Key points

Introduction

An advocate is often defined as a person who intercedes on behalf of another. Pediatricians, at their core, are essentially advocates for children. Most discussions related to pediatricians engaged in advocacy activities related to child maltreatment focus primarily on work done in the legislative and public policy arenas, with little or no attention paid to other areas in which advocacy occurs. Given that only a relatively small percentage of pediatricians actively participate in the legislative process, one could be left with the false impression that few pediatricians actively engage in activities or behaviors that could be characterized as advocacy. There are many opportunities for pediatricians to act as advocates with regard to the health, safety, and welfare of maltreated children that may not have been clearly acknowledged as such in the past. This discussion reviews how general pediatricians can engage in advocacy activities on behalf of maltreated children by

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  Recognizing and responding to child maltreatment in a clinical setting

  
  
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  Appropriately reporting suspicions of child maltreatment

  
  
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  Working collaboratively with outside agencies as cases of possible child maltreatment are investigated

  
  
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  Providing support to children and families when child maltreatment is suspected or identified

  
  
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  Providing education related to issues concerning the maltreatment of children

  
  
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  Participating in the development of policies and legislation at local, state, and national levels

  
  
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  Recognizing how pediatricians can be personally affected by the maltreatment their patients experience and how this can impact their ability to provide effective care

Child maltreatment is a diagnosis that can be difficult to make, and responding to it can be even more difficult. It is these fundamental difficulties that make a willingness to consider that any patient, from any family, could potentially be impacted by child maltreatment an act of advocacy in and of itself.

Introduction

An advocate is often defined as a person who intercedes on behalf of another. Pediatricians, at their core, are essentially advocates for children. Most discussions related to pediatricians engaged in advocacy activities related to child maltreatment focus primarily on work done in the legislative and public policy arenas, with little or no attention paid to other areas in which advocacy occurs. Given that only a relatively small percentage of pediatricians actively participate in the legislative process, one could be left with the false impression that few pediatricians actively engage in activities or behaviors that could be characterized as advocacy. There are many opportunities for pediatricians to act as advocates with regard to the health, safety, and welfare of maltreated children that may not have been clearly acknowledged as such in the past. This discussion reviews how general pediatricians can engage in advocacy activities on behalf of maltreated children by

• •
  

  Recognizing and responding to child maltreatment in a clinical setting

  
  
• •
  

  Appropriately reporting suspicions of child maltreatment

  
  
• •
  

  Working collaboratively with outside agencies as cases of possible child maltreatment are investigated

  
  
• •
  

  Providing support to children and families when child maltreatment is suspected or identified

  
  
• •
  

  Providing education related to issues concerning the maltreatment of children

  
  
• •
  

  Participating in the development of policies and legislation at local, state, and national levels

  
  
• •
  

  Recognizing how pediatricians can be personally affected by the maltreatment their patients experience and how this can impact their ability to provide effective care

Child maltreatment is a diagnosis that can be difficult to make, and responding to it can be even more difficult. It is these fundamental difficulties that make a willingness to consider that any patient, from any family, could potentially be impacted by child maltreatment an act of advocacy in and of itself.

Scope of the problem and why advocacy by pediatricians remains essential

The US Department of Health and Human Services reported that in 2012, child protective services (CPS) agencies received an estimated 3.4 million reports of suspected child maltreatment, involving approximately 6.3 million children; 60% of these reports were made by professionals. Most of the reports from professionals come from teachers (approximately 16%); physicians have generally been responsible for approximately 8% of reports. The most common form of maltreatment was neglect, followed by physical abuse, sexual abuse, and psychological maltreatment. Many children experience more than one form of maltreatment, or more than one episode of maltreatment. There were 678,810 children who were substantiated as being maltreated in 2012. It is estimated that at least 1640 children died from abuse during 2012 in the United States, although it is likely that between 50% and 60% of child fatalities due to maltreatment are not recorded as such on death certificates. Child maltreatment has both immediate as well as long-term impacts on children and the adults they become. The cost to individuals, families, communities, and society as a whole is enormous. The estimated lifetime economic cost resulting from new cases of child maltreatment from a single year is more than $120 billion.

In addition to their direct contact with children and families, pediatricians work collaboratively with a broad range of medical as well as nonmedical professionals who can impact the health, development, and safety of children. Consequently, pediatricians are in a unique position to affect how children can be protected, and how abuse and neglect are recognized and responded to in a wide range of settings.

Advocacy within a medical setting

The most effective form of advocacy that most pediatricians will engage in with regard to child abuse and neglect is by being highly skilled doctors who are familiar with the resources of their communities, provide excellent clinical care to children and families, and know how to recognize child maltreatment and what to do when they encounter it. The day-to-day, year-to-year relationships that pediatricians develop with children and families allow them to not only see and diagnose maltreatment in the office setting, but also to learn about and respond to problems that are occurring in the home as well as other circumstances that may place a child at risk of abuse or neglect. Additionally, pediatricians work closely with other service providers, both medical and nonmedical, and are in a position to effectively advocate on behalf of children and families so that they can engage with services that can help promote the health and welfare of children.

A willingness to consider that child maltreatment may be an appropriate addition to a particular differential diagnosis is, by definition, necessary to diagnose child maltreatment. By recognizing that any patient could potentially be abused and that pediatricians need to respond appropriately when the problem presents itself, pediatricians are advocating for patients. Making a diagnosis of child abuse can create significant tensions between the family and the pediatrician, consume significant amounts of time and other resources in an office, and may require that the pediatrician communicate with CPS and law enforcement and potentially appear in court. Recognizing the importance of all of these activities, and being willing to engage in them despite the difficulties, are important forms of advocacy. The various forms of child maltreatment manifest from a wide variety of circumstances, risk factors, and events. Each form of maltreatment presents with its own unique management challenges, as well as different ways that pediatricians can advocate for their patients.

Physical abuse

Pediatricians recognize that injuries, including injuries caused by physical abuse, can potentially happen to any child, in any family. With most other types of medical conditions, a diagnosis is made in the context of parents or other care providers who give histories that are as accurate and as truthful as possible. One of the common elements in physical abuse cases is that the historical information provided by caregivers may be compromised: the history may be omitted, modified, or simply be a lie. The diagnosis of physical abuse is often made despite attempts to hide the injury, or the true cause of the injury, from a pediatrician.

Some cases of possible physical abuse may be missed due to the nonspecific nature of the symptoms, whereas others may be missed because the significance of the physical finding may not be recognized due to a lack of history. For example, most infants who present with fussiness and vomiting have some underlying medical problem as the cause of their symptoms, but some have occult trauma. A willingness to include and keep child maltreatment on a differential diagnosis allows pediatricians to provide medical care that ensures the fewest missed diagnoses of child abuse.

Advocacy related to assessing for possible physical abuse includes obtaining and documenting a thorough history. Although documentation in medical records regarding the history is often terse, in cases of possible child abuse, it is appropriate to expand on the history that is being recorded. Pediatricians are often the first care providers to evaluate a child who has an abusive injury. The initial history obtained by the pediatrician may prove to be very important as the evaluation for possible abuse unfolds. It is critical to get specific details as to how/when/where an injury reportedly occurred, using follow-up questions as needed. Taking the time to collect the history and document it in the medical record is a critical opportunity to advocate for the child’s welfare.

Although focused examinations of patients based on the chief complaint constitute a significant proportion of physical examinations done in a general pediatrician’s office, recognition of child abuse often requires a more comprehensive examination. Taking the additional time to fully undress a potentially injured infant who presents with “fussiness and vomiting” might reveal bruising hidden under clothes or a diaper, or point tenderness on an extremity overlying an undiagnosed fracture. Certain areas of the body, such as the front and back of the pinnae, the inside of the mouth, and inner aspects of the lips, may be injured but are unlikely to be recognized as such without specifically looking for injury at those sites. Injuries at these sites would raise a concern of possible abuse, especially in young/nonambulatory children.

In situations in which a concern for occult trauma is present, or when trauma has been recognized, but the history provided is troubling for some reason, it is often appropriate to obtain additional imaging studies or laboratory tests. Pediatricians are sometimes reluctant to order such studies. A skeletal survey in a child younger than 2 years who has a concerning injury or presentation has great value, as it may reveal occult injury. Obtaining a repeat skeletal survey 2 or 3 weeks after the initial study can potentially identify injuries that had not been recognized on the initial study. Skeletal surveys also can assist in identifying previously unrecognized bone abnormalities related to metabolic disease, dysplasia, and so forth. Pediatricians should get confirmation from the radiologists who are reading the skeletal survey that “babygrams” or other limited surveys are not being done, and that the recommended imaging studies from the American College of Radiology are being obtained. This is particularly important if the study is being conducted at a location that conducts primarily adult imaging studies.

Children will sometimes present with unintentional injuries that may for some reason (eg, severity, unusual nature) raise strong concerns for abuse. Ensuring that such mimics of child abuse are recognized as such is a vital role of the pediatrician. A complete history of the events that reportedly resulted in injury may reveal information that assists in recognizing that an injury occurred due to a previously unacknowledged accidental event. A comprehensive evaluation looking for an underlying medical issue that may be causing or contributing to an apparent injury is essential in cases of possible physical abuse. A thorough review of all relevant past medical history and family history should be conducted. Referring a child to a subspecialist, such as a hematologist, endocrinologist, or a child abuse pediatrician, for further evaluation may be very helpful in distinguishing cases of child maltreatment from mimics of abuse.