Child Abuse, Neglect, &

Everything in Between
Mia Mallory, MD
Ndidi Unaka MD

Goals and Objectives

Highlight interesting cases we have seen in the
primary care, inpatient and emergency room
settings
Facilitate discussion regarding the integration of
primary/ hospital based care and behavioral
health

Session Structure
1. We will review a case and we will ask you if
there are additional questions you would ask
the family from a social work perspective
2. Provide details about what ultimately
happened in each case
3. Go over some interesting articles and key
points in regards to child abuse and neglect

Case #1: The Boy with the Silly Sodium

A 6 week old male presents to the ED with seizure
Found to have a low sodium of 119, seizure stopped
with 3% sodium bolus and Ativan intubated
Head CT normal
To PICU
History of vomiting intermittently x 1 day at home
but found that morning unresponsive and looked
blue in his crib so mom drove to ED

Case #1
Do you have any questions for the family?

Case #1
In PICU:
Extubated easily
No further seizures and sodium appropriately
returns to normal
Feeding well
Endo consult all labs reassuring, no cause for
low sodium found (?dehydration)

Transfers to floor in stable condition, doing well

Case #1
More Info
Formula fed, mixing properly
No water intake of any kind reported
Social hx:
Lives with mom and her boyfriend, who mom refers
to as dad and who found the patient on morning of
admission
Bio dad comes to hospital but not usually involved
Mom had open CPS case with prior child but closed
for years (due to maternal h/o drug abuse)

Some insights into the process of calling CPS

Many cases are clear cut suspicion for physical
abuse with no h/o trauma matching the injury or
imminent risk of harm or death
Gray areas medical neglect, failure to thrive,
medical non-compliance
The county will often require evidence of harm
(example: documented missed appointments)
when deciding to open a case

What is your duty?

YOU are a mandatory reporter:
In 48 states including Ohio
Must report at the time you suspect or have
reason to believe a child has been abused or
neglected

Child Welfare Information Gateway (2012). https://

www.childwelfare.gov/systemwide/laws_policies/statutes/manda.cfm. Accessed 4 March
2013.

Fact Check: Child Physical Abuse

In 2011, 676,569 children were victims of child abuse and
neglect in the United States
Breakdown of child maltreatment
78% neglect
18% physical abuse
10% sexual abuse

Despite the stats, estimated number of victims much

higher
Child Maltreatment 2011 Report. https://www.childwelfare.gov/systemwide/statistics/can.cfm. Accessed 18 March 2013.

Demographics and Risk Factors

Physical abuse affects children of all ages, genders, ethnicities, and
socioeconomic groups
Similar rates in male and female children
Although risk of physical abuse increases with age, fatal abuse and
serious abusive injuries are more common among children <2 years
Children in homes with annual incomes <$15000
3 times the number of fatalities
7 times the number of serious inflicted injuries
5 times the number of moderate inflicted injuries

Demographics and Risk Factors

Risk factors for infant maltreatment

maternal smoking
presence of more than 2 siblings
low infant birth weight
an unmarried mother

One study: found children living in households with

unrelated adults were ~50 times more likely to die of inflicted
injuries than were children residing with 2 biological parents
The US Department of HHS indicated rate of physical abuse is 2.1
times higher among children with disabilities than children
without disabilities

POP QUIZ:
Why is physical abuse underreported?
Physical abuse remains an underreported (and
often undetected) problem for several reasons
Individual and community variations in what is
considered abuse
Inadequate knowledge and training among
professionals in the recognition of abusive injuries
Unwillingness to report suspected abuse
Professional bias

What happened to our patient from Case

#1?
Inpatient social worker, attending physician , and
multiple residents interviewed mom on several
occasions
Called our child abuse center (Mayerson) for advice,
who advised a call to CPS
After a very upsetting discussion with mom, a referral
was made
Mom then called our social worker back to the room . . .
It was Kool Aid.

Case #2: The Spitty and Sleepy Baby

4 week old former full term infant boy who presents
to the ED with excess oral secretions and lethargy

Acute onset of yellow/ brown secretions from mouth

Refusal to take feeds
No respiratory symptoms, fevers, emesis
Some loose stools
Perfectly healthy until day of presentation
Patient brought to ED and mom reports vigorously
bulb suctioning patient during car ride

Case #2
Do you have any questions for the family?

Case #2
In ED:
Noted to have a fever, a fast heart rate, normal blood pressure but
lethargic with bruises and abrasions on face
Fever workup completed due to the patients age:
Blood count, cultures from blood and urine, spinal tap and started on broad
spectrum antimicrobials

Non accidental trauma work up initiated:

Liver enzymes elevated
Skeletal survey and head CT: Retropharyngeal air in soft tissues seen on
skeletal survey and head CT; confirmed on neck CT
Abdominal ultrasound: no free fluid in pelvis

ENT, social work and PICU consulted and patient transferred to PICU
for further management

Case #2
Birth history
Full term, went home with mom, jaundiced but no phototherapy, no
history of HSV, GBS -, no h/o STD

Social hx:
Patient lives with parents, MGM, MGMs fianc and 18 year old uncle
Mom employed as "child development caretaker" and works in a
family's home who has an autistic child
Dad works at manufacturing co. and works 3rd shift (19 days on, 2
days off)
Mom with no other children but dad has a 1 year old daughter who he
sees on weekends
Parents together for 18 months

Evaluation of Suspected Child

Physical Abuse
AAP policy statement 2007
Careful, thorough and well documented history and
physical!!!
Tests should be ordered judiciously and in consultation with
the appropriate subspecialty teams, including child abuse
specialists
Careful consideration of the patient's history, age, and clinical
findings should guide selection of the appropriate tests
Best Evidence] [Guideline] Kellogg ND,. Evaluation of suspected child physical abuse. Pediatrics. Jun
2007;119(6):1232-41.

POP QUIZ:
Name history and PE clues to child abuse
History offered does not adequately explain the injury with regard to its nature,
distribution or severity
Caretaker changes the history over time, or different caretakers offer conflicting stories
No history offered to explain a serious injury or one which is typical of abuse
Child is developmentally incapable of having acted as described or should not
reasonably be expected to have acted as described
Multiple injuries of various types and of different ages
Injuries are symmetrical (e.g. involve both hands or both feet)
Injuries found in areas typically used for punishment (e.g buttocks)
Inappropriate delay in seeking medical attention for an injury which is sufficiently
severe that a reasonable parent would have realized it required treatment
A serious injury is blamed on another child

Type of Injury/
Condition

Diagnostic Test

Comments

Fractures

Skeletal survey

Recommended for all children with fractures

and children with any suspicious injuries
under age 2
Recommend repeat in 2 weeks for high risk
cases

Bruises

CBC, PT, PTT, INR

Important to rule out hematologic disorders

Additional testing may be indicated after
initial screening

Liver injury

LFTs

May be helpful in diagnosing occult hepatic

injury

Intra-abdominal

Abdominal CT

IV contrast should be used and is preferable

to PO

Intracranial/
extracranial

Head CT: When CT used in

conjunction with films,
may enhance detection of
skull fractures
Brain MRI

MRI: more sensitive in picking up subtle

injuries, characterizing extent of intercerebral
edema, may provide better dating of
intracranial injuries, detecting cervical spine
fractures/injury

Pancreatic

Amylase, lipase

Urinary/ renal

UA

Cardiac

Cardiac enzymes: troponin

and CK-MB

Bone mineralization
disorders

Ca, alk phos, phosphorus,

vitamin D, PTH

Sugar et al: Bruises in Infants

Those Who Dont Cruise Barely Bruise
Objective of study
Determine frequency/ location of bruises in normal infants and
toddlers
Determine relationship between chronological and developmental age
to bruising

Cross-sectional survey in community physicians offices

6 private practice, 1 inner city

Subjects were children 3 yrs or younger in for WCC

Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget
Sound Pediatric Research Network, Arch Pediatr Adolesc Med. 1999 Apr;153(4):399-403.

Bruises in Infants
Results
Bruises found in 203 (20.9%) of 973 children who had no
known medical cause for bruising and in whom abuse was not
suspected
Only 2 (0.6%) of 366 children <6 months and 8 (1.7%) of
473 children <9 months had any bruises
Bruises in only 11 (2.2%) of 511 children who were not yet
walking with support (cruising)
17.8% of cruisers and 51.9% of walkers had bruises (p<.001)

Bruises in Infants
Results
Most frequent site of bruises
Shin and knee
Bruises on the forehead and upper leg were
common among walkers, but bruises on the face
and trunk were rare
Bruises on the hands and buttocks were not
observed at any age
There were no differences in bruise frequency by sex
African American children were observed to have
bruises much less frequently than white children

Bruises in Infants
Conclusions
Bruises are rare in normal infants and pre-cruisers and
become common among cruisers and walkers
Bruises in infants younger than 9 months and who are
not yet beginning to ambulate should lead to
consideration of abuse or illness as causative
Bruises in toddlers that are located in atypical areas, such
as the trunk, hands, or buttocks, should prompt similar
concerns

How Much is Too Much?

When a parent strikes a child hard enough to
produce bruising, he or she is striking with
sufficient force to stretch the soft tissues of the
skin and tear blood vesselssuch force is, by
definition, excessive

What happened to our patient from Case

#2?
PICU course:
Initially not allowed to eat by mouth, and continued antibiotis
Ophthalmology consult: no retinal hemorrhages
Transferred to floor on HD #2

Floor course:
Mayerson Center consult
Chest and abdomen CT requested due to unexplained elevation in liver enzymes

Hepatic laceration (equivalent grade 2) involving the posterior right liverin

other words, he had a large tear in his liver
He improved over the course of his stay and maternal Great Aunt given
temporary custody

Quick Points on Abdominal Injuries

Injuries to the abdominal viscera are thought to occur in less than 2% of
abused children
Although not recognized as frequently as other types of injury resulting from
child abuse, abdominal injuries can be among the most serious and are
potentially fatal
Types of injuries

Liver lacerations
Splenic rupture
Renal contusion/ laceration
Pancreatic pseudocyst
Duodenal intramural hematoma
Laceration of mesenteric blood vessels
Rupture of a hollow viscus (i.e. stomach, transverse colon)

Case #3: The Toddler Who Was Just Too

Hyper
3 year old boy who presents to clinic for a well
child check
Mom reports that he is extremely hyper and she
is having a tough time dealing with his behavior
at home
She is interested in starting him on ADHD
medication
She endorses no other concerns at this time

Case #3
Do you have any questions for the family?

Case #3
You inform mother that patient is too young for the diagnosis of
ADHD and offer tips regarding limit setting, disciple and behavior
modification for kids this age
Mom is adamant that she would like her son on medication and is
not interested in developing a behavioral plan or talking to our social
workers in clinic
Social history
Mother has an 8 year old and a 6 year old at home and is a single parent
She has a limited support system which includes her sister and mother
Mom works and is trying to go back to school, patient attends daycare,
no car and relies on public transportation

How do you tell a family you are calling

CPS?
Rely on your duty as a mandatory reporter!
Be honest that your job is to keep children safe
Provide any facts that support your decision to call
Do not place blame or make assumptions about how the county will
handle the case
A report to CPS does not always mean removal or loss of custody
The counties have access to some resources that we do not in the
hospital

POP QUIZ: What is a safety plan in

reference to discharge?
The countys plan for who will care for the child
upon discharge
Parent(s) maintains custody, but a family member or
family friend (as designated by the county) will be
responsible for the patients care
Allows the county 30 days to complete their
investigation

POP QUIZ: A Few More ABCs

What is a VAC?
Voluntary Agreement of Care: parent temporarily gives
custody to the county during the investigation
Foster parents can only be assigned when the county has
custody of a patient
Caregivers of children on a safety plan are not considered
foster parents

What is an EO?

Emergency Order: allows county to obtain emergency

custody of the patient

What happened to our patient in Case #3?

Mom is given pamphlets regarding parenting classes
and other resources in the community
She returns to the clinic 45 minutes latershe relays
that she is having thoughts of drowning her son in the
bathtub because she is so frustrated
Social worker gets back involved, the patients aunt is
contacted and a plan is developed for the children to
stay with aunt and mom to get plugged in with mental
health services

Case #4: Hes not breathing

20 year old male brought to our satellite location
Emergency department in a car by his friends
He took some heroin and hes not breathing
The patient was dragged from the car not breathing and
blue onto a stretcher and put in the trauma bay
Pt noted to have a strong pulse, apneic and cyanotic
Pts friends state that they were getting high

Case #4
Pts friends also state he didnt take any other drugs
An IV was placed immediately while the patients breathing was being
assisted
The patient was given 2mg of IV Narcan and pt immediately began to
breathe and became combative
While placing the patient in a gown and fully examining him, a pocket
knife was found in the pocket of his pants
Once coherent, the patient was asked what happened and he said that he
wanted to kill himself because he had to go to court for an OVI charge

Case #4
Pt states that he was in his friends garage snorting heroin and
thats the last thing he remembers
Pt asked for us not to call his mother and would like his cell phone
to call his sister
Pt states that he is not currently suicidal
Social work involvement:
Emergency Department (ED) social workers automatically respond to pages
for patients in the trauma room
ED social worker immediately interviews 2 friends who brought the patient
in to get a detailed story of the encounter
Social work contacts patients mother per friends request while the patient
was being cared for

Case #4
ED Social worker interviews patient when he is coherent
and describes the next steps of care to the patient
Once patient is stabilized he is transferred to a nearby
adult facility for psychiatric evaluation and 72 hour hold
given his suicide attempt
While at the adult facility, the police were contacted and
pt was charged with illegal possession of heroin
Does the ED Social Worker have any other duties regarding
this patient? (i.e, providing his cell phone, calling his sister,
contacting police).

Thanks for Having Us!