Child Neglect— Medical and Legal Implications April 18, 2019 Jeffrey Bomze, MD, FAAP 200 N. Wynnewood Ave.--# B417 Wynnewood, PA 19096 jeffrey.bomze@craftech.net

Most preventable form of child abuse: --Greater than 1500 fatalities/yr in US --Victims commonly under age 3 years --Victims commonly live in poverty

Definition of Child Neglect: Any action or failure to act which causes serious physical or emotional harm or puts the child at imminent risk for such harm --Multiple forms of abuse and maltreatment can coexist

Many forms of neglect: --Physical --Supervisory --Emotional --Educational --

Forms of neglect: --Nutritional --Medical --Dental

Physical neglect: Supervisory neglect: --failure to provide adequate food, clothing, shelter or hygiene Supervisory neglect: --inadequate supervision placing child at risk of physical, emotional and/or psychological harm

Emotional neglect: --failure to provide love, security, emotional support, psychological care when needed --failure to protect from exposure to domestic violence

Nutritional neglect: --failure to provide adequate nutrition to maintain physical growth and development --failure to prevent overnutrition-obesity and complications

Medical neglect: Dental neglect: --failure to prescribed medical care or treatment --failure to seek appropriate medical care in a timely manner Dental neglect: --failure to provide adequate dental care or treatment despite access to care

Educational neglect: --failure to enroll in school and ensure regular attendance --address special education needs

Factors impacting neglect: --accepted standards of care for children --role of communities --harm to child

Factors impacting neglect: --parents’ ability or intent --family’s resources—community resources --community norms

Family risk factors: --poverty, domestic violence --family stress, mental health/substance abuse --decreased social support, lack of knowledge

Evaluation: --Types of neglect --pattern of events --possible harm to child or potential harm --risk of imminent harm

Clinical presentations of neglect: --depends on type of neglect and any other types of abuse --occurs on a continuum

Physical neglect: --hygiene, lack of adequate clothing --injuries from lack of shelter—heat illness or frostbite

Supervisory neglect: --repeated burns, lacerations, fractures --serious injuries-MVAs, drownings, falls --burns, poisonings—“accidental trauma”

Emotional neglect: Educational neglect: --lack of emotional security --lack of follow up with psychological care Educational neglect: --truancy, poor attendance, homeschooling

Nutritional neglect: --malnutrition—undernutrition-failure to thrive --overnutrition—obesity with medical complications

Medical neglect: --serious illness and not signs not recognized or care sought --serious or life-threatening health conditions with lack of compliance with treatment plan or follow up --lack of primary care visits for at risk/complex children

Evaluation of neglect: --comprehensive history --social history: financial, education --psychosocial history: mental health, substance abuse --family history: domestic violence, criminal

Medical neglect: --most complex --continuum based on risk of harm and role of caregiver in neglect --? repeat neglect or risk to recur

Physical exam: --hygiene, clothing --nutritional status-hunger, diet-caution --height, weight, BMI, head circumference(< 2yo) --skin, muscle mass, hair, edema

Physical exam: --hair—infection, malnutrition, intentional --mouth—dental caries, abscesses --skin and nails—multiple scars and past injuries, ulcers, cracked or thin nails --unmanaged infections-scabies, lice

Additional studies-based on history, exam and concern --underweight-failure to thrive --obesity-complications-lipids, diabetes, liver --look for signs of physical abuse

Key factors in diagnosing neglect: --harm or imminent harm by caretaker’s action or inaction --type, severity, and frequency the neglect-minor injury from brief distraction --suspicion for physical, sexual and emotional abuse --? Continued deterioration despite education and family engagement in care

Differential diagnosis: --social factors versus physical or supervisory neglect --failure to thrive-can lead to cognitive bias preventing identification of medical illnesses --look for medical causes-undiagnosed conditions

Management-Report suspected abuse: --consult with child abuse team --multidisciplinary approach --report if suspicious for abuse, harm is done, interventions have failed, concern for other types of abuse

Management: --ensure patient safety-voluntary interventions or report to child protective services --hospitalization may be needed-dehydration, malnutrition/starvation, poisoning, burns, exacerbation of chronic disease, safety and discharge planning --hospitalize-chronic neglect, further evaluation, observe caregiver-child relationship

Education and documentation: --simple and clear treatment plan --family education-engage caregiver --follow up appointments --provide resources-insurance, transportation, nutritional assistance

Report to Child Protection: --child at risk of imminent harm --serious injury or serious medical illness caused by caretaker neglect --continued neglect despite resources --gross failure to provide adequate food, shelter, clothing, protection or education

Photo-documentation: --injuries, appearance, hygiene --nutritional status, skin condition --condition of any indwelling medical equipment

Religious objections to medical care: --most states with exemptions because of religious beliefs --respect parental religious beliefs and their role in child rearing --collaborative decisions

Religious objections to medical care: --legal issues when beliefs or practices interfere with appropriate medical care likely to prevent death or substantial harm or suffering --may need legal consultation for court authorization to override parental authority --may need to intervene if imminent threat to child’s life

Legal considerations: --need medical evidence of risk to minor’s life or health and consent requirements would delay care --need to report to child protective services --may need to consider referral to child protective services as temporary custody and/or court orders for treatment if not immediate need to treat

Religious exemptions: --American Academy of Pediatrics opposes religious exemptions when treatment is likely to prevent harm, suffering or death --Review of fatalities associated with religion-motivated medical neglect—over 80% would have had over 90% chance of survival with medical care

Sequelae of Neglect: --serious consequences in all domains of child development—physical, cognitive, emotional and social --post-traumatic stress disorder --effects in childhood on learning, parent-child interaction, high risk behavior, criminality --negative adult outcomes (heart disease, cancer, obesity, depression)