eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Child Abuse: Follow-up

Author: Lawrence R Ricci, MD, Director of Spurwink Child Abuse Program, Assistant Professor, Department of Pediatrics, University of Vermont College of Medicine
Coauthor(s): Ann S Botash, MD, Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University; Dylan M McKenney, MD, Resident Physician, Department of Psychiatry, Maine Medical Center, Portland
Contributor Information and Disclosures

Updated: Sep 10, 2009

Follow-up

Further Inpatient Care

  • Hospitalize the abused child if safety cannot otherwise be guaranteed.
    • The severity of the injuries should not be the sole determining factor for hospitalization.
    • Hospitalization may offer time to sort out difficult diagnostic (whether the injury is inflicted or accidental) and therapeutic (whether the child is safe going home) decisions.
    • Most seriously injured children are best monitored in an intensive care setting.
    • Depending on the complexity of services needed, the clinician should consider transferring the child to a specialized pediatric center.
  • Child abuse and neglect frequently occur in concert with other forms of family violence and disfunction, including spousal abuse and substance abuse. If a child witnesses domestic violence, this should be reported to child protective services.
    • In one study of the hospital records of mothers of 32 abused children, the records of 60% of the mothers were diagnostic or highly suggestive of previous maternal spousal victimization.
    • This study suggests that abused children are at high risk for exposure to violence against their mothers.
    • Such history of violence should be actively sought and aggressively treated in collaboration with community-based domestic violence programs.

Further Outpatient Care

  • In addition to the medical follow-up needs (eg, orthopedic, surgical, neurological) of the abused child, these children often need child protective and mental health follow-up care.

Deterrence/Prevention

  • Early detection of at-risk families and appropriate intervention may prevent future abuse. Likewise, identification of children with less severe physical abuse—with aggressive intervention—may prevent more severe subsequent injuries or death.
  • Research has shown evidence that breastfeeding may help to protect against maternally perpetrated child maltreatment, particularly child neglect.
  • A variety of strategies have been implemented to prevent child maltreatment. Until recently, little data have supported the effectiveness of most prevention strategies.
  • Perhaps the most proven program that targets high-risk families is the Nurse-Family Partnership (NFP), which establishes a long-term professional relationship between a visiting nurse and an at-risk mother prenatally. The Nurse-Family Partnership has demonstrated, in repeated randomized control trials, efficacy in lowering maltreatment rates as measured by several outcomes.6  
  • Other promising programs include the Early-Start and Triple P programs. These interventions share many commonalities.
    • Approaches are based on the strengths of the individual families or caregivers.
    • Trained professional staff work directly with the target population.
    • The whole family is engaged.
    • Healthy behaviors are promoted.
    • Community collaboration is stressed.
    • Effective parenting skills are taught including discipline techniques, age appropriate expectations, and secure attachment.
  • Both prenatal enrollment and long-term involvement are more effective.

Complications

  • Child maltreatment exposure is potentially the single greatest risk factor in the development of mental illness. 
  • Severe long-term complications may result from damage to organs or organ systems. This is especially true of traumatic brain injury. 

Prognosis

  • Without appropriate social service and mental health intervention, child abuse is usually a recurrent and sometimes escalating problem.
  • Approximately 1500 children die in the United States each year from child maltreatment.

Patient Education

  • Parents should be educated about appropriate discipline techniques including discouraging the use of physical discipline, particularly in high-risk families.
  • Parents should be informed that exposure to domestic violence could have profound and long-lasting adverse effects on a child's behavior.
  • Parents should be educated about the dangers of shaking infants.
  • For patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education articles Child Abuse, Bruises, and Black Eye.

Miscellaneous

Medicolegal Pitfalls

  • The practitioner's role, when possible, is to offer an opinion about the presence of abuse for the purposes of child safety. If the practitioner is not comfortable offering an opinion about inflicted trauma, it is incumbent on that practitioner to refer a child to a child abuse specialist who may offer such an opinion.
    • Although medical providers should document suspected perpetrators for the purposes of ensuring the safety of the child, further documentation regarding provider opinion about the guilt of the person in question is not part of the medical provider role.
    • Medical practitioners are held under the "reasonable medical certainty" standard. Although this is difficult to quantify, such a standard is suggested to mean that the practitioner is certain enough of the diagnosis to offer treatment for that diagnosis.
    • Simply saying that it is possible for an injury to have been accidental may not be helpful to law enforcement and child protective services. This is particularly true if "possible" is taken to mean anything is possible. The standard usually applied to injury assessment is reasonably possible, or with some degree of likelihood.
    • Medical providers should avoid offering an opinion that abuse did or did not occur based on their feelings about a parent or caretaker. Such criteria are notoriously inaccurate. Likewise providers may not know the entire story or have access to scene investigation that could significantly impact an opinion.
  • Medical providers are legally protected when reporting suspected abuse in good faith. However, it is never appropriate for the emergency practitioner to accuse someone of abusing his or her child or of lying about how an injury may have occurred.
  • Medical providers are at greater medicolegal risk if abuse is missed and a child is further injured than in reporting possible abuse that later turns out to be something else.
  • Aging bruises, once seemingly a simple task using standard aging charts, is now known to be much less precise than originally thought.
    • It may be possible to say that a bruise is probably fresh if it is red, blue, or purple, and a bruise is probably older if it is green, yellow, or brown.
    • Otherwise, bruise aging by color analysis should be discouraged.
 


More on Pediatrics, Child Abuse

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Differential Diagnoses & Workup: Pediatrics, Child Abuse
Treatment & Medication: Pediatrics, Child Abuse
Follow-up: Pediatrics, Child Abuse
Multimedia: Pediatrics, Child Abuse
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Lawrence R Ricci, MD, Director of Spurwink Child Abuse Program, Assistant Professor, Department of Pediatrics, University of Vermont College of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Ann S Botash, MD, Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University
Ann S Botash, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Helfer Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Dylan M McKenney, MD, Resident Physician, Department of Psychiatry, Maine Medical Center, Portland
Dylan M McKenney, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Kirsten A Bechtel, MD, Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, 
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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