Child Abuse for the General Pediatrician

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Child Abuse for the General Pediatrician

• Marcus DeGraw, MD
• St. Johns Hospital
• Detroit, MI

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Who am I?

• General Pediatrician with a fellowship completed
  in Child Abuse at Cincinnati Childrens Hospital
• Will provide any support necessary for inpatient
  or outpatient cases to St. Johns physicians

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What are child abuse specialists?

• Now over 12 University supported fellowship
  programs in the country
• Have received pre-approval and awaiting final
  approval to become a board certified specialty by
  the AAP
• Able to support physicians for physical and
  sexual abuse, neglect, Munchausens and other
  related child abuse cases.

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Why talk about abuse?

• You are mandated reporters
• Who Must Report?
• Physicians, including hospital interns or
  residents dentists podiatrists practitioners
  of limited branches of medicine or surgery
  registered nurses licensed practical nurses
  visiting nurses other health care professionals
  speech pathologists audiologists coroners
  Teachers Principals
• Under What Conditions?
• When they are acting in their official or
  professional capacities and know or suspect that
  a child under 18 years or a mentally retarded,
  developmentally disabled, or physically impaired
  child under 21 years has suffered or faces a
  threat of suffering any physical or mental wound,
  injury, disability, or condition of a nature that
  reasonably indicates child abuse or neglect.

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Why talk about abuse?

• Unfortunately, failure to report is a crime.
• Two local physicians charged with felony charges
  for failure to report child abuse. Detroit, 2003
• Nurse charged with two counts of misdemeanor
  failure to report child abuse in Greene County,
  Missouri. 2003
• Jury awards 5 million in damages after finding
  that three doctors failed to detect symptoms of
  child abuse in an infant who was later
  permanently disabled. Washington DC, 2004

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What to know about child sexual abuse.

• General pediatricians should examine male and
  female genitalia at every well child exam up to
  puberty/menarche
• Reason 1 Believe it or not, genitalia is as
  prone to abnormalities as other body parts (even
  girl parts!!!)
• Reason 2 1 of all office complaints involved
  vaginal pain, discharge or dysuria
• If you dont know what youre looking at you
  cant make an accurate diagnosis
• Pre-pubertal girls DO NOT get yeast infections as
  a general rule
• Reason 3 Kids who have never been examined will
  hate being examined when they have a true problem
• Reason 4 Knowing what the genitalia looks like
  helps differentiate previous abnormalities from
  new trauma (i.e. abuse)

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How to do a Proper exam

• Frog-legged position

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How to do a Proper exam

• Knee Chest Position

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What should an exam look like?
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What to know about child sexual abuse.

• 20 of adult woman in the U.S. have experienced
  sexual abuse. 20 retrospective studies
• Male sexual abuse is estimated at 7. Finklehor
  estimate
• Of the 63 million children in the U.S., ½ million
  are sexually abused.
• 500,000 children/year are abused.

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Signs of sexual abuse

• Behavior changes
• new fears
• depression
• acting out
• night terrors, nightmares
• runaway
• suicide attempt

• Physical symptoms
• discharge
• genital injury
• bleeding
• STD
• pregnancy

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The Emergent Examination

• Sexual Assault within 72 hrs
• Particularly when forensic evidence may be
  present
• Most likely will need a full rape kit
• Emergent symptoms
• Bleeding (anal or genital)
• Discharge
• History / signs of injury
• bruising, abrasion or laceration

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Non-Emergent Examination

• Sexual assault greater than 72 hours or no
  forensic evidence collection indicated
• No acute injury, discharge or bleeding
• Best done by a child abuse professional in a
  controlled setting
• 80 of examinations meet this criteria

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Why a Child Abuse Expert?

• MOST Pediatricians, FPs and ER docs are
  inexperienced at this.
• More than half of primary care physicians could
  not identify major parts of a female childs
  genital anatomy
• More than half could not recognize clear evidence
  of chronic sexual trauma
• Ladson et al AJDC l987

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Why a Child Abuse Expert?

• ER docs just as bad
• Study at Cincinnati Childrens Hospital 1994-1998
• Enrolled 46 kids thought to have chronic abuse
  findings on exam by ER doctors
• Follow up exams done by Child Abuse center docs
  found only 8 had clear evidence of abuse
• 32 kids had normal exams
• The rest had non-specific findings
• Makoroff, et al, Child Abuse and Neglect 2002

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TOP 10 BAD THINGS A DOCTOR UNTRAINED IN CHILD
SEXUAL ABUSE MAY DO

• 10- Uses the term virginal or intact to describe
  the hymen
• 9 - Does not recognize the importance of a
  prompt exam in cases of sexual abuse
• 8 - Believes that only female attending
  physicians should do genital examinations
• 7 - Uses a speculum to exam the genitalia of
  pre-pubertal girls

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• 6 Calls the abuse MD on call just to let them
  know Hey, the exam was normal
• 5 - Collects forensic specimens on all children
  who were assaulted within the previous 3 days
• 4 - Says this child was abused because she has
  no hymen
• 3 - Believes they can tell if an adolescent has
  had sex by an examination
• 2 Completes the GU exam in under 3 seconds
• 1 - Tells the prosecutor that they dont testify

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What to know about child physical abuse

• If you SUSPECT you must REPORT
• Most cases need to be admitted for medical and
  medical-legal reasons
• File 3200, order appropriate studies and ask for
  help!

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Accepted Protocols

• If child is less than 1 year old and you suspect
  physical abuse you should order
• Head CT, skeletal survey, LFTs and Optho consult
• If child is 1-2 years old and you suspect child
  physical abuse you should order
• Skeletal survey and others as necessary
• If child is gt 2 years old and you suspect abuse
  you should order tests as indicated by exam

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Dont forget siblings!

• All siblings of known or suspected abused
  patients should be examined and have studies
  based on the same protocol
• All siblings of known abuse cases should be
  placed in a safe environment pending results of
  the investigation.

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Skeletal Survey Protocol

• An American College of Radiology accepted
  protocol since 1997
• No room for self changes, this is a very specific
  protocol
• AP and Lateral Skull
• AP and Lateral Chest
• AP Pelvis and Abdomen
• AP dedicated of EACH Humerus, forearms, femurs,
  tib/fibs
• Lateral Lumbar Spine
• Lateral Cervical Spine
• AP feet
• PA or AP hands
• Check your own films!!!

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Examples

• 2 year old girl with Bilateral black eyes and
  vomiting for 2 days

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Examples

• 4 month old with irritability and lethargy

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Examples

• 6 month old accepted from outlying hospital for
  treatment of a femur fracture
• No other problems noted

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Referring hospitals Skeletal Survey
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How to Report Child Abuse

• 3200 Form to file with Protective services
• Must fill out form AND call in report
• Copy goes to police when filed
• File in county of childs residence
• Wayne County 313-396-0300
• Oakland County 248-975-5010
• Macomb County 586-412-6109

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Keeping children safe A guide for simple steps
to protect children from abduction and child
abuse

• Dr. Marcus DeGraw
• St. John Hospital
• Detroit, MI

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The Problem of Pedophilia

• Pedophilia involves sexual attraction/orientation
  towards children.
• Usually involves males.
• Sexual attraction/orientation of the person
  (usually a male) is toward a child rather than an
  adult.
• Sex offenders are often involved with two or more
  children, and the problem is often a recurrent
  one.
• Four percent of the population suffers from
  sexual orientation toward children.

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The Numbers

• In 1999, 93,000 kids were sexually abused.
• 50 of the abusers were parents of the children.
  18 were relatives.
• This means that almost 70 of children were
  molested by family members.
• In one year 58,200 children are victims of
  non-family abduction!

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Protection for Children

• The U.S. Congress passed three laws that require
  States to monitor child offenders.
• Wetterling Registration Act
• Lynchner Tracking and Identification Act
• Megan's Law
• On March 5, 2003, The Supreme Court ruled that
  information about registered child offenders may
  be posted on the Internet.

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Wetterling Registration Act

• 1994 - Jacob Wetterling Crimes Against Children
  and Sexually Violent Offender Registration Act is
  passed as part of the Federal Violent Crime
  Control and Law Enforcement Act of 1994.
• This law requires states to implement a sex
  offender and crimes against children registry.

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Megan's Law

• 1996 - Megan's Law amends the Wetterling Act.
• It requires states to establish a community
  notification system.

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Lynchner Tracking and Identification Act

• The Pam Lychner Sexual Offender Tracking and
  Identification Act of 1996 becomes an amendment
  to the Wetterling Act.
• It requires lifetime registration for recidivists
  and offenders who commit certain aggravated
  offenses.

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Other Amendments

• 1998 - Provisions contained in Section 115 of the
  General Provisions of Title I of the Commerce,
  Justice, and State, the Judiciary, and Related
  Agencies Appropriations Act (CJSA) amend the
  requirements of the Wetterling Act.
• Include heightened registration requirements for
  sexually violent offenders, registration of
  federal and military offenders, registration of
  nonresident workers and students.
• Also mandates participation in the National Sex
  Offender Registry (NSOR).
• 2000 - The Campus Sex Crimes Prevention Act
  amends the Wetterling Act.
• Requires offenders to report information
  regarding any enrollment or employment at an
  institution of higher education and to provide
  this information to a law enforcement agency
  whose jurisdiction includes the institution.

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Protecting Children

• Be Prepared!
• Well Exams
• Talk to your Children
• Pediatrician Teaching
• ID Kits
• Being Invovled
• Take kids to school
• Talk to them!
• Being Aware
• Who to call if there is a problem?
• Being Informed
• State and Federal Sex Offender Registries

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Be Prepared!

• Well Exams drilled into you at nauseum!
• Talk to Children
• Teach Kids Key information.
• Teach kids who might be safe in emergency.
• Teach them what types of behavior are
  inappropriate from adults and peers.
• Let your kids know they can talk to you about
  anything - even sexual abuse.
• Stranger Danger and Family Passwords
• Stranger Safety
• Even if nice, candy, zoo!
• Cars too!
• Safe and Danger areas

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Be Prepared!

• Pediatrician Teaching
• ID Kits
• Description Height, weight, hair and eye color
• Medical and other information
• Last Clothing worn
• FINGERPRINTS
• Some even use small hair sample

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Being Invovled

• Take your children to school or have them taken
  by a trusted person.
• Buddy system ALWAYS!
• Home security.
• Teach 911 and family back up.
• Block safe house/Neighborhood Watch
• Talk to kids about what might be suspicious and
  hear them!
• KNOW WHERE YOUR KIDS ARE!!!

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Being Aware

• Local Authorities Numbers CALL 1st
• Time is a very critical factor in abduction
  cases.
• Seventy four percent of children who are abducted
  and murdered are killed within three hours of the
  abduction.
• Ask for info to be entered into the National
  Crime Information Center's Missing Person File
• National Center for Missing Exploited Children
• http//www.missingkids.com/
• 1-800-THE-LOST

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Being Aware

• Local Division of FBI
• FBI Tips and Public Leads
• https//tips.fbi.gov/
• Call the Department of Homeland Security's
  Operation Predator 1-866-DHS-2ICE

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Being Informed

• State and Federal Sex Offender Registries
• National Alert Registry
• http//www.registeredoffenderslist.org
• http//www.nsopr.gov/
• http//www.teamamberalert.net/
• Search by Zip code (7 listed in mine)
• Federal List
• Small fee - 10 for list in your zip code with
  pictures, addresses and names. 5 a month for
  auto-updates
• State of Michigan Registry
• http//www.mipsor.state.mi.us/
• Search by Zip Code (6 shown by this method)
• Free Names, addresses and level of crime
  committed
• No pictures

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How to contact me

• Office 313-343-3481
• Pager 313-609-0177