eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect, Physical Abuse: Follow-up

Author: Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Coauthor(s): Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Contributor Information and Disclosures

Updated: Dec 12, 2008

Follow-up

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Physicians are mandated to report suspicions of physical abuse to the proper governmental authorities in all 50 states. Some states may require notification of law enforcement officials; other states may require notification of both law enforcement and child protective services (CPS). Notification requirements applicable to the physician's practice setting are found in each state's laws.
    • Suspicion of abuse typically is defined as when information before the physician would lead a competent professional to conclude that physical abuse is likely to have occurred. It should be noted that the physician participates in the evaluation of abuse but does not have the responsibility to prove that it has occurred or to determine the identity of the abuser. The law enforcement and court system have these responsibilities.
    • Once the report is made, usually in the form of a call to the state or county hotline followed by some form of written documentation, the state laws outline a time line for the subsequent evaluation.
    • CPS will screen the information, conduct an investigation, and provide supportive services for the child and family.
    • Law enforcement may become involved, depending on the locality and the circumstances of the case.
    • Under state statute, the physician making the report in good faith is able to claim immunity from criminal and civil liability should an angry caregiver file a lawsuit against the physician for making the report, even if, ultimately, it is determined that no maltreatment has occurred.
    • Additionally, the physician who fails to make a report of suspected abuse may be held liable for failing to report the case under the state's statutes.
  • The physician's documentation is vital to the investigation of physical abuse. This documentation should offer a time-sequenced record of the information surrounding the case and should contain specific information, including when physical abuse became known.
  • Because these cases have tremendous legal implications for the child and caregivers, it is important to create a clear, accurate medical record, which preserves the medical details of the case. Reliance on memory several years after the physician has evaluated a case will not serve the interests of the child and caregivers; whereas a well-documented medical record will serve these interests. The medical record may be admitted as evidence in any subsequent court actions involving the case and will be invaluable to the physician if called to testify in any court proceedings. Documentation should include the following:
    • Statements made by the child and caregivers on presentation for care
    • Details of the child's medical history and interview
    • Caregiver(s) interview(s)
    • Physical examination findings
    • Laboratory/diagnostic imaging studies results
    • Medical conclusions drawn from the collective information
  • Marx offers general documentation guidelines regarding the medical record related to statements made to the health care provider as follows:
    • Name of person making statement and his relationship to the child
    • Date and time that statement was made
    • Any questions, statements, or actions by the health care provider occurring before or possibly prompting the statement
    • Where possible, exact words of the statement using quotation marks to identify
    • Demeanor of the person making the statement
    • Others present when statement was made
    • Name and other identifying information of the person recording the information into the medical record
  • With regard to the child and caregiver interviews, documentation needs to reflect details surrounding the injury, including what was happening before the injury, the circumstances of the injury, and what happened after the injury. The physical examination and laboratory/diagnostic imaging workup should be documented as clearly as possible, complete with drawings and photographs of the injury. Specifically regarding photographs, the following advice is offered:
    • Clearly include the child's name and medical record number in the photo.
    • Include a centimeter ruler and color balance chart.
    • If possible, rephotograph the injuries during the healing process to show the progression/resolution of the injury.
    • Avoid instant film in favor of 35 mm film to achieve better quality photos.
    • Supplement photos with drawings in the chart because photos may fail to develop properly or may be lost during months to years of storage.
  • At the conclusion of the medical evaluation, it is important that the physician sifts through all the information known at that time and develops an impression and a set of treatment plans. Understand that additional information may be uncovered in later phases of the investigation; conclusions drawn should not overstate the certainty of what was known at that point in time.
    • The physician should summarize the clinical information from the history and interviews, physical examination, and laboratory and diagnostic studies, state whether the injury evaluated is consistent with the explanation provided or if it is inconsistent, and state why. Statements such as "no evidence of abuse" do not recognize that the investigation may uncover additional information that may contradict this statement.
    • Additionally, statements reflecting personal opinions about the child and caregivers are not appropriate for the medical record, because they may be misinterpreted easily.
  • In cases of physical abuse, the child and/or physician may be asked to testify in court. A physician may be called to testify in a child maltreatment case in the following 2 capacities:
    • The lay (fact) witness is asked to recount personal knowledge regarding the maltreatment events; usually, this entails describing what the findings were when the child presented for care and evaluation. The physician serving as a lay witness typically is asked to explain what they put in the child's medical record and how conclusions were drawn at the time of the medical evaluation.
    • In contrast, the expert witness is asked to provide the court with technical, clinical, and scientific information. The expert witness may offer opinions about certain medical facts in the case and does not need to have evaluated the child in question. An attorney in the case qualifies an expert witness by demonstrating to the judge that the physician has advanced knowledge in the form of training and experience. The expert can offer opinions but is not permitted to say whether the child is telling the truth; that is the role of the court.
  • Child testimony in court proceedings is an area of special concern because the court represents a formal adult setting that handles often contentious adult arguments. The AAP has issued a policy statement regarding children in court and specifically addresses the unique stress that the courtroom may cause for children called to testify in court proceedings regarding their own maltreatment.
    • Appearing in court creates anxiety, and no agreement exists about whether it is positive or negative for the child to face their alleged abuser in such a setting.
    • Children may testify in court if they can relay and receive information accurately, know the difference between telling the truth and a lie, and understand the need to tell the truth in court.
    • If the child is asked to testify, the pediatrician needs to be aware of the high levels of anxiety that inevitably will arise and assist the child and family in anticipating and planning around this effect.
  • Finally, one of the best ways to serve a child's best interests in legal proceedings is for physicians to carefully and accurately document in the medical record. A well-constructed chart containing all pertinent information has the greatest chance of speaking for the child's interests. Therefore, meticulous documentation is essential for child maltreatment cases.
 
Acknowledgments

The authors gratefully acknowledge the assistance of Dr. Lawrence R. Ricci in providing photographs to illustrate the various injuries that may be seen when evaluating children for suspected physical abuse. Despite being a busy clinician, educator and academic leader, Dr. Ricci made time to select cases for this article from his large archive. 



More on Child Abuse & Neglect, Physical Abuse

Overview: Child Abuse & Neglect, Physical Abuse
Differential Diagnoses & Workup: Child Abuse & Neglect, Physical Abuse
Treatment & Medication: Child Abuse & Neglect, Physical Abuse
Follow-up: Child Abuse & Neglect, Physical Abuse
Multimedia: Child Abuse & Neglect, Physical Abuse
References
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Further Reading

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Keywords

physical abuse, child maltreatment, child abuse, victimization, physical maltreatment, intentional injury, nonaccidental injury, inflicted injury, fracture, burn, bruise, subdural hematoma, SDH, abusive head trauma, AHT, shaken baby syndrome, SBS, shaking-impact syndrome, maltreatment, domestic violence, corporal punishment, fractures, whiplash syndrome, smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, skeletal fractures

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Contributor Information and Disclosures

Author

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Coauthor(s)

Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, 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

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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