ECHO DIAGNOSING CHILD MALTREATMENT: THE CHALLENGES FACED BY CLINICIANS John M. Leventhal, M.D. Yale School of Medicine

GETTING IT RIGHT Recognizing if abuse has occured Doing an appropriate evaluation Reporting to CPS Ensuring the child’s safety

TODAY’S TALK Some Basics Clinical questions to be addressed Challenges when evaluating young children with suspected abuse Approach to data collection Framework for decision-making

INJURIES AND AGES Abuse: -- fractures -- burns -- head injuries -- bruises -- fractures -- burns -- head injuries -- abdominal injuries Neglect: -- recurrent injuries -- poor hygiene -- failure to thrive/delayed development Age: < 3 years and particular focus on < 12 mths

PRESENTATION TO HEALTH CARE PROVIDER No history of trauma (sometimes a recent history of minor trauma) Caregiver alone with child (abuse) Clinical presentations: Acute injury (eg, fracture) Injuries over time (eg, pattern of failure to provide supervision or adequate care)

DIFFERENTIAL DIAGNOSIS Accidental injuries Birth trauma Bleeding disorders Medical problem Maltreatment

CLINICAL QUESTIONS What happened to the child? Are the child’s finding due to trauma or a medical problem If trauma, are the injuries due to abuse, neglect, accident, or birth trauma?

CLINICAL QUESTIONS 4. Three related questions: a. Should the child be reported to DCF? b. Is it safe for the injured child to go home? c. If abuse occurred, when did it occur?

KEY CHALLENGES Making the correct diagnosis: Children with abusive injuries are often young and non-verbal History is provided by parent (who may be lying or does not know the details) Clinicians have biases about whether abuse should be considered in a case Some clinicians are “nervous” about the diagnosis

COLLECTION OF DATA History Physical exam Radiology/Laboratory Scene Investigation Interviewing others Background “checks”

WHAT I WANT TO KNOW What happened (without interruption) Specific details: -- When were first symptoms or worry noted about the child? -- How did symptoms develop over time? (level of alertness, breathing problems, seizures) -- Who was present?

WHAT I WANT TO KNOW -- How did the parent respond? (unusual activities) -- Whom did the parent call? -- Who decided to bring child for medical care (who called 911)? -- What was the decision based on? -- Was there a delay in seeking care?

WHAT I WANT TO KNOW Details of the day (and previous day(s)) -- who else saw or played with child -- who provided care to the child -- when was child acting normally Child’s developmental skills Any recent trauma or falls History of injuries, bruises, bleeding from mouth or nose (sentinel injuires) -- was child brought for medical care

ADDITIONAL HISTORY Past Medical History -- Birth history -- Pediatric care; immunization status -- Growth and development -- Medical problems

FAMILY/SOCIAL HISTORY Relevant family hx Mental health hx Previous DCF involvement History of drug or alcohol use History of domestic violence Troubles with the law

PHYSICIAL EXAMINATION Head: HC, anterior fontanelle, hematoma of scalp Eyes: subconjunctival hemorrhages, retinal hemorrhages Mouth: tear of frena Abdomen: enlarged liver, tenderness Genitals and anus Skin: bruises (TEN-4)(FACES)

Blood count Bleeding Studies Screening blood tests for liver injury LAB DATA Blood count Bleeding Studies Screening blood tests for liver injury

DIAGNOSTIC IMAGING CT of head MRI of head and spine Skeletal survey (and repeat in 2 weeks) CT with contrast of abdomen (if screening blood tests abnormal)

WHAT TO SAY IF WORRIED ABOUT ABUSE OR NEGLECT When I see an injury like your son’s, I need to worry about the possibility of child abuse, that he has been hurt by an adult, and I am obligated by state law to report the case to DCF. (The hospital requires that I report the case to DCF.) Do you know what that agency does?

DECISION-MAKING RELATED TO ABUSE Link history provided to child’s findings: -- mechanism -- severity -- timing Use Leventhal’s Triangle to plot: -- decision about reporting of suspected abuse -- diagnostic likelihood of abuse/maltreatment

LEVENTHAL’S TRIANGLE Accident Report Abuse Neglect Asnes & Leventhal. Pediatr Rev. 2010;31(2):47-55

LEVENTHAL’S TRIANGLE Accident Probable Maltreatment Abuse Neglect

SUMMARY Collect appropriate information to fit the pieces together and understand what happened Carefully consider the differential diagnosis Be clear about decision-making