From the Division of Child Advocacy, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.
The author declares no conflicts of interest.
Reprints will not be available from the author.
Address correspondence to Janet Squires, MD, Division of Child Advocacy, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave., Pittsburgh, PA 15224-1529. Address e-mail to email@example.com.
Accepted December 15, 2011
Dr. Stephen Harvey's article “A Different Kind of Vigilance” is a poignant, first-hand account of a physician's concern about child sexual abuse. It was submitted near the end of October 2011, just weeks before a national child abuse scandal would break at a prominent university involving alleged abuse within a successful football program.1 Since then, multiple national leaders have questioned whether the child protection system in this country is doing enough to protect our children. Moreover, in social and work settings around the country, adults have had discussions about the role and responsibility of adults to protect children, both as professionals and as individuals.
Physicians have played a prominent role historically in elucidating the scope and significance of abuse of children. The modern era of child protection efforts is often dated to the seminal 1946 paper by John Caffey,2 an expert in the evolving field of radiology, in which he described the association of multiple fractures and subdural hemorrhages in young children. This was followed by a series of careful, thoughtful reports of injured children from clinicians like Henry Kempe and Frederic Silverman.3 This spotlight of medical data helped overcome the natural reactions of denial and secrecy in society, and 1974 federal legislation called Child Abuse Treatment and Protection Act (Public Law 93-247) mandated that each state would have a state agency charged with the protection of children. At this time, almost 40 years later, child abuse is universally accepted as a recognized medical entity. For ease of categorization, types of abuse are often simplistically separated into the 4 basic types of abuse: physical abuse, sexual abuse, emotional abuse, and neglect. In 2009, the field of Child Abuse Pediatrics became the 14th recognized subspeciality by the American Board of Pediatrics.
And yet, the diagnosis of child abuse remains one which is difficult to consider. A few examples of angst-causing aspects are illustrative. First, there are legal implications to the diagnosis of child abuse. Cases of documented and alleged child abuse enter into the civil legal arena, where placement of the child and rights of the parents to custody are addressed. For a subset of cases, in which abuse verification reaches a high legal standard and a specific perpetrator can be named, criminal proceedings can follow. Second, in an era whereby medical truth and advances ideally depend on evidence-based practices, there remain many aspects of incomplete medical knowledge about what “proves” abuse. Scientific studies are uniquely difficult to accomplish. The accuracy of the history part of an evaluation is suspect, and motivation of families to participate in any long-term study is typically missing. Third, interventions are complex, involving social determinants and family characteristics, most of which are outside the realm of medicine and which are not readily fixable.
Dr. Harvey's scenario describes a 3-year-old boy under anesthesia, where he notes physical signs that seem concerning for sexual abuse. He notes possible bruising around the anus and external genital warts. After contacting the state child protection agency, both an agency caseworker and a police officer come directly to his facility. Arrangements are made for the child to go directly to a consultative abuse evaluation setting. A lesser trained but more experienced professional, a physician assistant, assesses the findings as normal anatomical variants and states that genital warts can be acquired in this age group by nonsexual transmissions. Dr. Harvey describes his personal reactions, and wonders whether he has helped or hurt the child and family.
As one of the 187 currently board-certified child abuse pediatricians, I offer these responses to the author and to other physicians who appreciate the struggle involved: If children were really the focus of our culture, we would live in a world where every adult takes responsibility for the safety and well-being of all children. For professionals such as physicians, that may mean a variety of responses. These may range from asking nonaccusatory but probing questions, to arranging more frequent visits as a means of keeping an eye out for injury, to providing additional support to struggling parents, to making referrals when indicated to a well-trained and well-supported child protection system. It is a world where parents would actually respond to any concern about child safety with gratitude that other adults are looking out for the well-being of their child. It is a world where each child who is referred to the CPS system is better off after the referral process has taken place, even if the concerns were not substantiated. We are not there yet. But Dr. Harvey has enlisted as a foot soldier in the effort.
* The consulting professional physician assistant appears to be practicing within the current standards of medical knowledge. It is appropriate to refer any child no longer in diapers, who has newly recognized human papilloma virus (HPV) lesions, to a maltreatment assessment program. However, the significance as an indicator of abuse has changed. In the past, numerous genital findings were considered signs of trauma, but have subsequently been shown to occur in child populations selected as unlikely abuse victims, and thus are now considered normal variants. Most child abuse experts are decidedly conservative in assessing any medical finding as indicative of abuse unless it falls clearly into the 3 categories associated with abuse: (1) unequivocal signs of trauma (e.g., transected hymen), (2) infection highly associated with sexual acts (e.g., gonorrhea), and (3) pregnancy. Warts caused by HPV in past years were interpreted as a sexually acquired condition if they started after age 2 years. However, improved knowledge of HPV epidemiology now suggests that hand-acquired infections occur frequently in any age group where hand touching is frequent (e.g., diaper changing, washing). Still, 2 important concepts must be remembered. First, most children who have been sexually abused will have normal genital examinations. Although the percentage cannot be stated with certainty for obvious reasons, most experts will argue that >90% of sexually abused children will have normal genital examinations. Second, a normal genital examination can never rule out the possibility of sexual abuse.
* An unsubstantiated case does not mean that abuse has not occurred. Dr. Harvey mentions the often-misunderstood fact that most reports of abuse that are investigated will result in a finding of “unsubstantiated.” This simply means that the results of an investigation did not rise to the level of meeting the state's definition of child abuse, with the information known at that time. A large number of these children and families are identified as having needs and risk factors, which may be helped by the supportive community-based services that can be offered to the family. A finding of child abuse unsubstantiation never translates directly to an assessment that the original referral was in error.
* The role of the physician does not include the identification of the person who may be hurting the child. Physicians have the important tasks of documenting carefully the medical findings that suggest or prove abuse, and recording a careful, thorough chronological history leading up to presentation for medical care. The record should include a list of adults around the child, and a reporting of the observations made by those adults. But it is not the physician's role to ascertain who the “alleged perpetrator” is. That is the task of the investigative agencies of Child Protective Services (CPS) and law enforcement. Many times, the adult/ parent who brings the child may or may not know if abuse has happened, and may or may not be an abuser. Dr. Harvey's account suggests he made an unwarranted assumption about who the abuser might be. His language is a bit overdramatic, worried that he “had interfered with the bond between parents and child, and possibly ruined the reputation of an innocent man.”
* Here is the most important point: the goal of reporting a possible case of child abuse is to protect this child and other children in the future, and not to ferret out and indict bad parents and caregivers. Most CPS referrals, even from physicians, do not end with an assessment that abuse occurred. Few cases are black and white; many lie on the gray spectrum. A report allows community-based professionals to gather information, visit homes, and seek observations from multiple sources. They look for patterns of maltreatment, such as multiple reports. And these complex tasks themselves can often help adults face the risk factors for their own children, laying the groundwork for a recommitment to child safety in the future.
Name: Janet Squires, MD.
Contribution: This author wrote the manuscript.
Attestation: Janet Squires approved the final manuscript.
This manuscript was handled by: Peter J. Davis, MD.
1. Harvey S. A different kind of vigilance. Anesth Analg 2012; 114: 910–1
2. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Radiology 1946; 194: 163–73
3. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA 1984; 251: 3288–94