pediatrics
Overview of Child Maltreatment
Treatment of Child Maltreatment
Treatment of injuries Reporting to the appropriate agency Creation of a safety plan Family counseling and support Sometimes removal from the home Treatment first addresses urgent medical needs (including possible sexually transmitted infections) and the child’s immediate safety. Referral to a pediatrician specializing in child abuse should be considered. In both abuse and neglect situations, families should be approached in a helping rather than a punitive manner. Physicians and other professionals in contact with children (eg, nurses, teachers, day care workers, police) are mandated reporters who are required by law in all US states to report incidents of suspected abuse or neglect (seeMandatory Reporters of Child Abuse and Neglect). Every state has its own laws. Members of the general public are encouraged, but not mandated, to report suspected abuse. Any person who makes a report of abuse based on reasonable cause and in good faith is immune from criminal and civil liability. A mandated reporter who fails to make a report can be subject to criminal and civil penalties. The reports are made to Child Protective Services or another appropriate child protection agency. In most situations, it is appropriate for professionals to tell caregivers that a report is being made pursuant to the law and that they will be contacted, interviewed, and likely visited at their home if the report is accepted. In some cases, the professional may determine that informing the parent or caregiver before police or other agency assistance is available creates greater risk of injury to the child and/or themselves. Under those circumstances, the professional may choose to delay informing the parent or caregiver. Representatives of child protective agencies and social workers conduct an evaluation of the events and the child's circumstances and can help the physician or other professional determine likelihood of subsequent harm and thus identify the best immediate disposition for the child. Options include Protective hospitalization Placement with relatives or in temporary housing (sometimes a whole family is moved out of an abusive partner’s home) Temporary foster care Going home with prompt social service and medical follow-up A malnourished child suspected to be a victim of neglect should be hospitalized and given nutrition in an age-appropriate fashion before any other supportive nutritional care is initiated (eg, gastrostomy tube). A child who begins to thrive while hospitalized is potent evidence of neglect (or poverty with lack of food). The physician plays an important role in working with community agencies to advocate for the best and safest disposition for the child. Healthcare professionals in the US are often asked to write an impact statement, which is a letter typically addressed to a Child Protective Services worker (who can then bring it to the attention of the judicial system), about a child who is suspected to be the victim of maltreatment. The letter should contain a clear explanation of the history and physical examination findings (in layperson's terms) and an opinion as to the likelihood that the child was maltreated. A source of primary medical care is fundamental. However, the families of abused and neglected children frequently relocate, making continuity of care difficult. Broken appointments are common; outreach and home visits by social workers and/or public health nurses may be helpful. A local child advocacy center can help community agencies, health care practitioners, and the legal system work together as a multidisciplinary team in a more coordinated, child-friendly, and effective manner. A close review of the family setting, prior contacts with various community service agencies, and the caregivers’ needs is essential. A social worker can conduct such reviews and help with interviews and family counseling. Social workers also provide tangible assistance to the caregivers by helping them obtain public assistance, child care, and respite services (which can decrease stress for caregivers). They can also help to coordinate mental health services for caregivers. Periodic or ongoing social work contact usually is needed. Parent-aide programs, which employ trained nonprofessionals to support abusive and negligent parents and provide an example of appropriate parenting, are available in some communities. Other parent support groups also have been successful. Sexual abuse may have lasting effects on the child’s development and sexual adaptation, particularly among older children and adolescents. Counseling or psychotherapy for the child and the adults concerned may lessen these effects. Physical abuse, particularly significant head trauma, also can have long-lasting effects on development. If physicians or caregivers are concerned that young children have a disability or delayed development, they may request an evaluation from their state's Early Intervention system (seeEarly Intervention Services), which is a program to evaluate and treat children with suspected disabilities or developmental delays. Although emergency temporary removal from the home until evaluation is complete and safety is ensured is sometimes done, the ultimate goal of Child Protective Services is to keep children with their family in a safe, healthy environment. Often, families are offered services to rehabilitate the caregivers so that children who have been removed may be reunited with their family. If the previously described interventions do not ensure safety, consideration must be made for long-term removal and possibly termination of parental rights. This significant step requires a court petition, presented by the legal counsel of the appropriate welfare department. The specific procedure varies from US state to US state but usually entails family court testimony by a physician. When the court decides in favor of removing the child from the home, a disposition is arranged, typically to a temporary placement, such as foster care. While the child is in temporary placement, the child's own physician or a medical team that specializes in children in foster care should, if possible, maintain contact with the parents and ensure that adequate efforts are being made to help them. Occasionally, children are re-abused while in foster care. The physician should be alert to this possibility. As the dynamics of the family setting improve, the child may be able to return to the original caregivers. However, recurrences of maltreatment are common. 