Child Abuse: Diagnosis and Management

by Brian Alverson, MD

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    00:01 So when we see a concerning case of child abuse, how do we drill down on this? Well, part of the problem is that we have to be careful with the way we ask the child questions.

    00:12 Depending on the child’s age, they may change their answer because of a need to protect the parent or a feeling of guilt like they had brought it on.

    00:21 But also there are clear cases in the literature of children who have not been abused with pointed questioning eventually agreeing that this had happened.

    00:31 A classic example is of course the Salem Witch trial where people were repeatedly questioned and eventually said, “Yes, I saw that happen. The older person did that,” when they were questioning the children.

    00:45 So there are dangers of repeated questioning and implanting ideas in children and those dangers are real.

    00:52 So we have to conduct a forensic interview carefully.

    00:56 We do not lead the child, in that we say, “Hey, did he do this?” We allow the child to tell the story.

    01:03 It’s important to detail responses from the child early in the interview.

    01:08 We have to see what they say and document it thoroughly.

    01:12 Ask open-ended questions.

    01:14 Questions where the child can’t answer yes or no but has to expound on the circumstance and allow for silence and hesitation.

    01:22 It’s okay to pause, let the child consider their answer.

    01:26 That allows for the child to then express themselves and give new information.

    01:31 And certainly, we need to record these interviews for legal purposes.

    01:36 When we’re examining children, there are certain key findings of child abuse that you should know about.

    01:42 This is the classic shaken baby syndrome and an ophthalmologic evaluation may reveal retinal hemorrhages.

    01:49 So you can see here on this baby who was shaken that retinal hemorrhages have occurred in the retina.

    01:55 Now, it takes some experience looking at retinas and so often, we’ll call a pediatric ophthalmologist to document and photograph the eyes.

    02:05 If we suspect child abuse, it’s important to get a skeletal survey.

    02:09 A skeletal survey is an X-ray of literally every bone in a child and we look at all those and look for findings of fractures.

    02:17 Here’s a classic child abuse fracture of posterior rib fractures.

    02:22 We can see those bulges.

    02:23 That’s an older posterior rib fracture.

    02:25 Posterior rib fractures are classic for child abuse and they’re from squeezing an infant.

    02:30 They’re not from falling on the ribs.

    02:32 So the story is really squeezing, as in a parent frustratingy squeezing their child.

    02:37 You may repeat in certain causes skeletal surveys two weeks later if there’s an acute event because sometimes fractures show up a little bit delayed.

    02:47 You also will see things like midshaft fractures.

    02:51 These are very unlikely to be from a non-abusive circumstance.

    02:56 This is sort of a classic finding you can see on the hips where this patients has suffered both a femoral head fracture as well as a pelvic fracture and you can see those evidence of fractures.

    03:08 And this type of fracture right here is pathognomonic for a child abuse situation from a torsed leg injury.

    03:16 And then the last is we will often CT the brain if we expect some sort of shaken baby or head trauma.

    03:23 And here’s an example of a child who was abused and you can see the hemorrhage, which is much lighter on the CT scan and CT is the best way to check to acute blood for imaging.

    03:35 And here on a closeup, you can see the blood layering out in the subarachnoid space.

    03:41 So if a child has been abused, what do we do? Well the first is, of course, supportive care for the injuries.

    03:48 If there’s a broken bone, we will put the child in a cast as needed.

    03:52 Rib fractures generally don’t require casting.

    03:55 Remember that doctors are legally mandated reporters to child protective services.

    04:01 If you suspect child abuse, the law states that you have to report that child.

    04:06 Keep in mind it’s not your job to decide whether it happened.

    04:11 That is the responsibility of child protective services.

    04:15 You simply report when you suspect child abuse.

    04:18 It’s up to them to figure out whether it was abuse or not.

    04:23 It’s important to document with photos and video as much as possible.

    04:28 That information is admissible in the court of law and sometimes we’ll document things in written way that might leave things somewhat questionable by the defence.

    04:38 So a photograph and a video is critical for documentation of these children’s injuries.

    04:44 And lastly it’s critically important to consult a child abuse pediatrician, this is a subspecialty in pediatrics, whenever you can get your hands on one.

    04:54 Child abuse pediatricians are incredibly helpful for us in terms of not only providing necessary legal counsel and for help with placement of the child, but also for representing the child’s interest in the court of law.

    05:09 So during trials, child abuse pediatricians are routinely called upon to testify about the degree of injury whether or not it could be consistent with accident or abuse.

    About the Lecture

    The lecture Child Abuse: Diagnosis and Management by Brian Alverson, MD is from the course Pediatric Emergency Medicine. It contains the following chapters:

    • Forensic Interview
    • Child Abuse Management

    Included Quiz Questions

    1. Head CT scan
    2. MRI of the brain without contrast
    3. MRI of the brain with contrast
    4. Angiogram of the head and neck
    5. Head ultrasound
    1. Giving leading statements to the child
    2. Asking open ended questions
    3. Giving silence time for hesitation
    4. Recording all the statements
    5. Asking for details early in the interview
    1. Retinal hemorrhage
    2. Anterior shoulder dislocation
    3. Metaphyseal fracture
    4. Linear burn marks
    5. Torn frenulum

    Author of lecture Child Abuse: Diagnosis and Management

     Brian Alverson, MD

    Brian Alverson, MD

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    Very good lecture.
    By Agnes L. on 30. May 2017 for Child Abuse: Diagnosis and Management

    Great practical advice on a difficult topic. Helped me to understand how forensic interviews are conducted. Thank you.