Recognition and Evaluation of Child Maltreatment Elective Description
Introduction
Child abuse and neglect is a significant problem in the United States. In 2007, approximately 3.5
million children received an investigation by child protective services (CPS) agencies for
possible maltreatment. An estimated 753,357 children were found to be victims; a rate of 10.6
per 1,000 children.1 Neglect was the most common type of maltreatment, followed by physical
abuse and then sexual abuse. Identifying victims of child abuse, and ensuring their safety is a
multidisciplinary effort involving CPS, Law Enforcement and Health Care Professionals.
Pediatricians play a critical role by in the diagnosis, treatment and prevention of abuse by
working with CPS and police investigators, providing expert testimony in court, and raising
awareness through education. All physicians are legally mandated to report suspicions of child
abuse.
In spite of its prevalence, several studies have demonstrated that physicians are often unprepared
to recognize and address child abuse issues. One study of abusive head trauma found that 31%
of abusive head trauma victims were not recognized by the physicians who first evaluated them.
Of those missed children, 28% were reinjured and 41% had medical complications as a result of
the delay in diagnosis.2 In 1987, a survey of family practitioners and pediatricians found that a
significant number of physicians were unable to correctly identify structures on a photograph of
female prepubertal genitalia.3 A similar survey of pediatric chief residents in 2005 yielded
similar results, with only 64% correctly identifying the hymen. Half of the chief residents
surveyed thought that their residency training on sexual abuse was inadequate.4 Other studies
have also found that residency training in child abuse was inadequate.5, 6
Since victims of abuse may present to a physician in a variety of circumstances, a basic
understanding of child abuse is fundamental to the practice of pediatrics, regardless of the area of
specialty. Pediatricians are mandated reporters and their ability to recognize abuse and make the
appropriate referrals will depend upon their degree of knowledge and confidence. This elective
will provide residents with the tools necessary to identify and evaluate children who may be
maltreated. Furthermore, the skills acquired during this elective are applicable to all areas of
pediatrics. These skills include taking a detailed history, learning to do a thorough physical
exam, and working with other medical and non-medical professionals as part of a
multidisciplinary effort to address the patient’s health care needs.
The Suspected Child Abuse and Neglect (SCAN) Service at Doernbecher Children’s Hospital
(DCH) consists of a pediatrician and nurse practitioner, and provides consultations to the
inpatient units, emergency department and outpatient clinics. The SCAN service works closely
with the Social Work Department. In addition, both members of the service see patients at
CARES Northwest (CNW), the primary outpatient child abuse facility in Portland. The
physicians at CNW also provide consultations for patients at The Children’s Hospital at Emanuel
(CHE). The volume of consults at DCH and CHE, as well as at CNW will ensure that residents
are exposed to a wide range of child abuse topics. The residents will also be able to view
forensic interviews at CNW and attend court proceedings.
Ideally, residents will devote 4 weeks to this rotation but shorter periods can be accommodated
as well. Residents will maintain their ½ day of continuity clinic during the rotation. The rotation
can accommodate only one resident at a time.
Recognition and Evaluation of Child Maltreatment Elective
Information for Residents
Elective Directors:
Thomas J. Valvano, MD, JD
Medical Director, SCAN Service, Doernbecher Children’s Hospital
Assistant Professor of Pediatrics, Oregon Health & Science University
Pager: 13551
Phone: 503-494-8366
Dan E. Leonhardt, MD
Attending Physician, The Children’s Hospital at Legacy Emanuel
Examiner, CARES Northwest
dleonhar@lhs.org
On the first day of the elective: Page Dr. Valvano (13551) the day before or the morning of the
elective for orientation.
Schedule: Will be provided at orientation
Resources: A CD containing required reading, case scenarios, and List of References will be
provided at the start of the elective.
Medical Knowledge Competency Expectations for Elective in Child Abuse:
1. Recognize the effects of neglect and failure to thrive on a child’s physical and mental health,
school performance and social development
2. Recognize behaviors that raise a suspicion of medical child abuse, including:
a. Symptoms that cannot be confirmed
b. Symptoms that occur only in the presence of one caregiver
c. Histories provided by a caregiver that are inconsistent with the medical records
d. Seeking treatment from multiple medical providers or frequently changing providers
3. Identify histories associated with abuse such as:
a. Absence of history of trauma
b. Histories that are inconsistent between caregivers or that change over time
c. History inconsistent with injury pattern
d. History inconsistent with child’s development
e. History of minor trauma to explain severe injury
4. Learn the components of a skeletal survey and when one should be obtained
5. Compare the advantages of CT and MRI
6. Learn the range of presenting symptoms for abusive head trauma
7. Learn the injuries associated with rotational forces including large convexity subdural
hemorrhage and shearing injury to the brain
8. Understand the patterns of retinal hemorrhages and their association with abusive head
trauma
9. Recognize the significance of rib and metaphyseal fractures and their association with
abusive head trauma
10. Learn the injuries associated with short distance falls and stairway falls
11. Know the areas where normal bruising occurs and the areas associated with inflicted bruises
12. Understand the association between age, development and accidental bruises
13. Identify pattern injuries such as loop marks, slap marks, strap marks, bites
14. Understand why bruises cannot be dated by appearance
15. Identify patterns of abusive burns such as inflicted immersion and contact burns
16. Learn the types of forces necessary to cause transverse, spiral, oblique and buckle fractures
17. Identify complex skull fracture patterns and recognize their association with abuse
18. Identify evidence of healing of fractures on x-ray and interpret the significance of healing
fractures in the context of the medical history provided
19. Learn normal male and female genital anatomy
20. Recognize behaviors that are concerning for sexual abuse, including:
a. Imitation of adult sexual behavior
b. Mimicking sexual acts with objects
c. Sexual aggression towards other children
21. Know which birth marks, bleeding disorders, skin infections and other conditions can be
confused with abusive injuries
22. Recognize folk remedies including cupping and coining
23. Know the differential diagnosis for fractures, including Osteogenesis Imperfecta
24. Know when and how to report a suspicion of child abuse
25. Know how to accurately document and photograph suspicious injuries
26. Understand the different types of court proceedings and how the level of proof varies.
Activities on the elective to facilitate your learning:
1. Participation in inpatient child maltreatment consults as a member of the DCH SCAN team
or the CHE abuse team. These teams consist of an attending physician, social worker and
nurse practitioner.
2. Participation in outpatient child maltreatment evaluations at CNW. The resident will work
with physician and nurse practitioner examiners.
3. Observation of forensic interviews of children at CNW.
4. Participation in meetings with CPS and police investigators regarding ongoing abuse
evaluations.
5. Attendance at county multidisciplinary team (MDT) meetings. Participants at these meetings
include police, Department of Human Services, the District Attorney’s Office, DCH and
CNW.
6. Attendance at criminal or child protection court proceedings at which a medical provider is
testifying.
7. Shadow a CPS worker for a day.
8. Review of journal articles and video presentations on common child abuse topics to ensure
knowledge of all types of child maltreatment.
9. A series of 8 child abuse case scenarios to complete. Each case, which is presented in
PowerPoint format, covers a particular topic (e.g. burns, fractures, sexual abuse), and
includes photographs, imaging studies and laboratory results. Each case contains a series of
questions to be answered by the resident. At the end of the rotation, the resident will
complete the case scenarios with an attending physician as an interactive process to assess
and reinforce the resident’s knowledge of the rotation’s core concepts.
How you will be evaluated:
1. Completion of list of required journal articles and video presentations covering the core
concepts of child abuse and neglect.
2. Satisfactory completion of a series of 8 child abuse case scenarios developed as a way of
assessing resident comprehension of the fundamental issues in child abuse and neglect.
3. Assessment of resident’s professionalism, participation, and ability to function as part of a
multidisciplinary team through the global evaluation and multi-source feedback.
References:
1. US Department of Health and Human Services, Administration on Children, Youth and
Families. Child Maltreatment 2007. Washington, DC: US Government Printing Office;
2009
2. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive
head trauma. JAMA. 1999;281:621-626
3. Ladson S, Johnson CF, Doty R. Do physicians recognize sexual abuse? Am J Dis Child.
1987;141:411-415
4. Dubow SR, Giardino AP, Christian CW, Johnson CF. Do pediatric chief residents
recognize details of prepubertal female genital anatomy: a national survey. Child Abuse
& Neglect. 2005; 29:195-205
5. Narayan, AP, Socolar RRS, St Claire K. Pediatric residency training in child abuse and
neglect in the United States. Pediatrics. 2006;117:2215-2221
6. Woolf A, Taylor L, Melnicoe L, et al. What residents know about child abuse:
implications of a survey of knowledge and attitudes. Am J Dis Child. 1988;142:668-672
Recognition and Evaluation of Child Maltreatment Elective Curriculum
Goal #1: Understand that child maltreatment occurs in all racial, ethnic and socioeconomic groups.
Objectives
a. Accept that any parent or other caregiver can abuse a child
b. Identify risk factors or stressors which increase the
likelihood of abuse
Evaluation Method
Competencies Addressed
√ MK
√ PC
Global elective eval
Completion of child
□P
abuse case scenarios with □ ICS
an attending physician at
□ PBL
□ SBP
the end of the rotation
Goal #2: Become familiar with the different types of child maltreatment; including the various forms of physical, sexual and psychological abuse,
neglect, and medical child abuse.
Objectives
a. Recognize the effects of neglect and failure to thrive on
a child’s physical and mental health, school
performance and social development
b. Recognize behaviors that raise a suspicion of medical
child abuse




Instructional Strategy
Journal articles
Readings
Video presentations
Case scenarios


Instructional Strategy
Evaluation Method
Competencies Addressed
√ MK
√ PC
Participation in inpatient
 Global elective eval
child maltreatment
 Completion of child
□P
consults as a member of
abuse case scenarios with □ ICS
the DCH SCAN team or
an attending physician at
□ PBL
□ SBP
the CHE abuse team.
the end of the rotation
 Journal articles
 Readings
 Video presentations
 Case scenarios
Goal #3: Learn how to diagnose child abuse through the use of history, physical exam, laboratory analysis and imaging studies.
a.
b.
c.
d.
e.
f.
Objectives
Perform a detailed medical history that includes a time
line of events leading to the injury, past medical history,
developmental history, family history and social history
Identify histories associated with abuse
Identify the components of a skeletal survey and when
one should be obtained
Compare the advantages of CT and MRI
Recognize when to obtain coagulopathy screening labs
and how to interpret the results
Understand the importance of abdominal screening labs



Instructional Strategy
Participation in inpatient
child maltreatment
consults as a member of
the DCH SCAN team or
the CHE abuse team.
Participation in outpatient
child maltreatment
evaluations at CNW.


Evaluation Method
Global elective eval
Direct observation with
feedback
Competencies Addressed
√ MK
√ PC
√ ICS
□P
□ PBL
□ SBP
Goal #4: Understand the risk factors, clinical presentation and key features of abusive head trauma.
Objectives
a. Identify the range of presenting symptoms for abusive
head trauma
b. Describe the injuries associated with rotational forces
including large convexity subdural hemorrhage and
shearing injury to the brain
c. Understand the patterns of retinal hemorrhages and
their association with abusive head trauma
d. Recognize the significance of rib and metaphyseal
fractures and their association with abusive head trauma
e. Describe the injuries associated with short distance falls
and stairway falls





Instructional Strategy
Participation in inpatient
child maltreatment
consults as a member of
the DCH SCAN team or
the CHE abuse team.
Journal articles
Readings
Video presentations
Case scenarios


Evaluation Method
Global elective eval
Completion of child
abuse case scenarios with
an attending physician at
the end of the rotation
Competencies Addressed
√ MK
√ PC
□ ICS
□P
□ PBL
□ SBP
Goal #5: Learn how the pathophysiology of bruises and burns is used to differentiate between inflicted and unintentional injuries.
Objectives
a. Recognize the bodily areas where normal bruising
occurs and the areas associated with inflicted bruises
b. Understand the association between age, development
and accidental bruises
c. Identify pattern injuries such as loop marks, slap marks,
strap marks, bites
d. Describe why bruises cannot be dated by appearance
e. Identify patterns of abusive burns such as inflicted
immersion and contact burns





Instructional Strategy
Participation in inpatient
child maltreatment
consults as a member of
the DCH SCAN team or
the CHE abuse team.
Journal articles
Readings
Video presentations
Case scenarios


Evaluation Method
Global elective eval
Completion of child
abuse case scenarios with
an attending physician at
the end of the rotation
Competencies Addressed
√ MK
√ PC
□ ICS
□P
□ PBL
□ SBP
Goal #6: Understand the roles of bone biomechanics and healing patterns in the evaluation of inflicted and unintentional fractures.
Objectives
Instructional Strategy
Evaluation Method
Competencies Addressed
a. Describe the types of forces necessary to cause
√
MK
√ PC
 Participation in inpatient
 Global elective eval
transverse, spiral, oblique and buckle fractures
child maltreatment
 Completion of child
b. Identify complex skull fracture patterns and recognize
□P
consults as a member of
abuse case scenarios with □ ICS
their association with abuse
the DCH SCAN team or
an attending physician at
c. Identify evidence of healing of fractures on x-ray and
□ PBL
□ SBP
the CHE abuse team.
the end of the rotation
interpret the significance of healing fractures in the
 Journal articles
context of the medical history provided
 Readings
 Video presentations
Goal #7: Learn how to examine and treat victims of sexual abuse, including how characteristics of the genital anatomy affect physical exam findings.
Objectives
a. Recognize normal male and female genital anatomy
b. Recognize behaviors that are concerning for sexual
abuse
c. Understand why most genital and anal exams of abused
children are normal
d. Understand appropriate testing for sexually transmitted
infections
e. Understand the process of forensic evidence collection



Instructional Strategy
Participation in outpatient
child maltreatment
evaluations at CNW
Observation of forensic
interviews of children at
CNW
Case scenarios


Evaluation Method
Global elective eval
Completion of child
abuse case scenarios with
an attending physician at
the end of the rotation
Competencies Addressed
√ MK
√ PC
□ ICS
□P
□ PBL
√ SBP
Goal #8: Recognize medical conditions, normal variants, and folk remedies with clinical presentations that mimic abuse.
Objectives
Instructional Strategy
Evaluation Method
Competencies Addressed
a. Describe how birth marks, bleeding disorders, skin
√ MK
√ PC
 Participation in outpatient  Global elective eval
infections and other conditions can be confused with
child maltreatment
 Completion of child
abusive injuries
□P
evaluations at CNW
abuse case scenarios with □ ICS
b. Recognize signs of folk remedies including cupping and  Observation of forensic
an attending physician at
coining
□ PBL
□ SBP
interviews of children at
the end of the rotation
c. List the differential diagnosis for fractures
CNW
 Case scenarios
Goal #9: Understand how the physician collaborates with CPS, law enforcement and the court system in the investigation of child abuse allegations.
Objectives
a. Indicate when and how to report a suspicion of child
abuse
b. Accurately document and photograph suspicious
injuries
c. Understand the role of the multidisciplinary team,
including law enforcement, child protective services
and the legal system, in evaluating child abuse
d. Understand the different types of court proceedings and
how the level of proof differs.




Instructional Strategy
Participation in meetings

with CPS and police

investigators regarding
ongoing abuse evaluations.
Attendance at county
multidisciplinary team
(MDT) meetings
Attendance at criminal or
child protection court
proceedings at which a
medical provider is
testifying.
Shadow a CPS worker for
a day
Evaluation Method
Attendance records
Personal reflection
Competencies Addressed
√ MK
√ PC
√ ICS
√ P
□ PBL
√ SBP