Feb. 07, 2020
Arne H. Graff, M.D., is the division chair of Child Abuse Pediatrics at Mayo Clinic's campus in Rochester, Minnesota. His desire is to equip providers for potential child physical abuse (CPA) cases, helping them feel as comfortable as possible and removing the fear of reporting. He offers perspective on CPA and what trauma professionals' responsibilities are in this scenario.
How did you get into the child abuse field?
While I was working in North Dakota, a physician at Sanford Medical Center in Fargo talked me into working with him in a volunteer clinic. While there, I ran into enough child abuse cases that I realized I needed to get out of it or get better. So I did a fellowship in child abuse pediatrics.
Is child abuse common in Minnesota?
Around 84,000 reported cases of child maltreatment are reported each year in Minnesota, according to the Minnesota Department of Human Services and documented in the Child Maltreatment Report for 2017. Minnesota has as high an incidence as some other states, like California, but doesn't see as large of numbers due to population differences between Minnesota and the other states.
There are about 1,500 identified maltreatment deaths in Minnesota each year, but this is assumed underreported due to the difficulty in identifying many of the deaths as clearly caused by maltreatment. In Rochester, Minnesota, and the immediate region, we have around 400 reported maltreatment cases each year.
Which children are at highest risk of abuse?
A young child or infant is at highest risk.
Are any children overlooked for abuse?
Yes — teenagers. I don't want us as providers to just focus on little kids. Teens have a similar CPA pattern as other children. It's important you consider whether abuse is occurring if you see a 15-year-old with an injury that doesn't align with the history. Don't assume because they're teenagers, they aren't experiencing abuse.
Who abuses children?
People who have access to children hurt children: parents, child care providers, grandparents and school personnel. Anyone has the capacity to hurt children.
That said, it's important to know that 82% of abusers are ages 18 to 44, and 80% of CPA is inflicted by parents, according to data from Child Welfare Information Gateway.
Is denial of mechanism of injury common in these cases? If so, any advice?
Since we don't know how often abuse is missed, we can't guess at how often it's denied. Personal experience is that even with serious injuries, denial is common. Considering that one of the caregivers may not have knowledge of events that occurred with his or her partner, denial can be a normal answer. Therefore, asking about domestic as well as pet violence is important, and also interviewing caregivers separately. By emphasizing mandated reporting requirements and indicating concern about their child, we hopefully will maintain a working relationship with the family.
Any tips for assessing a child's injury?
Every injury presented must be consistent with the child's medical history and developmental ability. If it doesn't line up, ask why. It doesn't mean there's abuse occurring, but it does mean something's going on that doesn't make sense.
Our job is to consider the injury's cause — medical, accidental and then nonaccidental trauma — as well as medical history and mechanics. It's not our job to immediately assume, if we don't like how it looks, that somebody's abused the child. We have to start with ruling out other options, especially with a nonverbal child.
In 30% to 40% of cases we see, we have to say we can't determine if an injury was abuse or accidental, and we need to consider potential options for the injury.
How should I determine which tests are needed?
First, it's important to know that exams have limits. You can't determine abuse simply by physical exam. However, being financially responsible means to not shotgun and do every test available.
If you need to consult on a potential CPA case, my colleague Donald (Chris) C. Derauf, M.D., and I are available 24/7 every day for curbside consults at no cost. We do 300 to 400 of these a year. You may call us through the MATC to discuss what you're seeing in a case, and we can advise on screening. We are your resource and encourage people to call and bounce things off us.
How do I figure out who did it?
You and I don't care. It's not our job. Our primary role is to prove it's not abuse and look at accidental injuries or other conditions that may have caused the injury. Also, our job is not to rule out people who may have abused the child, or determine reason or intent — leave that to the legal system.
How can I help stop CPA?
If you can recognize CPA early through a sentinel event — a case where injuries in children nonmobile or under age 4 can't be explained by a simple accident, such as significant bruising to the head or neck — you can make a difference. For these children, consider the injury to be caused by someone. Bruising in a nonmobile child should be a red flag if not immediately explained by multiple people.
Sentinel injuries, without witnessed accident, carry high risk of further injury or death. According to an article by Sheets and others in the April 2013 issue of Pediatrics, 27% of kids who've been seen by a provider and demonstrated to have had a sentinel event will return with serious injuries or dead.
What's my responsibility?
These are critical steps for providers in potential CPA cases:
- Identify other possible injury causes.
- Recognize these things are serious. Once considering CPA as a potential cause, you are a mandated reporter. It doesn't have to be proved, just suspected. You can't simply write in your notes that you're concerned and not report. You must contact child protective services about a safety plan and tell them why there's concern.
- Conduct testing in a timely manner; it's important for safety and complete diagnosis.
- Remember multiple types of abuse can coexist. Do a complete exam for neglect; don't just focus on a bruise.
- Don't send the family home until all test results come through, or the child potentially may be going into an unsafe environment. While you're doing your work, child protective services (CPS) will develop a safety plan. We can't send the family out until this plan is finished and documented by the physician.
- Make a complete description of the injury, including photos.
Any suggested approach with the family if CPA is suspected?
Since it's not our role to decide who did it, I usually use this approach and advise providers to consider it. I say to the caregiver present: "With this type of injury, without a known medical problem causing it or a witnessed accident, I am concerned someone may have hurt your child. Because of this, I am a mandated reporter and have already spoken with child protective services. They will want to talk with you about safety plans for your child. I also want to recommend some tests that may better tell us why the injury occurred and if there are other injuries present we cannot see on the exam."
It's important to help families understand that just because the child looks happy and OK, it doesn't rule out other injuries.
Any pitfalls you'd suggest avoiding with CPA?
We fail to recognize our blinders. If you're homeless or a minority, statistics say CPA cases are overreported, according to a 2011 publication in Journal of the National Medical Association. However, studies indicate if you're white middle class and present with an infant to the emergency room, people don't even think about abuse. Also, if we know members of the family personally, there's a tendency to say, "They are nice people. They wouldn't do this."
If we think there might be abuse, we need to get CPS involved, period. Letting our biases influence who we report puts kids at risk. Remember, reporting may help services be put in place to assist the family.
Which patients who've survived potential CPA need transfer for further work-up?
The work-up needs to be completed at the time the concern is raised. Depending on the child's age, it may include:
- A dilated eye exam by an eye expert, to be completed within 48 hours
- A skeletal survey immediately and again in two to three weeks
- A head CT if under age 1 or obvious head trauma
- Abdominal labs
If testing can't be completed, transfer to a larger center is indicated. If testing can be done and a safety plan put in place, the child may be evaluated at the local site only and be watched overnight or be sent home, depending on tests and exam.
For more information
Minnesota's Child Maltreatment Report, 2017. Children and Family Services, Minnesota Department of Human Services.
Perpetrators of child abuse and neglect. Child Welfare Information Gateway.
Sheets LK, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131:701.
Dakil SR, et al. Racial and ethnic disparities in physical abuse reporting and child protective services interventions in the United States. Journal of the National Medical Association. 2011;103:926.