. Remember, it’s suspicion, not proof,” Paulk emphasizes. “As long as practitioners are reporting without malice, they’re usually protected.”
“CPS investigations can be traumatic for a family,” concedes Guins, “but I would report 100 times to save one child’s life.” On the other hand, “the satisfaction of preventing an unnecessary CPS investigation is immense.”
“The biggest emotional toll in these cases is when in your gut you know a child is being abused or neglected and nothing gets done,” says Golden. “The situation is not severe enough and CPS doesn’t have the staff to follow up in a timely manner. You make the report and call back two or three weeks later, and nobody’s gotten to it yet. That takes a big toll.”
Golden has experienced both sides during her 30 years in the profession. As a school nurse, she reported suspicions about a situation that turned out to be benign. “I did it from the right place of caring and concern. That’s all we can do as clinicians. If you’re wrong and a family is disrupted, it’s better than a child’s continuing to be abused.”
At first, the family was very angry, Golden says, but eventually they forgave her. “About three months later, the mother came in and said, ‘I appreciate your willingness to risk being wrong to be sure a child is safe.’ ”