1. Screening for Child Abuse
Samuel Merritt University
Primary Healthcare I Spring 2012
Alicia Kletter RN MSN FNP
My name is Alicia Kletter and I’m a family nurse practitioner who specializes in perinatal substance abuse. In my current role, I am unfortunately in the position to suspect, confirm and report child abuse at least a few times each year. This lecture will focus on the epidemiology of child abuse in the United States, the risk factors for child abuse in the family, and physical exam findings that you should look for in a suspected child abuse case, and the mandatory reporting that we, as nurse practitioners in the State of California, are required to comply with. This lecture will follow the case of Lola, a child whose mother I cared for in my clinical site.

2. Introduction to Case of “Lola”
8-month old little girl
Her mother is my patient in methadone maintenance
I have known the mother 1 year, Lola her whole life
Mother’s boyfriend violent and not the child’s father
After an argument, intoxicated boyfriend took off with 8-month old Lola
Mother is hysterical, in clinic seeking our help
At the time that I reported a CPS case for Lola, she was an 8-month old little girl. Her mother was successfully being treated in the clinic where I work with methadone maintenance to help her with a longstanding addiction to heroin and other opiates. I had been caring for Lola’s mother since she entered my program 4 months pregnant, so I had known Lola’s mother for about a year, and Lola for her entire 8-months of life. Lola’s mother, while free of illicit drug use, was occasionally associating with people from her “old life on the streets” and had been talking to the therapist in our program about this being a trigger for relapse. At every weekly therapy session, I had our therapist assess for abuse, both of Lola and of her mother. We were fearful of a new relationship she was having with a gentleman well known in the neighborhood for being violent and addicted to drugs.
One afternoon Lola’s mother came into the clinic hysterically crying and stating that “he took my baby”. Calming down enough to tell us the bare-bones details, she stated that her boyfriend had taken Lola in her stroller an hour ago and he was drunk and she couldn’t find them. She admitted that she and the boyfriend had been fighting, but claimed “I know he won’t hurt her”. Realize that Lola is not this gentleman’s daughter, but rather he’s a current boyfriend and thus has no parental rights to take the child. Our clinic’s security guard had seen the gentleman pushing Lola in her stroller about 45 minutes ago, and had noted that the boyfriend did seem to be slurring his speech and under the influence of some substance when he stopped by the clinic at that time looking for Lola’s mother. Understand that since our patients attend the clinic every day, and this gentleman was well known in the neighborhood, it’s not unlikely that he’d stop by the clinic looking for Lola’s mother. So clearly, we have a case of possible child abuse and Lola’s life is possibly in danger from being pushed around the Tenderloin in San Francisco by an intoxicated, violent, angry gentleman who is not her father.

3. Introduction & Definition
Child abuse occurs worldwide
Consequences for children may be serious and long term.
Health care providers play essential roles
protecting children through recognition and reporting
Let’s use the case study to learn about child abuse screening, risk factors for abuse, physical exam findings and reporting requirements. Let’s start with a general overview of what child abuse is, by definition. According to the references on the website UpToDate, child abuse occurs worldwide, with serious and long term consequences for affected children and their families. Health care providers play essential roles in protecting children through the recognition and reporting of suspected inflicted injury.

4. Introduction & Definition
Child Abuse Prevention and Treatment Act (1996)
Act or failure to act
Results in death, serious physical or emotional harm, sexual abuse, exploitation, imminent risk of serious harm
Involving a child
By a parent or caretaker
The four major types of child abuse are:
Physical abuse
Sexual abuse
Emotional abuse
Child neglect
Here in the United States, each state is responsible for providing its own definitions of child abuse and neglect as long as they are consistent with federal law. The Child Abuse Prevention and Treatment Act (abbreviated CAPTA), defines child abuse as “any recent act or failure to act resulting in death, serious physical or emotional harm, sexual abuse, exploitation or imminent risk of serious harm involving a child by a parent or caretaker (including any employee of a residential facility or any staff person providing out-of-home care) who is responsible for the child's welfare.” A child is typically defined as a person under the age of 18.
The four major categories of child abuse are physical abuse, sexual abuse, emotional abuse, and child neglect. This lecture will focus mostly on physical abuse & neglect, but be sure to read up on and learn about other types of child abuse whenever you have the opportunity, as you do not want to miss this in your clinical practice.
Going back to our case study about Lola, what type of abuse do you think she was suffering from? On the surface, it doesn’t seem to be physical abuse. What about neglect? Emotional abuse? Hopefully we do not find evidence of sexual abuse. Let’s talk about Lola again in a moment. Let’s first see how common child abuse is in this country.

5. Epidemiology of Child Abuse
1 million cases substantiated annually by CPS
17% physical abuse
2,500 children die in US each year from abuse
Under age 1 more common
Minority children have higher rates of abuse
Speculation that stereotypes result in more reporting in minority children
Who is abusing children in this country?
Fathers
Mothers’ boyfriends
Female babysitters
Mothers
In the United States, over 1 million cases of child abuse and/or neglect are substantiated annually by child protection services. Many more cases are reported, but 1 million are found to be legitimate and substantiated reports of abuse. Approximately 17 percent of these cases involve physical abuse. Worldwide in developed countries such as the United States, estimated prevalence of physical abuse during childhood is anywhere from 5-35%, with some statistics reporting that as few as 5% of actual abuse cases are reported. We will talk later in this lecture about the reasons why child abuse isn’t reported. In the United States, up to 2,500 children die of inflicted injuries annually with children under age one year affected disproportionately. The incidence of fatal child abuse may be underreported, according to observational studies which looked at child death certificates.
The following statistics are certainly controversial, but higher rates of child abuse have been reported for minority children. For example, in a 2005 study cited on the website UpToDate, the rate of reported child abuse and neglect among African-Americans was 20 per 1000 children, as compared with 11 per 1000 children for white children. The suspicion is that child abuse may be over-identified among minority children – meaning we as medical providers stereotype our patients and their caregivers. Another study demonstrated this point in a retrospective review of 388 children younger than three years of age who were hospitalized for treatment of acute primary skull or long bone fracture. Minority children were more likely to be evaluated and reported for suspected abuse, even after controlling for the likelihood of abusive injury.
So who are the child abusers in this country? The most common perpetrators of physical abuse, in descending order of frequency, are fathers, mothers' boyfriends, female babysitters, and mothers.

6. Risk Factors for Child Abuse
Parental Risk Factors
Young
Single parents
Low education level
Unstable family situation
Drug / alcohol abuse
Psychiatric illness
Abused themselves as children
Environmental Risk Factors
Poverty (?)
Unstable family situation
Social isolation
Distant / absent extended family
Acceptance that violence is a means of problem solving
Parental risk factors for abuse include young or single parents, parents with lower levels of education, and unstable family situations, such as marital discord, homelessness, loss of employment, or death of family member to name a few. Unfortunately, parents who abuse their own children were often abused or neglected themselves as children. This illustrates that abuse or neglect of their own children is possibly a learned behavior. Drug and alcohol abuse and psychiatric illness (such as depression or impulse disorders) also may play a role in perpetuating child abuse in families.
Let’s talk about factors in the family environment that can put a child at risk for abuse. Poverty is usually assumed to be a risk factor, but child abuse in poor families often is detected more readily because of increased contact with social workers, police, and medical providers who are aware of the manifestations of child abuse. The level of suspicion for child abuse also tends to be higher in families with lower socioeconomic means, whether this is warranted or not. And again, these families come in contact with individuals who might suspect and report child abuse more readily than a more affluent family. In fact, child abuse in affluent families may remain "hidden" because of the perception that it won’t happen in these types of families, a lower level of suspicion when something seems “off”, and the greater ability of affluent families to protect themselves from detection and legal consequences. Also, unstable family situations as mentioned previously on this slide lend to increased risk for child abuse. And additionally, social isolation, distant or absent extended family, and the acceptability of violence as a means of problem solving all are environmental factors that increase the risk for child abuse.
It is impossible to read the words on the diagram on this slide, and for the life of me I could not figure out how to paste a large enough version of this diagram on the slide for you to read. So instead I’ve included it in the reading assignments for this week’s module. It’s a diagram of a model adopted from the Centers for Disease Control’s Social-Ecological Model as a Prevention Framework for child abuse. I found the diagram very interesting and full of useful information about individual, family, community and societal risk factors for child abuse as well as protective factors against child abuse.

7. Risk Factors for Child Abuse
Victim Risk Factors
Age less than 1 year old
Past history of abuse
Speech / language delay
Congenital anomalies
Hyperactive children
Adopted children
Step children
Failure to thrive
Let’s finish up this section before returning to our case study by examining the data about who the victims of child abuse tend to be. For starters, age is a factor in child abuse. Statistics show that 67% of abuse of children occurs in those less than 1 year of age, and 80% occurs by the time the child is three. Another troubling statistic is this: an abused child has a 50 percent chance of experiencing further abuse and a 10 percent chance of dying if the abuse is not detected at the initial presentation. So a past history of abuse lends to an increased risk of more abuse and even death from abuse. Children with speech or language disorders, children with learning disabilities, those with conduct disorders, and psychiatrics illnesses are also at an increased risk for child abuse. Congenital anomalies, intellectual disability, and chronic or recurrent illnesses also place the child at increased risk of incurring abuse. Hyperactive children, adopted children, and stepchildren also are abused more frequently. And finally, to confuse the issue a little, conditions such as failure to thrive, developmental delay, conduct disorders, and learning difficulties, may be both risk factors for and the result of child abuse or neglect. For example, the child may have an organic reason for failing to thrive, let’s say severe reflux and he won’t eat. This illness and failure to thrive can place a child at risk for abuse. But conversely, a child who is otherwise healthy but is being abused and/or neglected can also present with failure to thrive.

8. What are Lola’s Risk Factors
Age less than 1 year
Drug abuse in immediate environment
Family violence in her home
Poverty (?)
Mother has a boyfriend
DO WE NEED TO MAKE A CPS REPORT?
So back to the case of Lola and her mother. We knew immediately that we had to call the police, as this was possibly a child abduction case at the very least and probably more. Lola’s mother was hysterical and begging us to call the police for help initially, although when the call was actually placed and we were outside waiting for the police she became upset and said she didn’t want to get her boyfriend in trouble, that she was sure he wasn’t going to hurt Lola, and that he was going to “kick my ass” when he gets caught. This immediately worried us for multiple reasons – one being that he’s a known violent gentleman and we are now considering whether he’s abusing Lola’s mother, my patient. We unfortunately didn’t have to wait long to realize our suspicions were correct. While we were outside the clinic waiting for the police to arrive, we hear a loudly screaming child and look up to see the boyfriend running toward us pushing a crying baby Lola. He runs right up to my patient and punches her in the face. Thankfully at that very instant the police arrive. The boyfriend is arrested and taken away.
What were Lola’s risk factors for abuse? Well, she is under one-year of age for starters. She lives in an environment where drug abuse is rampant, although as far as we could tell her mother wasn’t abusing drugs. She lives in poverty, although as mentioned earlier this is a controversial risk factor for abuse. Her mother has a boyfriend, as we learned that after fathers, mothers’ boyfriends are the second most common perpetrators of child abuse. There is clearly family violence going on, as we later learned that this wasn’t the first time Lola’s mother was physically injured by her boyfriend. Can you think of any other factors that might put Lola at risk for child abuse?
So what do we do next? We have to report this case to child protective services, correct? Well, at the time I wasn’t sure. I mean, we all knew that it was a risky situation, Lola’s mother was being abused, and the boyfriend was clearly under the influence of something when he took her out in the stroller through unsafe neighborhoods. But Lola was always well dressed, clean, happy and appeared well-fed and cared for. So what exactly was the reason for the CPS call? In San Francisco, and I’m hoping this is true in other areas but I haven’t had personal experience with it, CPS has the equivalent of an “advice line” where anyone, medical providers included, can call and speak with an emergency child welfare worker and seek advice about whether a case must be reported or not. This can be done anonymously – meaning I can call and ask advice without divulging the patient name. If the advice is “you must make a report” then I have to report with my name of course. So the counselor in our program and I called the advice line and promptly learned that a CPS case was warranted simply because the child’s mother is being abused. So if an adult is being abused and doesn’t want to report it, but she’s living with children in the home, you have to report to CPS possible child endangerment. I honestly had no idea this was the case. Also, after I made the report I learned that there had been anonymous reports in the past week about my patient and worried individuals didn’t like that she was spending time with this gentleman and Lola at the same time. So, a CPS case was warranted at this time. Now, it isn’t at this point so obvious as to which category of child abuse this falls into, definitely the child is endangered but it will become clearer soon enough, unfortunately.
Since Lola had been gone for over an hour and was crying uncontrollably upon her return, the police called paramedics to take her in for medical evaluation. Lola’s mother also went with Lola to the Emergency Room to seek treatment as she’d been punched in the face. I called the Emergency Department to let the attending physician know that they were on their way and that it was a case of intimate partner violence and possible child abuse. The police took statements from us, as medical providers, about the observations of abuse we had witnessed between Lola’s mother and her boyfriend.

9. Physical Exam Findings of Abuse
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Face most common location for injury
Bruising most common type of injury noted
How can you tell if intentional vs unintentional bruise?
Adult bite marks versus another child
Physical abuse and neglect often leave visible marks on the victim’s skin. Emotional abuse leaves marks on the victims psyche and mental health. In the case of Lola, she was taken to the Emergency Department and given a thorough examination, which revealed burn marks in the shape of cigarettes on her back. We were not the pediatrician for Lola and had never taken care of her. It was an awful realization. Lola’s mother was treated for a large bruise on her face, but thankfully had no fractures or other physical injuries.
Let’s take a moment to talk about physical signs of child abuse. There is a good lecture by Dr. Walter Lambert that is available for your review on Medscape. He is an expert from Florida who has worked with hundreds of child abuse victims. His presentation goes through not only common physical signs of abuse, but also some interesting, uncommon physical findings that might look like abuse, but really are not. The link for his lecture is pasted here on this slide and the hyperlink is in the notes section of this slide. Please take the time to read through his lecture notes and look at the photos. This lecture today really cannot focus on the copious amounts of data and photos that are involved in the physical examination findings of child abuse, and Dr. Lambert’s lecture does a fine job of presenting this information. It can be difficult to differentiate intentional injury resulting in bruising from unintentional, regular bruising in a rambunctious child. Non-inflicted bruising tends to occur on bony prominences, such as the forehead, extremities, and front of the body, whereas central bruising to the buttocks, back, trunk, genitalia, inner thighs, cheeks, earlobes, or neck is suggestive of abuse. Bite marks are another red flag for abuse, especially if they are adult bite marks. Children bite each other, but an adult mouth is cm wide versus a much smaller mark for a child. Also, human bite marks usually are superficial, in contrast to the deep punctures or slashes of animal bites and marks of individual teeth may or may not be distinguishable. Lets go back and talk about Lola’s case for a moment as it related to physical examination of the suspected child abuse victim.

10. Physical Examination of Lola
Cigarette burns on her back
No other physical injuries noted
Lola was noted to have what appeared to be cigarette burns on her back. She was noted to have no other evidence of physical abuse, although with fresh bites and bruises it may take a day or two to appear. The Emergency Department Social Worker was called in and proceedings were made for Lola to be placed in foster care until it could be ascertained that Lola’s mother was not the perpetrator of the abuse and until Lola’s mother’s own abuse was handled in some way. We kind of lost touch with the Emergency Department and the social worker for a few days after learning that an emergency child welfare worker was on his way to evaluate the case and there was even word that Lola’s mother would be going to a residential program for women-only who have substance abuse issues and are being physically abused.  
Cigarette burns are circular wounds, 8 to 10 mm in diameter, and of uniform depth. They present with an indurated heaped-up margin. One of the differential diagnoses that you don’t want to confuse with cigarette burns is impetigo. It may be difficult to distinguish cigarette burns from impetigo, but impetigo involves superficial skin layers and occurs in crops or groups of wounds, whereas cigarette burns usually are third-degree, deep, and relatively painless. Impetigo occurs on the face or on the dorsa of the hands or feet whereas cigarette burns can be seen anywhere. In addition, impetigo heals cleanly with antibiotic therapy, whereas cigarette burns heal slowly and leave scars. See the photos on this slide as a comparison between impetigo and cigarette burns. Can you tell which is which? The photo on the left is impetigo on the buttocks and the photo on the right is a cigarette burn on a child’s back.

11. Physical Abuse Bruising
Locations Suggestive of Abuse Patterns
Locations Suggestive Accidental Bruising
Before we move on from physical abuse and it’s manifestations on a child’s body, let’s look at one more slide. Also, remember to look at Dr. Lambert’s presentation referenced on a previous slide for a comprehensive review of abuse skin signs. You reading load for this week includes time to review his lecture.
It is clear from current literature that patterns of accidental bruising in young children is strongly influenced by their level of independent mobility, with non-mobile infants least likely to sustain accidental bruises. Thorough investigation of a baby with an unexplained or inadequately explained bruise is essential, as some may have underlying coagulopathies while others may have been abused. But once children start to move around independently, all bets are off and bruising increases incrementally. Some statistics I found from a study in the British Journal of Medicine said that the prevalence of accidental bruising was 17% for children crawling or cruising and >50% for those newly walking children. However, in these children, the bruising patterns tend to be found in specific locations (see the figure on the right of this slide). The most common site for accidental bruises in mobile children are the knees and shins.  In young children (defined as <6 years old), accidental bruising to the head occurs predominantly in a ‘T’ shape across the forehead, nose, upper lip and chin, and in more than a third (37%) bruising is also found on the back of the head. According to the study I read and in my own experience, it is clear that accidental bruising can occur on the front of the body and over bony prominences. But <6% of accidental bruises to the face are found on the cheeks or periorbital area, so this should raise suspicion for abuse. In contrast to the accidental bruise patterns just discussed, abusive bruises are found predominantly on the head and neck. Again, bruising occurring on the ear, neck and cheeks is extremely rare for accidental bruises. See the figure on the left of this slide for locations of abusive bruising. Any part of the body may be bruised as a consequence of abuse, but specific areas such as the forearms, upper limb and area adjoining the trunk, or outside thigh may indicate ‘defensive bruising’ where the child has tried to protect themselves from the blows being rained upon them. Be sure to document bruising found on children during routine or other exam, whether accidental or otherwise. We will talk more about reporting and documenting in a moment.

12. Talking to Parents About Abuse
Should tell parents that a report is being made
Stress that it’s for the child’s safety
Expect relief, hysterical denial or even violence
Have a safety plan in place for unaccused parent, child and clinic staff if necessary
One of the most difficult tasks I encounter in my clinical practice is having to tell a parent that I must file a child abuse report with Child Protective Services. Parental reactions to the news have ranged from appreciation to hysterical denials to even violence. I will talk about Lola’s case in a moment to illustrate this point. The possibility of a violent reaction from distraught or angry parents is anxiety-provoking even for a child abuse expert and more so for us health-care providers with less experience in this delicate area. When disclosing to parents that a CPS report must be filed, it is critical to explain to the parents, in an empathetic, supportive, and non-accusatory manner, the reasons why it is necessary to file a report of suspected child abuse or neglect. Whether or not the parents have harmed their child, they deserve to know and must be told that a report is being made, an investigation will be conducted, and the reasons why the investigation is necessary. You should emphasize that your first concern is for the safety and well-being of the child. The literature on this topic states that parents usually understand the need for the CPS investigation when they are told that it is necessary for the safety of the child and legally required when an injury is inconsistent with the history. But in my own experience, parents are usually irate and defensive and rarely has this conversation gone smoothly. I am not trying to dissuade you from reporting, in fact you are legally obligated to report, but you should be prepared for a difficult conversation and it’s OK to ask for help from someone more experienced in these matters, if possible. After disclosing that a CPS report must be made for the child’s safety, the parents should be given information regarding what will happen once the report is filed, such as a visit from a CPS worker, social worker, and/or the police.  
Don’t forget that when a CPS case is reported there is potential for further violence aimed at the child, at the parent or caregiver who isn’t accused, the parent or caregiver who IS accused and even the clinic staff, yourself included. Let’s look at the case of Lola again.

13. Lola’s Case – after the CPS Report
We were threatened by accused abuser
Mother of child also angry about CPS report
She herself is being abused by the accused child abuser
Mother transferred out of our care
I have lost touch with case
How can you protect yourself and your staff after a CPS report is made?
After sending Lola and her mother to the Emergency Department, we didn’t hear from them for a few days. Last we heard from the Social Worker in the Emergency Department, Lola was being placed in temporary foster care while the details of the case were being sorted out and Lola’s mother was being evaluated for intimate partner violence. A few days later, our security guard was talking outside with a few patients when suddenly Lola’s mother’s boyfriend appeared and said something like “I know someone in this clinic reported me to CPS and I’m going to find out who is it and make sure they never report another person again”. Needless to say, we were all pretty shaken up about it. Violence toward staff who report CPS cases is thankfully rare, but in our case we got together all the clinic supervisors and made a plan of action to address possible further acts from this angry gentleman – for example we called the police every time the gentleman appeared and was aggressive. Nobody involved in the case was to walk alone to or from the clinic. Front office staff were alerted to who the aggressive gentleman was so they could be on the look-out in case he entered the clinic. These are just a few things that we did to protect ourselves.
Over the course of the next week or so, this gentleman came around a few more times, eventually settling on the fact that he thought our security guard had made the CPS report and while never physically touching the security guard, he was verbally abusive and threatening. A police report was made each timer and the gentleman was officially mandated to stay away from the clinic. It was never clear to me why he wasn’t in jail or what his status was with the courts, since the last I’d seen of him he’s been arrested after punching my patient. In an interesting twist, which we didn’t expect but now we realize is probably, unfortunately, typical – Lola’s mother reappeared at our clinic and angrily said that she could not trust us anymore, we had betrayed her and Lola and she wanted to transfer to another clinic. Unfortunately, Lola’s mother DID transfer within a week to our sister clinic a few blocks away and we lost touch with her and Lola. The violent boyfriend ceased to come around our clinic anymore and last I heard, Lola’s mother was reunited with Lola so long as she stayed away from the boyfriend. It was determined that Lola’s mother was not the perpetrator of the cigarette burns, I do not know if it was determined that the boyfriend was or not. I haven’t seen the boyfriend in many many months, which means he might be back in jail for something, as he’s a regular in the neighborhood and usually around. As is often the case, I continue to feel unsettled by this case and wonder what more we could have done for Lola and her mother, both of whom were being abused. If you think about this case you realize that the cycle of violence does indeed continue, since Lola’s mother had been abused herself as a child, is now abused as an adult, and is raising a child who was abused at least one time in her life. You know that once a child is abused, the risk for further abuse is great.

14. Mandated Reporting
Those who typically have frequent contact with children
Social workers
Teachers
Health care workers
Mental health professionals
Child care providers
Medical examiners
Law enforcement
In your assigned readings for this week, I’ve included a PDF document from the Child Welfare Information Gateway, which is a division of the Department of Health and Human services of the federal government. In this document, it describes what exactly is a mandated reporter, what our legal and professional obligation is for reporting child abuse, and how to report child abuse by state. On page 11 of this document you will see the specific requirements for the State of California.
So who, besides us nurse practitioners, is a mandated reporter? Individuals designated as mandatory reporters typically have frequent contact with children, such as: social workers, teachers and other school personnel, physicians and other health-care workers, mental health professionals, child care providers, medical examiners or coroners, and law enforcement officers. Interestingly, in some states, including California, commercial film or photograph processors are mandated reporters of child abuse. Also substance abuse counselors and probation or parole officers may be mandated reporters. Each state also has different forms and different places where the child abuse case must be reported. I know that in San Francisco where I work, I call a special phone number as part of Child Protective Services to make a formal report of child abuse, and per the law, I must disclose my name and professional title as part of the mandated reporting protocol. Only in certain situations, though, will my name be disclosed as the reporting individual. Please take a moment to browse the PDF document, especially the first few pages of descriptive information and the content specific to California which starts of page 11.

15. Few Additional Thoughts
Sexual Abuse in Children
>100,000 each year in the US
Approx 1% (underestimated?)
Girls > boys
Can present with variety of nonspecific medical complaints
Do you have the expertise to evaluate & interview possible victim?
Do you have the expertise to collect forensic evidence?
The US Department of Health and Human Services reports that >100,000 children are sexually abused annually in this country. Each year approximately 1 percent of children experience some form of sexual abuse and many experts believe that this number of reported sexual abuse grossly underestimates the true prevalence. Sexual abuse of children occurs primarily in the preadolescent years. Girls are more likely than boys to be sexually abused; however, boys are less likely to report sexual abuse. Sexual abuse should be a lecture all on its own, as there is much to learn and consider when caring in the professional role for a child that you suspect is being or has been sexually abused. My only experience with the care of sexual abuse victims is as a nurse in the Emergency Room at Highland Hospital and it’s only been adult victims. In my career thus far, I have not seen nor had to report sexual abuse of my pediatric patients. I always worry that I’m not finding it because I don’t know what to look for. Victims of sexual abuse include children from all social, cultural, and economic backgrounds. However, some features related to family structure and parenting have been associated with a small increased risk of childhood sexual abuse. These features include poor parent-child relationships, poor relationships between parents, the absence of a protective parent, and the presence of a non-biologically related male in the home, such as a mother’s boyfriend. Victims of sexual abuse may present to you, the medical provider, with a variety of medical complaints. The patient may be brought in for medical attention specifically for evaluation of possible sexual abuse, or the patient may present for routine care or acute evaluation of medical or behavioral concerns that are not obviously related to the abuse. Most of the complaints that are possible indicators of sexual abuse are nonspecific and are listed in the table on this slide, courtesy of the website UpToDate. Those that are more specific for inappropriate sexual contact or exposure include rectal or genital bleeding and/or sexually transmitted infections that were not acquired perinatally.
Victim behaviors that may indicate a child has been sexually abused include perpetration of sexual abuse and/or sexually explicit acting out, developmentally inappropriate knowledge of sexual activities, or developmentally inappropriate play (such as repeatedly touching an adult's genitals or asking an adult to touch the child's genitals). Such behaviors are learned and are not a normal part of childhood fantasy.
If you encounter a situation where you are told outright that a child is being sexually abused, or you suspect that a child is being sexually abused – I would suggest that you include experts from your local Child Protective Services who are specifically trained in the sexual abuse of children and / or police investigators who are also specifically trained to handle such cases. Evidence might be needed in court some day and I know I’d want an expert collecting that evidence. I am not an expert. I know that young children do not have the developmental ability to understand progression of time and events, so I’d want a skilled medical professional to interview and evaluate a young child who is possibly being sexually abused. My point here is that sexual abuse of children is something that you must take seriously and know your limitations, even as you become tenured nurse practitioners, in your ability to accurately assess for, interview victims and collect forensic specimens. I know I’d refer immediately to the proper authorities, being that the sexual abuse division of CPS or the Emergency Room for a forensics test. This brings us to another thought I want to discuss with you.

16. Few Additional Thoughts
Child Protective Services. A quick Google image search using these three words brings up images such as the ones you see on this slide. Different generations have different attitudes about authority and government agencies, and Child Protective Services often gets a bad rap in the media. The internet is full of images such as these with inflammatory websites claiming CPS tears families apart, ruins children’s lives, and is a “domestic terrorist”, as seen on this slide. It is true that there are horrifying consequences when CPS messes up and loses a child in foster care, or fails to recognize abuse and a child dies. I am not denying that. I don’t even think it’s excusable. It’s just awful and horrifying. BUT, in my experience with CPS here in San Francisco for the past 5 years in which I’ve worked very closely with them, I have come to appreciate the tremendous task they are faced with on a daily basis. Their goal is to keep the child united with the birth family, as statistics show that even if the outcome isn’t great, it’s still often better than foster care or another alternative. BUT, again, this is a monumental task and is complicated by many factors – including repeat offenders, no safe family members to send the child to live with, lack of safe, adequate foster families – just to name a few. As mentioned on an earlier slide, one of the reasons why suspected child abuse isn’t reported to CPS by medical providers is that they think they can do a better job than CPS. I think, that like some big lumbering governmental agencies, CPS has it’s issues. But there is no way that I want to be responsible for the outcome of a child’s life and legally, there would be consequences for not reporting suspected child abuse. Again, I have had good experiences with CPS and use them all the time as a resource for information and a place to send children who need to be protected acutely or permanently. Some of my patient’s newborns end up in foster care at some point in their first year of life and without fail, my patients report that their newborns are well cared for and loved in these settings. Again, I am one provider with a small number of patients in one city in this vast country, but I would hesitate to jump onboard with a colleague’s attitude that “I can do better than CPS” and “CPS is a death sentence” as these images portray. Do not forget also that your patients have the same access to these images and information as you do, along with stories from their friends about CPS taking their children away and possibly other awful personal experiences. Your patients will be rightfully scared of CPS and this will be reflected in how they respond when you tell them you are making a mandated report. But again, I have seen over and over the good that CPS can offer a family and the multitude of resources that a family becomes eligible for once a CPS case is opened. I will finish up this section with a quote from one of my patients who said as she was nearing the end of her CPS case and it was about to be closed permanently “I am grateful to CPS for giving me the chance to make changes that proved I could care for my baby. Without CPS and all the services they offered me, I would not be here today with my daughter. I will tell all the other women in this program, if given the chance, to work with CPS and let them help you”. This was spoken by a patient of mine who when she entered treatment was injecting 4 grams of heroin into her neck, was living in a SRO in the Mission in SF, and was trading sex for drugs. She was 37 weeks pregnant when she came into my program. She delivered a baby girl 2 weeks later and was immediately referred to CPS. Her daughter is now 3.5 years old, my patient is working as an administrative assistant for a local delivery company, she has stable housing for her and her daughter and she’s been illicit-drug free for 3.5 years. Anyway, just one small example but powerful nonetheless.

17. Summary
Realize that you have the child’s best interest in mind when making a report
Know your patient demographics and what risk factors for abuse are present
Don’t assume that someone else will report
So in summary, what are the highlights I want you to take away from this lecture and know when you are out in clinical practice working as a nurse practitioner?
Firstly, I wish for you to feel confident that you have the child’s best interest in mind when you begin down the path of suspecting, confirming and reporting child abuse. It is a delicate, uncomfortable situation, no one is denying that. I would advise that the first time you must do this, that you seek help, if possible, from a colleague who has done it before, or even from the CPS reporting agency who can walk you through the proper steps in making a child abuse report.
Secondly, know who is at risk in your practice. Statistics can be confusing, as they point to minority children being abused more frequently than white children – but this might in fact be because of stereotypes and increased suspicion of abuse among these children.
Child abuse can be present, and will be seen among all demographics and socioeconomic classes. Be up to date on the literature and screening tools, if used, that your clinical practice site utilizes. Maybe your practice site has a preprinted form that prompts you to ask questions at each visit with a pediatric patient or maybe not. Maybe you are taught to focus on signs of abuse, maybe not. Regardless of the culture of your clinical practice site, be aware of this troubling event that is occurring on a regular basis to our pediatric patients and perform due diligence when you suspect that something isn’t quite right. A child’s life may depend on you.
And finally, don’t assume that just because you are a new nurse practitioner that you don’t know what’s going on or that since no body else has noted or reported it doesn’t mean child abuse isn’t occurring. One disturbing report that I read offered the following statistics about lack of reporting among medical professionals. The reports says that “despite mandatory reporting laws in the US, some primary care providers do not report suspected abuse. A prospective observational study of 1683 US injured children who were seen in a primary care setting found that 76 percent of 140 children with possible physical abuse and 27 percent of 73 children with likely or highly likely physical abuse were not reported to child protective services by their primary care providers. In a follow-up study of these findings, those providers who did not report suspicious injuries to CPS described alternative management strategies designed to monitor for or limit future abuse, and some felt that they could intervene more effectively than CPS. The report continues on to identify other barriers to mandatory and voluntary reporting, including inadequate training to recognize clinical manifestations of child abuse, cultural attitudes about violence and abuse, a misperception that CPS intervention is ineffective, and lack of support from professional societies and colleagues to make a child abuse report.
In closing, recognition of child abuse can save a life – just as recognizing your adult patient is having a heart attack or diagnosing your geriatric patient with cancer early enough for treatment to be effective. Of course, the latter two scenarios we would expect all providers to do without question, but why is reporting suspected child abuse such a difficult task? We have covered some of the reasons why this is true in this lecture – including failure to recognize abuse and fear of consequences for the child, the parent or caretaker and the medical provider. There is much more to learn about child abuse, and abuse in general, and we cannot cover it all in this lecture or in this class. There are some other topics which are controversial and it would be interesting to debate them in class, but that is not possible this semester, so think about them as your become nurse practitioners and enter the work force. Some of these topics are: What is abuse versus punishment? Can a pregnant women who is using drugs and living on the street be prosecuted for child abuse? And what about situations you see sensationalized in the media – for example the mother who let her young daughter have botox? Or the incredibly obese toddler whose parents let her eat Twinkies and pizzas for dinner with a full gallon of milk? Are these cases of child abuse? Should they be? Take it upon yourselves, as professionals, to learn all you can about this topic and seek help from professional organizations and trusted colleagues as you begin your role as nurse practitioner caring for the most vulnerable of our patients.