CHILD ADVOCACY
CONSULTATION
10.21.15
Sarah Brown, DO, FAAP
Child Abuse Pediatrician
Child Advocacy Service
Bronson Children’s Hospital
Disclosures
• I work as an expert witness in Child Abuse
Medicine in criminal, probate, and civil litigation.
• I discuss off-label indications for medications and
therapeutics.
• I have no affiliations or financial relationships
related to any drug, therapeutic, or programming
to disclose.
Objectives
• Become confident fulfilling medical duties under
Michigan’s Child Protection Law.
• Provide care in accordance with recent guidelines
for medical care of sexual abuse victims.
• Evaluate patients for physical abuse in line with
American Academy of Pediatrics clinical reports.
• Refine emergency and routine referral indications
for patients needing Child Abuse Pediatrics
consultation.
Definition of Abuse
• Harm or threatened harm to a child that results
from the actions of a parent or caregiver.
• The abusive injury is the result of a caretaker’s
action, not the caretaker’s intent.
Types of Maltreatment
• Physical Abuse
• Sexual Abuse
• Emotional Abuse
• Medical Abuse “Munchausen’s By Proxy”
• Physical Neglect
– Nutritional Neglect: “Failure to Thrive”
• Medical Neglect
• Emotional Neglect
Child Abuse Incidence
• CPS (NCANDS) Data
– Physical abuse incidence: 2/1000
• Telephone surveys of parents
– Physical abuse: 4-5/1000
– Shaking child under 2: 10/1000 = 1%
• National Incidence Study
– Neglect: >20/1000 = >2%
– Physical abuse: 5.7/1000
• Prevalence: Survey adults (ACE studies)
– Physical abuse 27-30%
– Sexual abuse
Women: 1 in 4 Men: 1 in 6
2006: 4569
hospitalizations
Medicaid infants: 133/100,000 risk of hospitalization
for serious physical abuse
Levanthal, 2012
You are a mandated reporter
A physician [and others!] who has reasonable
cause to suspect child abuse or neglect shall make
immediately, by telephone or otherwise, an oral
report, or cause an oral report to be made, of the
suspected child abuse or neglect to the
department. Within 72 hours after making the oral
report, the reporting person shall file a written
report as required in this act.
855-444-3911
Michigan mandated reporters
•
•
•
•
•
•
•
•
•
•
•
•
physician, physician’s assistant, nurse, medical examiner
dentist, registered dental hygienist
person licensed to provide emergency medical care
audiologist
psychologist, marriage & family therapist, licensed
professional counselor
social worker, LBSW, LMSW
registered social service technician, social service technician
friend of the court employees
school administrator, school counselor, teacher
law enforcement officer
member of the clergy
regulated child care provider
You are a mandated reporter
If the reporting person is a member of a hospital or
agency, the reporting person shall notify the
person in charge of the hospital/agency of his or
her finding and that the report has been made, and
shall make a copy of the written report available to
the person in charge. A notification to the person in
charge does not relieve the member of the staff of
the obligation of reporting to the department. One
report from a hospital/agency shall be considered
adequate to meet the reporting requirement.
Detention of child in temporary
protective custody
(1) If a child suspected of being abused or neglected is
admitted to a hospital or brought to a hospital for outpatient
services and the attending physician determines that the
release of the child would endanger the child's health or
welfare, the attending physician shall notify the person in
charge and the department [CPS]. The person in charge may
detain the child in temporary protective custody until
the next regular business day of the probate court, at
which time the probate court shall order the child detained in
the hospital or in some other suitable place pending a
preliminary hearing as required by section 14 of chapter 12A of
the probate code of 1939, 1939 PA 288, MCL 712A.14, or order
the child released to the child's parent, guardian, or custodian.
Religious Beliefs
A parent or guardian legitimately practicing his
religious beliefs who thereby does not provide
specified medical treatment for a child, for that
reason alone shall not be considered a negligent
parent or guardian. This section shall not
preclude a court from ordering the provision
of medical services or non-medical remedial
services recognized by state law to a child where
the child’s health requires it nor does it
abrogate the responsibility of a person
required to report child abuse or neglect.
Medical Care after Sexual Assault
What is an emergency?
• Medical, psychological or safety concerns such as
acute pain or bleeding, suicidal ideation, or
suspected human trafficking.
• Alleged assault that may have occurred within
120 hours (5 days).
• Need for emergency contraception.
– Effective for 120 hours
• Need for post-exposure prophylaxis for STIs.
– Gonorrhea and chlamydia – any time
– HIV – must start within 72 hours (sooner = better)
Adams et al., 2015
What is an emergency?
• Medical, psychological or safety concerns such as
acute pain or bleeding, suicidal ideation, or
suspected human trafficking.
ER
• Alleged assault that may have occurred within
120 hours (5 days).
• Need for emergency contraception.
– Effective for 120 hours
• Need for post-exposure prophylaxis for STIs.
– Gonorrhea and chlamydia – any time
– HIV – must start within 72 hours (sooner = better)
Adams et al., 2015
333.21527 Sexual medical forensic examination
(1) If an individual alleges to a physician or … hospital that
within the preceding 120 hours the individual has been the
victim of criminal sexual conduct … [the physician or staff]
shall inform the individual of the availability of a sexual
assault medical forensic examination, including the
administration of a sexual assault evidence kit. If consented
to by the individual, the attending health care personnel shall
perform or have performed on the individual the sexual
assault medical forensic examination, including the procedures
required by the sexual assault evidence kit. The attending
health care personnel shall also inform the individual of the
provisions for payment for the sexual assault medical
forensic examination under section 5a of 1976 PA 223, MCL
18.355a.
Bronson Child Advocacy Services
•
•
•
•
Inpatient consultations
24/7 nurse triage
24/7 emergency sexual assault exams
Monday-Wednesday-Friday clinic
• 1-800-BRONSON = 1-800-276-6766
– ask for the Child Advocacy Nurse on call
• Clinic Phone: 269.341.8909
• Child.Advocacy@bronsonhg.org
Suspected Physical Abuse
Indicators to Initiate Guideline
HISTORY
EXAM
• Child reports assault or inflicted injury.
• There is no history of an injury event in a child
with physical injuries.
• Observed injuries are not consistent with
stated injury event.
• Child is not developmentally capable of stated
injury event (especially infants).
• History of injury event changes substantially
over time (especially if the history changes as
more injuries are found).
• History of injury event lacks expected detail.
• There is a delay in calling 911 or seeking
reasonable medical care, beyond our
expectations of a reasonable caregiver.
• Inappropriate parent-child interaction
(witnessed or reported).
• Signs of medical neglect: immunizations not
up-to-date, missed well child visits, no
identified primary care physician.
• Indication that caregiver was under the
influence of alcohol or drugs at the time of the
injury.
• History of seeking health care from multiple
sites and settings.
• Any bruise in an infant or child who does not pull to stand. For walking
children, any bruise in an unexpected location (especially Ears, Neck,
Abdomen, Genitals, Hands, Feet). Small bruises over the forehead,
zygomatic arch, elbow/forearm, iliac crest, lumbar spine, greater
trochanter, shin are often caused by minor accidents in walking children.
• Bruises, marks, or scars in patterns suggesting inflicted injury.
• Burns not consistent with stated or presumed injury (especially “dip”
pattern burns or burn patterns suggestive of branding).
• Intra-oral injuries (including frenulum tears) not explained by injury event.
• Rapidly enlarging head circumference or macrocephaly in infants.
• Genital or anal injuries not explained by injury event.
• Any other significant injury not explained by injury event.
RADIOLOGY
•
•
•
•
•
•
Fracture in an infant or child who cannot walk.
Multiple fractures.
An unexpected finding of a healing fracture.
Metaphyseal fracture (also known as “bucket-handle”, “corner”, “chip”).
Rib fracture (especially posterior or multiple).
Complex or basilar skull fracture, epidural hematoma (EDH), subdural
hematoma (SDH), subarachnoid hematoma (SAH), brain contusions,
cerebral edema, and anoxic/hypoxic brain injury not explained by injury
event, especially in young children.
• Any other significant injury not adequately explained.
Suspected Physical Abuse
Indicators to Initiate Guideline
HISTORY
•
•
•
•
EXAM
• Child reports assault or inflicted injury.
• Any bruise in an infant or child who does not pull to stand. For walking
• There is no history of an injury event in a child
children, any bruise in an unexpected location (especially Ears, Neck,
with physical injuries.
Abdomen, Genitals, Hands, Feet). Small bruises over the forehead,
• Observed injuries are not consistent with
zygomatic arch, elbow/forearm, iliac crest, lumbar spine, greater
Observed
injuries are not consistent with
stated injury event.
stated injury event.
trochanter, shin are often caused by minor accidents in walking children.
•Child
Child isisnot
developmentally
capable of stated
marks,
or scars
in patterns
suggesting inflicted
injury.
not
developmentally
capable •ofBruises,
stated
injury
event
(especially
infants).
injury event (especially infants).
• Burns not consistent with stated or presumed injury (especially “dip”
History of injury event changes substantially
over time.
• History of injury event changes substantially
pattern burns or burn patterns suggestive of branding).
over time (especially
the historychanges
changes as as more
• Intra-oral
injuries
(including
frenulum tears) not explained by injury event.
(especially
if theif history
injuries
are
found).
more injuries are found).
• Rapidly enlarging head circumference or macrocephaly in infants.
History of injury event lacks expected• detail.
• History of injury event lacks expected detail.
Genital or anal injuries not explained by injury event.
• There is a delay in calling 911 or seeking
• Any other significant injury not explained by injury event.
reasonable medical care, beyond our
expectations of a reasonable caregiver.
RADIOLOGY
• Inappropriate parent-child interaction
• Fracture in an infant or child who cannot walk.
(witnessed or reported).
• Multiple fractures.
• Signs of medical neglect: immunizations not
• An unexpected finding of a healing fracture.
up-to-date, missed well child visits, no
• Metaphyseal fracture (also known as “bucket-handle”, “corner”, “chip”).
identified primary care physician.
• Rib fracture (especially posterior or multiple).
• Indication that caregiver was under the
• Complex or basilar skull fracture, epidural hematoma (EDH), subdural
influence of alcohol or drugs at the time of the
hematoma (SDH), subarachnoid hematoma (SAH), brain contusions,
injury.
cerebral edema, and anoxic/hypoxic brain injury not explained by injury
• History of seeking health care from multiple
event, especially in young children.
sites and settings.
• Any other significant injury not adequately explained.
Suspected Physical Abuse
Indicators to Initiate Guideline
HISTORY
EXAM
• Child reports assault or inflicted injury.
• Any bruise in an infant or child who does not pull to stand. For walking
in an any
infant
child
wholocation
does (especially
not pullEars,
to Neck,
stand.
• There is no history of an injury event in• aAny
child bruisechildren,
bruiseor
in an
unexpected
with physical injuries.
Genitals,
Feet).inSmall
over the forehead,
For walkingAbdomen,
children,
anyHands,
bruise
an bruises
unexpected
location
• Observed injuries are not consistent with
zygomatic arch, elbow/forearm, iliac crest, lumbar spine, greater
(especiallytrochanter,
Ears, Neck,
Hands,
Feet).
stated injury event.
shin areAbdomen,
often caused byGenitals,
minor accidents
in walking
children.
• Child is not developmentally capable of stated
• Bruises,
marks,
scars in patterns
suggesting inflicted
injury.
Small bruises
over
theor forehead,
zygomatic
arch,
injury event (especially infants).
• Burns not consistent with stated or presumed injury (especially “dip”
elbow/forearm,
iliacorcrest,
lumbar
spine,
greater trochanter,
• History of injury event changes substantially
pattern burns
burn patterns
suggestive
of branding).
over time (especially if the history changes
as are •often
Intra-oral
injuries by
(including
frenulum
tears) not
by injury
event.
shin
caused
minor
accidents
inexplained
walking
children.
more injuries are found).
• Rapidly enlarging head circumference or macrocephaly in infants.
• Bruises, marks,
oranal
scars
innot
patterns
suggesting
• History of injury event lacks expected detail.
• Genital or
injuries
explained by
injury event. inflicted injury.
• There is a delay in calling 911 or seeking
• Any other significant injury not explained by injury event.
reasonable medical care, beyond our
expectations of a reasonable caregiver.
RADIOLOGY
• Inappropriate parent-child interaction
• Fracture in an infant or child who cannot walk.
(witnessed or reported).
• Multiple fractures.
• Signs of medical neglect: immunizations not
• An unexpected finding of a healing fracture.
up-to-date, missed well child visits, no
• Metaphyseal fracture (also known as “bucket-handle”, “corner”, “chip”).
identified primary care physician.
• Rib fracture (especially posterior or multiple).
• Indication that caregiver was under the
• Complex or basilar skull fracture, epidural hematoma (EDH), subdural
influence of alcohol or drugs at the time of the
hematoma (SDH), subarachnoid hematoma (SAH), brain contusions,
injury.
cerebral edema, and anoxic/hypoxic brain injury not explained by injury
• History of seeking health care from multiple
event, especially in young children.
sites and settings.
• Any other significant injury not adequately explained.
Suspected Physical Abuse
Indicators to Initiate Guideline
HISTORY
EXAM
• Child reports assault or inflicted injury.
• There is no history of an injury event in a child
with physical injuries.
• Observed injuries are not consistent with
stated injury event.
• Child is not developmentally capable of stated
injury event (especially infants).
• History of injury event changes substantially
over time (especially if the history changes as
more injuries are found).
• History of injury event lacks expected detail.
• There is a delay in calling 911 or seeking
reasonable medical care, beyond our
expectations of a reasonable caregiver.
• Inappropriate parent-child interaction
(witnessed or reported).
• Signs of medical neglect: immunizations not
up-to-date, missed well child visits, no
identified primary care physician.
• Indication that caregiver was under the
influence of alcohol or drugs at the time of the
injury.
• History of seeking health care from multiple
sites and settings.
• Any bruise in an infant or child who does not pull to stand. For walking
children, any bruise in an unexpected location (especially Ears, Neck,
Abdomen, Genitals, Hands, Feet). Small bruises over the forehead,
zygomatic arch, elbow/forearm, iliac crest, lumbar spine, greater
trochanter, shin are often caused by minor accidents in walking children.
• Bruises, marks, or scars in patterns suggesting inflicted injury.
• Burns not consistent with stated or presumed injury (especially “dip”
pattern burns or burn patterns suggestive of branding).
• Intra-oral injuries (including frenulum tears) not explained by injury event.
• Rapidly enlarging head circumference or macrocephaly in infants.
• Genital or anal injuries not explained by injury event.
• Any other significant injury not explained by injury event.
RADIOLOGY
•
•
• Fracture in a non-mobile infant or child. Exception: linear parietal skull
Fracture
in an
infant
or child
whoand
cannot
fractures with
adequate
explanation
of injury
no socialwalk.
concerns.
Multiple fractures.
Multiple
fractures.
• An unexpected finding of a healing fracture.
An
unexpected
finding
of asa “bucket-handle”,
healing fracture.
• Metaphyseal
fracture
(also known
“corner”, “chip”).
• Rib fracture (especially posterior or multiple).
• Complex or basilar skull fracture, epidural hematoma (EDH), subdural
hematoma (SDH), subarachnoid hematoma (SAH), brain contusions,
cerebral edema, and anoxic/hypoxic brain injury not explained by injury
event, especially in young children.
• Any other significant injury not adequately explained.
Suspected Physical Abuse Guideline
Consult MSW
Physical Abuse enters Differential Diagnosis
Photodocumentation
of all visible findings
Decide together whether
concerns warrant
by hospital staff, CPS, or police
Reminder: CPS cannot take
photos of genitals/anus
Physical Exam to include entire skin
report to CPS
1-855-444-3911
surface, detailed HEENT, and anogenital
send DHS-3200 form
http://michigan.gov/ search 3200
Altered LOC or any other indicator of drug/toxin exposure: order both
•
MSW takes additional
social history and manages
visitors, considers 1:1 staff
supervision, identifies
other at-risk children
•
Bronson Test: “Drug Screen, urine, 8”, positives order Mayo Test: CDA7X “Drug Abuse Survey with Confirmation,
Panel 9, Chain of Custody, Urine”. Bronson also can run methadone, oxycodone, buprenorphine, tricyclic screens.
Mayo Test: PDSUX “Drug Screen, Prescription/OTC, Chain of Custody, Urine”
0-5 months of age
• *CT Head
• Bone Survey
6-23 months of age
• Bone Survey
• *CT Head if
*Alternatively, MRI
Brain if clinically well
and low suspicion for
skull fracture
24+ months of age
• Plain films of areas that are
- face/scalp/neck injury
- rib fracture/chest injury
- witnessed/confessed
shaking or head injury
*Alternatively, MRI Brain
as described in 0-5 months
painful/swollen/deformed
Consider Bone Survey if more
than 2 areas, difficult exam,
developmental delay
• CT Head if indicated by
history or visible injuries
Consider CT C-Spine
based on identified injuries
Poor po, vomiting, abdominal pain, blood
in stool, abdominal bruising, distention,
hypoactive bowel sounds
Yes
CT Abdomen/Pelvis
Elevated/positive results
with IV contrast
Lab screening: CMP, lipase, UA,
No
consider occult blood, stool
Suspected Abusive Bruising
Suspicious
bruising
identified
Does child pull to a stand?
No
Bleeding
Disorder
Evaluation
not needed.
Return to
Suspected
Physical
Abuse
Guideline
Yes
•
•
•
•
No
Patient clearly describes cause of injury
Independent witness describes cause of injury
Bruising is patterned (e.g. “handprint” “belt mark”)
Patient has a separate injury that is clearly abusive
(fracture, burn, abdominal trauma, etc.)
Indicators for bleeding disorder evaluation:
•
•
•
•
•
•
•
•
•
Yes
Small non-patterned bruises over bony
prominences (forehead, zygomatic arch,
elbow/forearm, iliac crest, lumbar spine,
greater trochanter, shin)
Circumcision or medical procedure bleeding
Bleeding from umbilical stump
Family history of specific bleeding disorder
Ethnic heritage: e.g. Ashkenazi Jew (Factor XI)
Petechiae at clothing pressure lines
Bruising at pressure points (like from seatbelts)
Recurrent epistaxis
Excessive bleeding with dental work
Extensor surface bruises larger than expected
No
Clinical suspicion for von
Willebrand persists?
May need repeat testing,
referral to bleeding clinic
Current or previous
mucocutaneous bleeding?
Add platelet aggregation testing
Yes
Less
suspicious
for abuse
• Screen for occult injuries
according to Suspected
Physical Abuse Guideline
• CBC, CMP, PT, aPTT,
Factor IX (9) Activity,
von Willebrand Profile
(Mayo Test: VWPR)
• Identify medications/
toxins/supplements that
predispose to bleeding
• Clinical evaluation for
medical conditions that
predispose to bleeding
(Cancer, Ehlers-Danlos,
Scurvy, etc.)
Bronson Child Advocacy Services
•
•
•
•
Inpatient consultations
24/7 nurse triage
24/7 emergency sexual assault exams
Monday-Wednesday-Friday clinic
• 1-800-BRONSON = 1-800-276-6766
– ask for the Child Advocacy Nurse on call
• Clinic Phone: 269.341.8909
• Child.Advocacy@bronsonhg.org
Case
• 3 mo Caucasian male presents to Urgent
Care Center with facial bruising
• Mom discovered marks after arriving
home tonight
• Cared for by Mom’s LTP during the day
• LTP states child banged himself in the
head repeatedly with a plastic toy.
3 mo male, facial bruising
• Child has been fussy, but otherwise eating
well, sleeping well, no fevers, no
symptoms of illness
• No family history of bleeding or bruising
disorders
3 mo male, facial bruising
Case #2: 3 mo male, facial bruising
Your job now
• Assess for additional injuries
• Rule out other causes
• Protect the child from further harm
3 mo male, facial bruising
Thank you!
bronsonhealth.com
brownsa@bronsonhealth.org