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?