An estimated one-and-a-half to two million children are abused and/or neglected in the United States each year. Approximately 3,000 children die each year at the hands of a caretaker.
Adrienne Atzemis, MD discusses the warning signs of child abuse, how the protection program at St. Louis can help child abuse victims, and when a pediatrician should refer to St. Louis Children's Hospital.
Selected Podcast
Physical Child Abuse
Featured Speaker:
Learn more about Adrienne Atzemis, MD
Adrienne Atzemis, MD
Adrienne Atzemis, MD, is a Washington University emergency medicine physician at St. Louis Children’s Hospital.Learn more about Adrienne Atzemis, MD
Transcription:
Physical Child Abuse
Melanie Cole (Host): An estimated 1.5 to 2 million children are abused or neglected in the United States each year. Approximately 3,000 children die each year at the hands of a caretaker. My guest today is Dr. Adrienne Atzemis. She’s a Washington University child abuse pediatrician at Saint Louis Children’s Hospital. Welcome to the show Dr. Atzemis. Tell us a little bit about the prevalence and statistics of child abuse in this country.
Dr. Adrienne Atzemis (Guest): Thank you, Melanie. Yes, far too many children suffer from child maltreatment. The national survey of children’s exposure to violence estimated that 1 in 4 children have experienced abuse or neglect at some point in their lives, and 1 in 7 children experienced maltreatment in the last year. As you said, many children die each year as a consequence of maltreatment, but thankfully pediatricians can act in meaningful ways to protect children from abuse.
Melanie: Are there some risk factors, some certain things you’d like to identify that would let a pediatrician know that maybe this is a child who is at higher risk of being abused?
Dr. Atzemis: Yes, there are many risk factors that we see on a regular basis. Although child physical abuse is seen across all societal, cultural, racial, and socioeconomic spectrum, there are known risk factors. Those include, poverty, family violence, social isolation, a young age – both of the child and of the parent or caretaker, children with disabilities and with chronic illness are just a few of them.
There is one known risk factor that pediatric providers can actively do something to modify, and that is correcting caregivers in appropriate developmental expectations of young children. And by that, I mean – and as an example – a parent who believes, let’s say their 18-month-old daughter could be successfully potty trained will feel significant frustration when their best efforts are unsuccessful, and they will begin to wrongly attribute wrongly expected potty accidents to a child’s willful disobedience. That dynamic is, unfortunately, prime for physical abuse, so pediatricians have an opportunity by thorough attention to and then discussion of appropriate developmental expectations to ease the parenting stress that can lead to physically abusive situations.
Melanie: Dr. Atzemis, the American Academy of Pediatrics has a policy report for clinicians on being able to identify some of the warning signs of child abuse. Please speak to that a little bit.
Dr. Atzemis: Yes, I always use the AAP’s policy. The 2009 one was published, and I like that one because it really gives pediatricians some guidance in concrete steps. What they stated was, “the ability to detect and properly diagnose physical abuse is dependent on the clinician's ability to do three things,” and I would like to talk about each of those.
The first is recognizing suspicious injuries. The most common, the earliest, and the easily recognizable finding of physical abuse is a bruise. Now, because pediatricians see active, healthy children with mild bruising so often, there’s a tendency to just dismiss all mild bruising as normal, or an expected consequence of play, or normal childhood accidents, like falling from the bed, or falling on the playground. But that isn’t the correct way to think about bruising. By understanding the characteristics of normal, expected bruising, and then recognizing when a bruise doesn’t fit that pattern, providers can identify children who require additional evaluation, both for potential medical disease and child maltreatment.
Normal bruises are typically found on children who have attained the skill of upright mobility, meaning they’re cruising, they’re moving, they’re independently walking. Those children, once they’ve attained that skill, they generally have bruises that are few in number, have an indistinct shape, that are on the front of the body on a bony prominence like a forehead or the shin. Bruises that are on infants that aren’t mobile, that are on the soft parts of the body like the cheek, the ear, the neck or abdomen, the thigh, the back of the body, are numerous, are clustered together, have a distinct pattern – those bruises should prompt an evaluation because those are most frequently associated with inflicted trauma. Even one small bruise on the cheek of a 4-month-old should be considered a warning sign of inflicted trauma.
The second step is to do an appropriate medical evaluation. Now, when there’s a credible concern for physical abuse – maybe it’s because there was a history of abuse that was provided by a parent or an investigator, or there’s a physical finding that the provider sees, or there’s a diagnosis of physical abuse in a sibling – those children should be evaluated by a medical provider with at least a comprehensive physical exam and history. Every inch of skin needs to be visualized with particular attention to body parts that are frequently missed. We frequently see injuries missed behind the ear, in the mouth or on the genitals.
But then there are some children who will require additional evaluation for an injury that’s occult. And by occult, I mean it can’t be detected by a history and physical alone. For example, very young children, primarily under 6 months of age, they require blood work like a CBC, CMP and a urinalysis to evaluate for internal injuries, like liver and kidney injury. They also need a skeletal survey to detect occult fractures like rib fractures and what we call classic metaphyseal fractures – fractures at the ends of the long bone. And then many of them will also need brain imaging to detect signs associated with abusive head trauma, like a subdural hematoma, the yield of those screening tests decreases and we can more safely rely on history and physical exam.
I would really encourage providers to seek consultation with the child abuse team here at Children’s Hospital when they are deciding what screening tests are indicated. And Dr. Kondis and I – my partner, Dr. Kondis, are always available for such consultations via Children’s Direct.
Now, the third step, that is where we just need to use all of our pediatric experience just put it all together. We need to ask, “Does this fit?” Does the history match the developmental capabilities of the child? Do the physical findings match that history? Is there a finding that it explained by a diagnosable medical disease? And then, we need to acknowledge that when it doesn’t all fit together that we need to consider that abuse is the most likely diagnosis and then we need to take appropriate steps.
Melanie: And if this is something that’s identified by the pediatrician, what is their next step, and what’s required for mandating reporting? Are there some deterrents to this reporting system that might keep a pediatrician from reporting it accurately?
Dr. Atzemis: Yes, that’s a great question, Melonie. All pediatric providers are considered mandated reporters in every state, but in Missouri, it means if we have reasonable cause to suspect that a child has been or will be a victim of child maltreatment, we must make a report to Missouri Children’s Division. That language might seem a little vague, but it is written that way purposefully, and the reason is because no one should feel that their suspicion has to be confirmed or proven prior to making a hotline call. The investigation of that suspicion is not the responsibility of the reporter, so each provider has a personal responsibility to ensure that a report is made properly. That responsibility can’t be delegated or transferred to somebody else.
There are certain allowances made like, for example, here at the hospital, we know that one medical team can designate one person to make the report on behalf of the entire team. Pediatricians in practice, or in private practice, or in a group practice can also utilize that allowance, that one person can make that hotline report. But then each mandated reporter should take the steps to ensure that that hotline was made correctly.
Now, you asked about deterrents, and I see that frequently. That is pediatricians feel a lot of discomfort and frustration with making a hotline report, and that’s frequently because they don’t or aren’t part of the investigation of the protection of the abused child, and they feel really disconnected from the process. Here at Children’s Hospital, when I see a case when I’m involved, when the initial reporter is a medical provider or a clinic staff member like the receptionist, or even a housekeeping staff member who made that report, I will frequently reach out to that person who made the report to discuss the case. Many times, providers tell me that they were very – they questioned whether or not they should make the report. They were feeling really insecure. They really didn’t know how to address it, and they really struggled with that decision to make the report.
Many, many times, I’ve been able to very honestly tell them that I believe their decision to make that report saved that child’s life – truly saved that child’s life by making that hotline. It only takes one case like that to really understand the importance of mandated reporting, and that encourage and support clinicians in their duty and their responsibility to make that hotline. If a provider ever feels disconnected from that process or the outcome of a hotline, I really encourage them to call. Talk directly to Children’s Division, the investigator, or the investigator supervisor, or if we, at Children’s Hospital -- the Child Protection Program here is involved, then please reach out to us because we will make sure that we connect them to that process.
Melanie: And what does your Child Abuse Protection Program offer these patients?
Dr. Atzemis: The Child Protection Program at Saint Louis Children’s Hospital is a multidisciplinary team. Our team includes physicians who are child abuse pediatricians, myself and Dr. Kondis. We also have a group of nurse practitioners who both do care in our clinic on an outpatient basis and see patients in the Emergency Room when it’s required. We have support staff, and then we have this excellent team of social workers who work very closely and are very knowledgeable about the child protection system in Missouri and in Illinois since so many of our patients are also from Illinois.
Our program becomes involved when any person here at hospital requests us to be involved, and that includes primary care doctors or people outside of our system. They call and say that they are concerned about a particular child, we will address it as a team. Our team frequently does inpatient consultations, but also outpatient consultations, and then we’ll also do medical record reviews.
Melanie: And in summary, Dr. Atzemis, tell us what you would like pediatricians to know about identifying abuse in their pediatric patients. What do you want them to know about referring?
Dr. Atzemis: I just want them to know that they need to consistently think of abuse as a possibility. Not that I want them to think poor things about their patients or to not believe families when they come in with accidental injuries, but they need to constantly think of the possibility and keep their eyes open for those signs. Once they see that, to really reach out and get the support that is available to them to best care for that child in that situation. Many times that means just calling us and they can always call us through Children’s Direct. Dr. Kondis or myself are on call 24/7 and will always be able to offer support and assistance if they feel that a patient of theirs is being somehow maltreated or abused.
Melanie: And what can a pediatrician expect from your team after referring a patient to you?
Dr. Atzemis: They should expect that we will reach out to them and talk to them about the case. There are times that a family sometimes doesn’t want a lot of information provided, but we always do reach out to our referring physicians. Sometimes they even know more information that we do because they’re close to the family and the family may feel safer and more comfortable talking to them. We will let them know what’s happening. If for some reason, they haven’t heard from us, to please call us and we’d be happy to discuss their case.
Melanie: Thank you, so much, for being with us today. It’s really so heartbreaking, but such important information. Thank you, Dr. Atzemis, for being with us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678- 4357. You’re listening to Radio Rounds at Saint Louis Children’s Hospital. For more information on resources available at Saint Louis Children’s Hospital, you can go to SaintLouisChildrens.org, that’s SaintLouisChildrens.org. This is Melanie Cole. Thanks, so much for listening.
Physical Child Abuse
Melanie Cole (Host): An estimated 1.5 to 2 million children are abused or neglected in the United States each year. Approximately 3,000 children die each year at the hands of a caretaker. My guest today is Dr. Adrienne Atzemis. She’s a Washington University child abuse pediatrician at Saint Louis Children’s Hospital. Welcome to the show Dr. Atzemis. Tell us a little bit about the prevalence and statistics of child abuse in this country.
Dr. Adrienne Atzemis (Guest): Thank you, Melanie. Yes, far too many children suffer from child maltreatment. The national survey of children’s exposure to violence estimated that 1 in 4 children have experienced abuse or neglect at some point in their lives, and 1 in 7 children experienced maltreatment in the last year. As you said, many children die each year as a consequence of maltreatment, but thankfully pediatricians can act in meaningful ways to protect children from abuse.
Melanie: Are there some risk factors, some certain things you’d like to identify that would let a pediatrician know that maybe this is a child who is at higher risk of being abused?
Dr. Atzemis: Yes, there are many risk factors that we see on a regular basis. Although child physical abuse is seen across all societal, cultural, racial, and socioeconomic spectrum, there are known risk factors. Those include, poverty, family violence, social isolation, a young age – both of the child and of the parent or caretaker, children with disabilities and with chronic illness are just a few of them.
There is one known risk factor that pediatric providers can actively do something to modify, and that is correcting caregivers in appropriate developmental expectations of young children. And by that, I mean – and as an example – a parent who believes, let’s say their 18-month-old daughter could be successfully potty trained will feel significant frustration when their best efforts are unsuccessful, and they will begin to wrongly attribute wrongly expected potty accidents to a child’s willful disobedience. That dynamic is, unfortunately, prime for physical abuse, so pediatricians have an opportunity by thorough attention to and then discussion of appropriate developmental expectations to ease the parenting stress that can lead to physically abusive situations.
Melanie: Dr. Atzemis, the American Academy of Pediatrics has a policy report for clinicians on being able to identify some of the warning signs of child abuse. Please speak to that a little bit.
Dr. Atzemis: Yes, I always use the AAP’s policy. The 2009 one was published, and I like that one because it really gives pediatricians some guidance in concrete steps. What they stated was, “the ability to detect and properly diagnose physical abuse is dependent on the clinician's ability to do three things,” and I would like to talk about each of those.
The first is recognizing suspicious injuries. The most common, the earliest, and the easily recognizable finding of physical abuse is a bruise. Now, because pediatricians see active, healthy children with mild bruising so often, there’s a tendency to just dismiss all mild bruising as normal, or an expected consequence of play, or normal childhood accidents, like falling from the bed, or falling on the playground. But that isn’t the correct way to think about bruising. By understanding the characteristics of normal, expected bruising, and then recognizing when a bruise doesn’t fit that pattern, providers can identify children who require additional evaluation, both for potential medical disease and child maltreatment.
Normal bruises are typically found on children who have attained the skill of upright mobility, meaning they’re cruising, they’re moving, they’re independently walking. Those children, once they’ve attained that skill, they generally have bruises that are few in number, have an indistinct shape, that are on the front of the body on a bony prominence like a forehead or the shin. Bruises that are on infants that aren’t mobile, that are on the soft parts of the body like the cheek, the ear, the neck or abdomen, the thigh, the back of the body, are numerous, are clustered together, have a distinct pattern – those bruises should prompt an evaluation because those are most frequently associated with inflicted trauma. Even one small bruise on the cheek of a 4-month-old should be considered a warning sign of inflicted trauma.
The second step is to do an appropriate medical evaluation. Now, when there’s a credible concern for physical abuse – maybe it’s because there was a history of abuse that was provided by a parent or an investigator, or there’s a physical finding that the provider sees, or there’s a diagnosis of physical abuse in a sibling – those children should be evaluated by a medical provider with at least a comprehensive physical exam and history. Every inch of skin needs to be visualized with particular attention to body parts that are frequently missed. We frequently see injuries missed behind the ear, in the mouth or on the genitals.
But then there are some children who will require additional evaluation for an injury that’s occult. And by occult, I mean it can’t be detected by a history and physical alone. For example, very young children, primarily under 6 months of age, they require blood work like a CBC, CMP and a urinalysis to evaluate for internal injuries, like liver and kidney injury. They also need a skeletal survey to detect occult fractures like rib fractures and what we call classic metaphyseal fractures – fractures at the ends of the long bone. And then many of them will also need brain imaging to detect signs associated with abusive head trauma, like a subdural hematoma, the yield of those screening tests decreases and we can more safely rely on history and physical exam.
I would really encourage providers to seek consultation with the child abuse team here at Children’s Hospital when they are deciding what screening tests are indicated. And Dr. Kondis and I – my partner, Dr. Kondis, are always available for such consultations via Children’s Direct.
Now, the third step, that is where we just need to use all of our pediatric experience just put it all together. We need to ask, “Does this fit?” Does the history match the developmental capabilities of the child? Do the physical findings match that history? Is there a finding that it explained by a diagnosable medical disease? And then, we need to acknowledge that when it doesn’t all fit together that we need to consider that abuse is the most likely diagnosis and then we need to take appropriate steps.
Melanie: And if this is something that’s identified by the pediatrician, what is their next step, and what’s required for mandating reporting? Are there some deterrents to this reporting system that might keep a pediatrician from reporting it accurately?
Dr. Atzemis: Yes, that’s a great question, Melonie. All pediatric providers are considered mandated reporters in every state, but in Missouri, it means if we have reasonable cause to suspect that a child has been or will be a victim of child maltreatment, we must make a report to Missouri Children’s Division. That language might seem a little vague, but it is written that way purposefully, and the reason is because no one should feel that their suspicion has to be confirmed or proven prior to making a hotline call. The investigation of that suspicion is not the responsibility of the reporter, so each provider has a personal responsibility to ensure that a report is made properly. That responsibility can’t be delegated or transferred to somebody else.
There are certain allowances made like, for example, here at the hospital, we know that one medical team can designate one person to make the report on behalf of the entire team. Pediatricians in practice, or in private practice, or in a group practice can also utilize that allowance, that one person can make that hotline report. But then each mandated reporter should take the steps to ensure that that hotline was made correctly.
Now, you asked about deterrents, and I see that frequently. That is pediatricians feel a lot of discomfort and frustration with making a hotline report, and that’s frequently because they don’t or aren’t part of the investigation of the protection of the abused child, and they feel really disconnected from the process. Here at Children’s Hospital, when I see a case when I’m involved, when the initial reporter is a medical provider or a clinic staff member like the receptionist, or even a housekeeping staff member who made that report, I will frequently reach out to that person who made the report to discuss the case. Many times, providers tell me that they were very – they questioned whether or not they should make the report. They were feeling really insecure. They really didn’t know how to address it, and they really struggled with that decision to make the report.
Many, many times, I’ve been able to very honestly tell them that I believe their decision to make that report saved that child’s life – truly saved that child’s life by making that hotline. It only takes one case like that to really understand the importance of mandated reporting, and that encourage and support clinicians in their duty and their responsibility to make that hotline. If a provider ever feels disconnected from that process or the outcome of a hotline, I really encourage them to call. Talk directly to Children’s Division, the investigator, or the investigator supervisor, or if we, at Children’s Hospital -- the Child Protection Program here is involved, then please reach out to us because we will make sure that we connect them to that process.
Melanie: And what does your Child Abuse Protection Program offer these patients?
Dr. Atzemis: The Child Protection Program at Saint Louis Children’s Hospital is a multidisciplinary team. Our team includes physicians who are child abuse pediatricians, myself and Dr. Kondis. We also have a group of nurse practitioners who both do care in our clinic on an outpatient basis and see patients in the Emergency Room when it’s required. We have support staff, and then we have this excellent team of social workers who work very closely and are very knowledgeable about the child protection system in Missouri and in Illinois since so many of our patients are also from Illinois.
Our program becomes involved when any person here at hospital requests us to be involved, and that includes primary care doctors or people outside of our system. They call and say that they are concerned about a particular child, we will address it as a team. Our team frequently does inpatient consultations, but also outpatient consultations, and then we’ll also do medical record reviews.
Melanie: And in summary, Dr. Atzemis, tell us what you would like pediatricians to know about identifying abuse in their pediatric patients. What do you want them to know about referring?
Dr. Atzemis: I just want them to know that they need to consistently think of abuse as a possibility. Not that I want them to think poor things about their patients or to not believe families when they come in with accidental injuries, but they need to constantly think of the possibility and keep their eyes open for those signs. Once they see that, to really reach out and get the support that is available to them to best care for that child in that situation. Many times that means just calling us and they can always call us through Children’s Direct. Dr. Kondis or myself are on call 24/7 and will always be able to offer support and assistance if they feel that a patient of theirs is being somehow maltreated or abused.
Melanie: And what can a pediatrician expect from your team after referring a patient to you?
Dr. Atzemis: They should expect that we will reach out to them and talk to them about the case. There are times that a family sometimes doesn’t want a lot of information provided, but we always do reach out to our referring physicians. Sometimes they even know more information that we do because they’re close to the family and the family may feel safer and more comfortable talking to them. We will let them know what’s happening. If for some reason, they haven’t heard from us, to please call us and we’d be happy to discuss their case.
Melanie: Thank you, so much, for being with us today. It’s really so heartbreaking, but such important information. Thank you, Dr. Atzemis, for being with us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678- 4357. You’re listening to Radio Rounds at Saint Louis Children’s Hospital. For more information on resources available at Saint Louis Children’s Hospital, you can go to SaintLouisChildrens.org, that’s SaintLouisChildrens.org. This is Melanie Cole. Thanks, so much for listening.