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Scenario: What is the role of the physician when child abuse is suspected?

How should the doctor proceed in screening for child abuse? To whom can a generalist refer a complex case? How does the physician talk to parents when there are signs of physical abuse? Do you tell the parents or guardians that you are obligated to report abuse to the authorities?

Reply:

Becoming involved with a situation that is possibly child abuse or neglect presents dilemmas for the physician, who often experiences angst about continuing a relationship with parents while simultaneously suspecting child maltreatment. Retaining a professional demeanor can be difficult when confronting caregivers who might have inflicted serious emotional or physical trauma on a child.

Certainly, the time required to work through a case is disruptive to schedules and may not be eligible for payment. There are standard diagnostic codes and modifiers for reporting medical services related to child abuse, but the reimbursement rate is extremely variable among states and payers. The potential time needed for case review meetings and court-related activities is also a problem.

Questions that might help guide a physician's response to possible child abuse are: How do I justify not responding to the medical and social needs of this child? What might happen to the child if I do not act appropriately at this time? How would I act if the child's condition were not abuse but was due to a complicated medical problem?

All 50 states have laws that mandate reporting by physicians in cases where there is a suspicion of child abuse. It is important to note that "suspicion" is not a certain diagnosis or an accusation but is a request for further investigation to assure that children are protected and safe. Failure to report could result in charges being filed against the doctor, and a medical liability suit for failure to diagnose could ensue if a child whose initial harm was not reported returns with more serious injury or death.

Physicians say they are reluctant to report because they "know the family well," "don't trust child protection workers in their state," or "don't want to make the parents angry." Some physicians still are not willing to accept that children are abused and neglected by parents and other caregivers. But this mind-set is wrong, as the evidence proves --including an estimated 2,000 deaths a year from abuse and neglect. It is appropriate, although often difficult, to discuss your duty to report with parents.

Primary care and emergency physicians now have new colleagues to help with the more complicated cases. In November 2009, the American Board of Pediatrics offered the first certification examination in the new pediatric subspecialty, child abuse pediatrics. Of the 216 pediatricians who sat for the examination, 184 passed. Several other pediatricians will join the group when the examination is offered for the second time in 2011.

There are some qualified pediatricians who chose not to take the examination but whose experience and expertise are the same as that of the board-certified group. These specialists in child abuse and neglect are available to answer questions, provide consultations and manage cases as needed. They also are carefully trained or have the experience needed to follow cases through sometimes demanding legal processes.

Child abuse pediatricians are experts in collaborating with each other and communities to implement and evaluate child maltreatment prevention programs. They're skilled in diagnosis, intervention, interdisciplinary evaluation and case management. They also are leaders in education about violence, abuse and neglect, and they are producing significant research that often has instant application in establishing best practices and creating an expanding evidence base for the field.

The prevalence of child maltreatment remains unacceptably high in the U.S. Not only does it take a terrible emotional and physical toll, but the economic costs also are staggering. Consequently, when a physician is faced with the dilemma of reporting a case, or managing a case where abuse or neglect clearly leads the differential diagnosis list, consultation with a subspecialist is helpful.

What should a primary care physician do if child abuse is suspected and a subspecialist is not available?

If a child presents to an emergency department or to a primary care office with an emergent condition, the first priority is medical-surgical resuscitation and stabilization of the child. Investigation can follow when the child's condition improves.

After the child's medical needs have been met, physicians can turn to next steps. All physicians should have a contact phone number or e-mail address for the nearest child abuse evaluation center or for a child abuse pediatrician known to them. In most locales, the nearest children's hospital either should have or know how to contact a child abuse pediatrician. Many initial questions about evaluating a case, deciding whether a report is necessary and what should happen to ensure optimal case management can be answered with a simple query.

If a rapid consultation is not available, address the most important points yourself:

• Conduct interviews and exams in a calm, nonaccusatory manner while explaining that the reason for these steps is the accurate discovery of the cause of the child's condition.
• Take an appropriate history with a timeline of who cared for the child at what times in the days preceding his or her presentation.
• Document carefully parents' or other caregivers' explanation of any new trauma or condition.
• Document any changes in the child's health, behavior, environment, caregivers or other social parameters.
• Conduct a thorough physical examination, and document it in detail.
• Photograph the apparent injuries. This may require reporting so that an investigator with training in appropriate photo documentation can assist.
• Review x-rays and laboratory tests that may apply to the child's apparent condition.
• Document an initial differential diagnosis.

It is best to report the suspicion of abuse as soon as possible, especially when a child has significant injuries or signs of abuse or neglect. Child protective services workers and, in many cases, law enforcement officers, are specially trained to conduct investigations that are coordinated with medical professionals.

In some locations, interagency communications and relationships suffer from a lack of trust and respect. If this holds true where you are practicing, you should make every effort to address the situation and to find solutions acceptable to all, keeping in mind the overarching principle of working together to provide the best care to the child and the family.

--Robert W. Block, MD, American Board of Pediatrics Subboard of Child Abuse Pediatrics, founding chair 2006-09; professor and Daniel C. Plunket Chair, Dept. of Pediatrics, University of Oklahoma College of Medicine

Ethics Forum discusses questions on ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654; fax 312-464-4613. Opinions in Ethics Forum reflect the view of the author and do not constitute official policy of the AMA.

The print version of this content appeared in the July 5 issue of American Medical News.

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