Child Abuse Elective

Recognition and Evaluation of Child Maltreatment Elective

Information for Residents

Elective Directors:

Thomas J. Valvano, MD, JD

Medical Director, SCAN Service, Doernbecher Children’s Hospital

Assistant Professor of Pediatrics, Oregon Health & Science University

Pager: 13551

Phone: 503-494-8366

Dan E. Leonhardt, MD

Attending Physician, The Children’s Hospital at Legacy Emanuel

Examiner, CARES Northwest

dleonhar@lhs.org

On the first day of the elective: Page Dr. Valvano (13551) the day before or the morning of the elective for orientation.

Schedule: Will be provided at orientation

Resources: A CD containing required reading, case scenarios, and List of References will be provided at the start of the elective.

Child abuse and neglect is a significant problem in the United States. In 2007, approximately 3.5 million children received an investigation by child protective services (CPS) agencies for possible maltreatment. An estimated 753,357 children were found to be victims; a rate of 10.6 per 1,000 children.¹ Neglect was the most common type of maltreatment, followed by physical abuse and then sexual abuse. Identifying victims of child abuse, and ensuring their safety is a multidisciplinary effort involving CPS, Law Enforcement and Health Care Professionals. Pediatricians play a critical role by in the diagnosis, treatment and prevention of abuse by working with CPS and police investigators, providing expert testimony in court, and raising awareness through education. All physicians are legally mandated to report suspicions of child abuse.

In spite of its prevalence, several studies have demonstrated that physicians are often unprepared to recognize and address child abuse issues. One study of abusive head trauma found that 31% of abusive head trauma victims were not recognized by the physicians who first evaluated them. Of those missed children, 28% were reinjured and 41% had medical complications as a result of the delay in diagnosis.² In 1987, a survey of family practitioners and pediatricians found that a significant number of physicians were unable to correctly identify structures on a photograph of female prepubertal genitalia.³ A similar survey of pediatric chief residents in 2005 yielded similar results, with only 64% correctly identifying the hymen. Half of the chief residents surveyed thought that their residency training on sexual abuse was inadequate.⁴ Other studies have also found that residency training in child abuse was inadequate.^{5, 6}

Since victims of abuse may present to a physician in a variety of circumstances, a basic understanding of child abuse is fundamental to the practice of pediatrics, regardless of the area of specialty. Pediatricians are mandated reporters and their ability to recognize abuse and make the appropriate referrals will depend upon their degree of knowledge and confidence. This elective will provide residents with the tools necessary to identify and evaluate children who may be maltreated. Furthermore, the skills acquired during this elective are applicable to all areas of pediatrics. These skills include taking a detailed history, learning to do a thorough physical exam, and working with other medical and non-medical professionals as part of a multidisciplinary effort to address the patient’s health care needs.

The Suspected Child Abuse and Neglect (SCAN) Service at Doernbecher Children’s Hospital (DCH) consists of a pediatrician and nurse practitioner, and provides consultations to the inpatient units, emergency department and outpatient clinics. The SCAN service works closely with the Social Work Department. In addition, both members of the service see patients at CARES Northwest (CNW), the primary outpatient child abuse facility in Portland. The physicians at CNW also provide consultations for patients at The Children’s Hospital at Emanuel (CHE). The volume of consults at DCH and CHE, as well as at CNW will ensure that residents are exposed to a wide range of child abuse topics. The residents will also be able to view forensic interviews at CNW and attend court proceedings.

Ideally, residents will devote 4 weeks to this rotation but shorter periods can be accommodated as well. Residents will maintain their ½ day of continuity clinic during the rotation. The rotation can accommodate only one resident at a time.