Abandonment and Neglect
Neglect is broadly defined as failure to meet a child’s basic needs. Neglect is the most common form of child maltreatment, and its effects on health can be as injurious as those of physical or sexual abuse. There are different types of neglect, including:
physical neglect: failure to provide basic needs such as housing or food;
supervisory neglect: failure to provide adequate supervision for the child’s developmental level;
medical neglect: failure to provide prescribed medical care or to seek care in a timely manner;
psychological/emotional neglect: failure to provide adequate support, affection, nurturance.
Abandonment is an extreme form of neglect. It occurs when a child has been left by parents whose whereabouts are unknown, or when the parents fail to maintain contact for a significant period of time.
Clinical Presentation
Concern for neglect may arise during the emergency department visit, although abandoned and neglected children may be brought to the emergency department by Child Protective Services (CPS) for medical evaluation. Other possible presentations include complications of a chronic disease due to medical neglect, significant delays in seeking medical care, failure to thrive, and injuries or intoxications occurring in the setting of lack of supervision.
Diagnosis
Perform a thorough physical examination, with particular attention to a general assessment of the state of hydration, nutrition, vital signs, growth parameters, and hygiene. Undress and examine the child thoroughly for physical stigmata of abuse or neglect. Other physical findings could include dental caries or dermatological problems (infections, infestations). Abandoned and neglected children can also have significant behavioral and emotional health issues that require immediate attention.
In some cases the need for a CPS report will be clear, such as a toddler intoxicated by an illegal substance, while other cases are more nuanced. There are no clear guidelines for deciding when to report medical or supervisory neglect. In a complex case, utilize an interdisciplinary approach, possibly including social work, primary care, pharmacy, and inpatient teams. Assess the patient’s risk of imminent harm. Evaluate whether there is an immediate health risk to the child, and characterize the nature and severity of potential or actual health consequences. Also note any risk factors, family strengths, availability of resources to assist with identified concrete needs, patterns of neglect, prior CPS involvement, and the results of prior interventions.
ED Management
If the patient is at imminent risk of harm in the current living environment, await a safe discharge plan from CPS, or admit to the hospital if indicated for medical or safety reasons. In a case where decision-making about the need to report to CPS extends beyond the emergency department visit and there is not imminent risk of harm, meticulously document the evaluation to date, and communicate clearly with the inpatient team and/or primary care provider.
In cases of abandonment, report to CPS and/or the police, per local child abuse reporting laws and protocols. If possible locate the parent or another family member known to the child. Disposition options in the management of an abandoned child include CPS transferring custody to an approved relative, or alternatively placement in a temporary shelter or foster care. If medical care is necessary, or if community-based resources do not exist, admit the patient to the hospital.
Indications for Admission
Abandoned or neglected child who requires medical care
Abandoned or neglected child at imminent risk of harm, when community placement resources do not exist
Bibliography
Chart Documentation in Cases of Suspected Child Abuse
Medical professionals evaluating children in whom child abuse diagnosis is a consideration must ensure that the medical record is complete, comprehensive, objective, and fact-oriented. A well-documented medical record is essential in these circumstances and is a critical tool in child abuse investigations. The data entered in the record provides information about the statements provided, diagnoses considered, and ancillary tests performed, as well as the medical provider’s assessment, treatment, and recommendations made.
Chart documentation that occurs soon after the evaluation of the child takes place is more reliable than notes written after a significant amount of time has passed. It is important to document the date, time, and place of the interviews, who was present, the language spoken, and if translator services were utilized. Also include any additional information obtained from other sources, such as police reports, child protective workers, etc.
History of the Presenting Problem
The principal diagnostic component of the child abuse assessment lies in the history obtained from the parent(s), and the child suspected of being abused. Interview the parents first, and separately, and if the child is verbal, interview him/her alone. In suspected physical abuse cases, gather information in a non-accusatory, but meticulous manner in order to determine if the injuries found could be explained by the history provided. It is crucial to interview the person(s) who was with the child at the time of the injury and it is especially important to ask if they actually witnessed the child when he/she sustained the injury. Document a detailed history of what happened and where and when it occurred. Note how the child was before and after the injury and the order in which symptoms developed. It is essential to clearly document the child’s account of how he/she sustained the injury. In those cases in which a child is suspected of being sexually abused, document the circumstances surrounding the disclosure and what the parents know about the suspected sexual abuse.
Most children being evaluated for sexual abuse do not have specific medical findings. Therefore, the history provided by the child is the most important part of the evaluation. This will enable the clinician to make appropriate medical and protective decisions. When interviewing a child, allocate time to establish rapport before introducing the topic of concern. Rapport building allows the child to feel comfortable and it provides the clinician an opportunity to assess the child’s developmental level to guide the choice of appropriate language during the interview.
Use open-ended questions during the interview. These questions usually begin with “who,” “how”, “what,” “when,” “where,” or “why.” These types of questions allow the child the freedom to describe details of what happened without jeopardizing the integrity of the interview. For example, you can ask: “Tell me, why you are here today?” Or, “Tell me, what happened that brought you to the hospital?” If the child discloses that her stepfather touched her inappropriately, avoid using leading or suggestive questions such as: “Did he touch you on your vagina?” In contrast, a non-leading question might be phrased “Where did your stepfather touch you?” Record the child’s statements without correcting grammatical errors or paraphrasing the child. Use quotations as often as possible. Describe the child’s demeanor and emotional state during the medical evaluation.
Statements made by a child are often considered “hearsay,” a statement made out of court offered into evidence in order to establish the truth of the matter asserted in the statement. In other words, the child’s words are offered in court to prove that what the child said is actually the truth. Generally, hearsay statements are not admissible in court, although two pertinent exceptions are the excited utterance exception and the medical diagnosis or treatment exception. Documentation of the features that allow a statement to qualify as a hearsay exception increases the chances the child’s words will be admissible in court.
Excited Utterance
The excited utterance exception is a hearsay statement that relates to a stressful event. Three requirements are necessary for a statement to fall under this exception: the child must have experienced a stressful event; the child’s statement must be associated with the event; and the child must still be experiencing the emotions caused by the event. Document the type of stressful event, the amount of time that passed between the event and when the child first made the statement, the child’s speech (including spontaneity and emotions), what questions led to the disclosure, and when was the first secure opportunity the child had to disclose.
Medical Diagnosis or Treatment Exception
This relates to the belief that people are honest with medical professionals and therefore the information provided is trustworthy. Under this exception the information obtained in the medical history including chief complaint, review of systems, past medical history, and the child’s description of the cause of injury are admissible in court. It is important to document the characteristics of the patient’s statements that enhance their reliability, including the child’s advanced knowledge of anatomy, description of distinctive sensory/visual details of sexual acts, and emotions displayed when the statement was made.
Past Medical History
Birth History
Document if the pregnancy was planned, as well as any complications during pregnancy or delivery, traumatic birth, prematurity, etc. Certain injuries are related to birth trauma and may go unnoticed by medical providers. Request the child’s birth medical record and pictures or videos of the baby taken at birth to correlate with the medical findings.
Developmental History
Documenting the patient’s developmental capabilities is crucial when trying to correlate the mechanism of injury with the story provided. Ask the parents to provide a video of the child performing a certain activity (rolling over, climbing, etc.) if they report a milestone has been met but not observed by the clinician. Note whether the examiner or another objective observer was able to substantiate the information provided.
Medical Conditions
Certain medical conditions can mimic abuse or may play a role in the injury noted. List the child’s medical problems provided by the parent and inquire about those pertinent to the case (e.g., rickets and inherited bone disorders when evaluating a fracture). Documenting pertinent negatives informs the person reviewing the medical record that a certain diagnosis was considered in the differential.
Medications
Note any medications, alternative medicine, or vitamins given to the child, as the parents may give the patient medications that can cause serious medical problems without their knowledge. Also consider the effects of mislabeling and dispensing and dosage errors in the differential diagnosis.
Hospitalizations/Injuries
Note any hospitalizations, motor vehicle accidents, fractures, burns, or other serious injuries for which the child was treated in the past. If possible, obtain the patient’s medical records. These may reveal injuries or medical conditions not recalled by parents or the child. Document this information in the medical record, including the source used.
Primary Care Provider
Note the name and contact information of the child’s primary care medical provider. Also obtain the patient’s immunization record. Some children who are neglected/abused may not be up to date with their vaccinations or have a regular health care provider.
Surgeries
It is important to include anogenital surgeries or procedures that may have left residual findings.
Review of Systems
When evaluating a child for sexual abuse, pay particular attention to the genitourinary and gastrointestinal systems. Note the presence of specific symptoms and the time of presentation in relationship to the sexual contact reported. Ask about a history of vaginal pain, bleeding, discharge, vaginal foreign bodies, self-stimulation, genital trauma, and the use of tampons. Inquire about dysuria, frequency, urgency, or enuresis. Dysuria, pain, and bleeding are highly associated with genital-to-genital contact.
Document any history of constipation, anal pain, bleeding, itching, hemorrhoids, encopresis, or infections. In cases of possible physical abuse, document the time line of changes in mental status, irritability, seizures, vomiting, breathing difficulties, and loss of consciousness. If a fracture is suspected, note the presence of any decreased range of motion, swelling, or deformity.
Behavior
Children that are abused or neglected may exhibit changes in their behavior. Inquire and document whether the child has been exhibiting any behavioral changes, sexualized behavior, or advanced sexual knowledge. Depression, suicidal ideation or attempts, self-injurious behavior, running away, and substance abuse could be indicators of abuse.
With the recent advances in technology and easy access to internet and cameras in multiple electronic devices, there are increased reports of exposure to pornographic images and inappropriate photographs or videos. It is important to inquire and document if the child has been found with or watching pornographic materials. In addition, ask the child/parent if inappropriate pictures or videos of the child have been taken/found. These pictures/videos corroborate the child’s account and can assist in the prosecution of child sexual abuse cases.
Family History
Include any condition that may predispose the patient to injuries, such as osteogenesis imperfecta, bleeding disorders, etc., although these conditions could coexist with abuse. Also note a parental history of abuse or psychiatric illness.
Social History
Document the names of all of the child’s caretakers, including daycare providers and whether any of these people reside in the patient’s home. A history of substance or alcohol abuse and intimate partner violence can put a child at risk for abuse/neglect. Knowledge of these risk factors will help determine if it is safe for the child to go home.
Documentation of the Physical Examination
A thorough and complete physical examination is indicated for all children and adolescents suspected of being abused or neglected. Include the following in the medical record.
Growth Parameters
These are especially important when evaluating a child for failure to thrive and possible neglect. Chart current values on a growth curve and compare them with previous measurements if available.
Injuries
Describe the pattern, shape, location, size, and color of any marks, bruises, burns, bites, scars, and/or other lesions concerning for abuse. Look for sentinel injuries, which are poorly explained minor injuries in infants, such as subconjunctival hemorrhages or a torn frenulum. These injuries have been noted in children in whom serious physical abuse was later diagnosed. Include a careful inspection of the skin and oral mucosa, particularly of areas where injuries are easily missed, such as the labial and sublingual frena, ears, scalp, anogenital area, hands, and feet. Include all positive and pertinent negative findings (e.g., no retinal hemorrhages noted in a child with suspected inflicted head trauma).
Emergency medical providers may need to perform examinations on children suspected of being sexually abused when a child abuse expert is not immediately available. In order to properly document genital findings, refer to American Professional Society on the Abuse of Children (APSAC) published guidelines for standardized language to describe normal, variants of normal, and abnormal genital findings. Use the clock face to describe the location of the injury. The 12 o’clock position is anterior (urethra being at 12 o’clock). The anal examination can be performed in the lateral decubitus, supine, or knee–chest position. Document the following about the anogenital examination:
1. Position in which the patient was examined (e.g., supine, knee–chest).
2. Sexual maturation stage.
3. Use of magnification (colposcope or other magnifying instrument).
4. Whether the exam was photographed or video-recorded (see Photographic Documentation below).
5. The presence or absence of lesions, bruises, petechiae, etc. of each anatomical structure (labia, clitoris, vestibule, hymen, fossa navicularis, posterior fourchette, vagina).
6. The shape of the hymen (crescentic, annular, redundant, etc.). Make note of the presence of warts, bruises, tears, petechiae, and/or ecchymosis (e.g., “hymen crescentic-shaped with an acute complete transection at 6 o’clock, few petechiae noted at 3 and 5 o’clock”). Avoid terms like “virginal” or “intact.”
7. Utilize body and/or genital diagrams demonstrating the site and type of injury.
8. Anal tags, fissures, bruises, lacerations, scars, rashes, discharge, bleeding, and/or other lesions. Note the normal variants of the anal examination so that these are not confused with abnormal findings.
9. For the male genitalia, write a description of the penis and scrotum, noting the presence of circumcision and any lacerations, scars, ecchymoses, rashes, discharge, erythema, and/or other lesions.
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