Physical Child Abuse Treatment & Management

Updated: Apr 24, 2017
  • Author: Angelo P Giardino, MD, MPH, PhD; Chief Editor: Caroly Pataki, MD  more...
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Treatment

Medical Care

Treatment for physical abuse is a complex endeavor involving an interdisciplinary team approach. The nature of the injury determines the form of medical therapy, and the details of the caregiving environment determine the psychosocial supports needed to keep the child safe.

For medical issues, skeletal fractures of the long bones may require casting, and orthopedics should be consulted for assistance with diagnosis and management.

If clinical consideration is being given to the possibility of osteogenesis imperfecta (OI), a genetics consultation may also be valuable.

Burns vary in severity and treatments range from cleansing the area to skin grafting. Plastic surgery should be consulted for assistance with management of more serious burns; transfer to a burn unit may be indicated. See Initial Evaluation and Management of the Burn Patient for burn management.

The most severely injured children, such as those with CNS injury, may require resuscitation and will need intensive care. A multitude of specialists may need to be involved in order to correctly evaluate and treat these seriously ill children. Whenever abusive head trauma is suspected, ophthalmology should be consulted for a formal evaluation, including examination of the eyes for retinal hemorrhages.

Psychosocial management that requires a significant amount of coordination among various services providers, including the physician and other healthcare providers, complements the medical management. Recommendations from the American Academy of Pediatrics state that pediatricians are mandated reporters of suspected abuse, and reports to child protective service agencies are required by law when the physician has a reasonable suspicion of abuse. Transferring a child’s care to another physician or hospital does not relieve the pediatrician of his or her reporting responsibilities. In addition, thorough documentation in medical records and effective communication with nonmedical investigators in child protection may improve outcomes of investigations and protect vulnerable children. [24, 25]

The child protective services (CPS) agency in each community is responsible for performing investigations of cases in which physical abuse is suspected and relies on the physicians to provide the details of the medical evaluation. In addition, CPS assesses the caregivers' background, caregiving abilities and potential, environmental safety, risk for repeat abuse, and risk to other siblings. A variety of CPS service plan options are available, ranging from periodic contact with the child and family to removal of the child from the home, either temporarily or permanently, with termination of parental rights. The CPS process for child maltreatment cases typically involves the following steps:

  • Intake - Screening of reports and acceptance of case

  • Initial risk assessment - Caregiver interviews, medical information gathering, home evaluation, and possibility of contact with law enforcement

  • Case planning - Determination of safety for the child with essentially 3 options: (1) the child goes home with the caregiver with or without services depending on the circumstances, (2) the child is removed from home and family with caregivers' consent and offered services to assist them in working towards reunifying with the child, and (3) the child is removed from the home and family without caregivers' consent, involving court action and incorporation of legal steps and processes to determine the ultimate plan for the child.

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Surgical Care

In cases of severe or multisystem trauma, involvement of a pediatric surgeon may be necessary for care and surgical treatment of injuries.

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Consultations

The following consultations may be warranted:

  • Pediatric radiologist expertise is important because many abusive fractures in infants are subtle on radiographs. Routine pediatric radiologist involvement is ideal. In locations where pediatric radiologists are not routinely available, one should be consulted in cases in which dating of bone injuries become central to the maltreatment investigation and when concerns arise regarding osteogenesis imperfecta (OI) or other bone mineralization problems.

  • Orthopedists can assist with diagnosis and management in cases of skeletal fractures of the long bones.

  • Hematologists can assist with diagnosis and management of bleeding disorders.

  • Geneticists may be needed for a detailed workup for OI or other collagen disorders for characterization of the collagen disorder.

  • Plastic surgeons may be needed to assist with the management of serious burns.

  • Ophthalmologists should be involved whenever abusive head trauma (AHT) is suspected, for a formal evaluation including examination of the eyes for retinal hemorrhages via dilated direct ophthalmoscope examination, ideally with retinal photography to allow for independent peer review.

  • Child psychiatrist, behavioral-developmental pediatrician, or psychiatric social worker may be needed to assess the mental health needs of the child and family, as well as to coordinate an overall psychosocial treatment plan.

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