Pediatrics

Oct. 03, 2023

Injuries from child abuse can be subtle, sometimes with no visible external signs. At times, you may get the whole story when a child or adolescent makes a disclosure of abuse. At other times, the patient is not old enough to talk or meaningfully articulate what occurred, or caregivers are trying to hide what happened. Yet, you recognize protecting a child is critical as a medical professional. Inconsistencies between the history you are given and the injuries you are seeing may be telling you this situation is not right — that the young patient may have been abused.

Katie L. Johnson, M.D., a child abuse pediatrician at Mayo Clinic's campus in Rochester, Minnesota, offers tips to ensure you do not miss even covert cases of child abuse:

1. Get the full injury story, if possible. Though impossible with nonverbal infants, it is crucial to have children old enough to provide their own injury history do so. Simply ask the child directly, "What happened?" Get as many details as possible, for example, in what position the child fell, how far and onto what surface. It is important to know if anyone witnessed the injury. At times, a child's story will not correspond with the physical exam because of the child's fear or because the child has been coached by an adult who wants to hide the true circumstances of the injury. If the patient is an adolescent, it is important to spend time speaking with the patient individually to ask about any concerns for abuse.
2. Focus on the medical needs of the patient. Stay in your medical lane. While it is important for the medical history to be complete, it is not your job to "get to the truth" or take on the role of an investigator. Be sure not to ask any leading questions of children. Open-ended questions or prompts such as "tell me more about that" are best practice.
3. Perform a full head-to-toe skin exam. If you are concerned that the history may not adequately explain the injury, make sure to perform a full head-to-toe skin examination. Put the child in a gown and make note of any bruises, burns or scars on the child's body. For children up to 4 years of age, use the TEN-4-FACES-P rule, which means that bruising to the torso, ears, neck, frenulum, angle of the jaw, cheek (buccal region), eyelid, subconjunctival hemorrhages and patterned bruising indicates high risk of abuse. In addition, any bruise to a pre-mobile infant — one who is not yet pulling to stand or cruising — is concerning.
4. When the history does not match the injury, call the child abuse team. After the initial history and skin examination, contact a child abuse expert for further guidance. The Mayo Clinic Center for Safe and Healthy Children and Adolescents has a physician on call 24/7/365. This physician will help guide you with next steps in the work-up, mandated reporting and how to communicate your assessment with the family. This physician also can help guide you regarding whether the child should be transferred to a higher level of care and make recommendations for the care of other children within the household.
5. Be intentional in your communication with families. When you must make a mandated report, it is best practice to tell the family this directly. Huddle with your team and have a plan for what you will say. While explosive behavior from a family or caregiver is rare, be mindful of your own safety. Position yourself between the family and the door, bring a social worker or nurse in with you, and know how to call security if needed. Sit down and speak in a calm, nonaccusatory tone. Emphasize that this is a standard process you must follow as a medical professional.
6. Be careful of profiling. Be aware of your own potential biases and ensure you do not make any assumptions or judgments based on sociodemographics. Base any conclusions or reports on objective findings or behavior only, and not on "bad vibes" about a person or family.
7. Document your observations and call child protective services (CPS). Document the history and injuries in writing and, if possible, with photodocumentation. High-quality photographs of injuries — both close-up and far away, with good lighting and a measuring device — are helpful in these cases. Follow your state's statutes for reporting. This usually requires a verbal report to CPS and sometimes a written report, as well. Find out if your institution has a standard form for the written report.
8. Seek advice from CPS for dismissal. CPS will advise on whether the child can go home or needs to stay in the hospital until further safety planning can be completed. In some situations, the child may be discharged into the care of CPS. This is referred to as protective custody. CPS also can inform you about who will have medical decision-making authority for the child. Document the guidance CPS gives you about disposition and medical decision-making.

"More often than we'd like, child abuse-related injuries are missed," says Dr. Johnson. "At the same time, we do not want to over-report, as this has adverse consequences for both families and systems. It is our responsibility to be objective, thorough and to educate ourselves about the signs of child abuse. This will help us be the best advocates for children in our care."

For more information

Refer a patient to Mayo Clinic.