Identifying Child Abuse
Despite a federally mandated system for reporting child abuse or neglect to a child protective service agency, our most vulnerable population remains unprotected. One recent report showed a 3% rise in child maltreatment–related fatalities, suggesting increased severity of abuse. Primary care providers are well positioned and legally bound to act on children’s behalf by watching for potential “red flags” and, when clinical evidence warrants it, by making the decision to report suspected abuse.
About 5% of sexually abused children contract a sexually transmitted disease.30 Appropriate laboratory tests that can be performed in the office setting include:
- Urinalysis for presence of semen
- Nucleic acid amplification testing (NAAT) for chlamydia and gonorrhea (with positive results requiring that sexual abuse be considered in children beyond neonatal age, according to CDC guidelines33); anorectal and pharyngeal infections with Neisseria gonorrhoeae are commonly found in sexually abused children
- Serologic testing for HIV33
- Urine pregnancy testing in patients of childbearing age.
As these lab specimens are collected, chain of custody must be maintained. Results may be used as evidence in the event of prosecution.
REFERRALS AND FOLLOW-UP
What referrals are made—to clinical specialists, law enforcement, social services, and other agencies—is based on the nature of the abuse, the dynamics of the family involved, the identity of the alleged perpetrator, and the perceived need to ensure the child’s safety. It is the role of these interrelated agencies to confirm the child’s diagnosis, provide for the child’s immediate safety, and ensure links within the systems involved to follow him or her into adulthood, if necessary.
Timely referral to specialized clinicians may spare the child from having to undergo multiple examinations or interviews.33 Although the burden of proof and identification of the perpetrator(s) lie with professional investigators, determination of the cause or possible causes of a child’s injury is often critical to the legal case. Specialists in child abuse, often teamed with a forensically trained interviewer to obtain a specialized history from the child who is verbal, are trained to provide the expert opinions required by the court.
Like referral options, follow-up will depend on the type of abuse that a child has experienced. Medical follow-up, as in the child in the case study, may involve orthopedists, ophthalmologists, or clinicians in other relevant specialties. A psychologist may manage counseling services for the patient and family or foster family.
A SHARED RESPONSIBILITY
Recognition of child abuse is the first step to prevent further victimization. Comprehensive education is critical for health care providers, school nurses, teachers, or anyone who comes into contact with children on a daily basis; increased awareness has been universally identified as a means to prevent child abuse. It is also imperative to educate legislators regarding the extent of this problem and to garner their support for community prevention programs.
For the primary care clinician, it is unfortunate but true that a high level of suspicion for abuse must be maintained; the best available screening tools are the astute clinician’s eyes and brain. During routine annual exams, children should be observed for any indication of abuse, and their interactions with parents should be evaluated as well. Anticipatory guidance during well-child visits has been found to help build parents’ trust in the clinician’s knowledge and compassion, increasing their adherence to effective advice and improving their parenting behavior.40
Public policies and social programs can effectively enhance family functioning, playing a key role in the protection of children.41 Existing research into the causes and effects of child abuse should be used to formulate preventive programs for schools, churches, and local health care providers.
CONCLUSION
No recipe exists for the prevention of child abuse. Health care providers must not hesitate to report suspicion of abuse. This action does not always lead to removal of children from their homes; rather, involving families and children in “the system” can give them access to services of which they might otherwise remain unaware. Home visits, anger management programs, parenting classes, counseling services, and early childhood education can instill and reinforce more positive attitudes and action, for the benefit of all involved.
