1. ECHO DIAGNOSING CHILD MALTREATMENT: THE CHALLENGES FACED BY CLINICIANS
John M. Leventhal, M.D.
Yale School of Medicine

3. GETTING IT RIGHT Recognizing if abuse has occured
Doing an appropriate evaluation
Reporting to CPS
Ensuring the child’s safety

4. TODAY’S TALK Some Basics Clinical questions to be addressed
Challenges when evaluating young children with suspected abuse
Approach to data collection
Framework for decision-making

5. INJURIES AND AGES Abuse: -- fractures -- burns -- head injuries
-- bruises
-- fractures
-- burns
-- head injuries
-- abdominal injuries
Neglect:
-- recurrent injuries
-- poor hygiene
-- failure to thrive/delayed development
Age: < 3 years and particular focus on < 12 mths

6. PRESENTATION TO HEALTH CARE PROVIDER
No history of trauma (sometimes a recent history of minor trauma)
Caregiver alone with child (abuse)
Clinical presentations:
Acute injury (eg, fracture)
Injuries over time (eg, pattern of failure to provide supervision or adequate care)

7. DIFFERENTIAL DIAGNOSIS
Accidental injuries
Birth trauma
Bleeding disorders
Medical problem
Maltreatment

8. CLINICAL QUESTIONS What happened to the child?
Are the child’s finding due to trauma or a medical problem
If trauma, are the injuries due to abuse, neglect, accident, or birth trauma?

9. CLINICAL QUESTIONS
4. Three related questions: a. Should the child be reported to DCF? b. Is it safe for the injured child to go home? c. If abuse occurred, when did it occur?

10. KEY CHALLENGES Making the correct diagnosis:
Children with abusive injuries are often young and non-verbal
History is provided by parent (who may be lying or does not know the details)
Clinicians have biases about whether abuse should be considered in a case
Some clinicians are “nervous” about the diagnosis

11. COLLECTION OF DATA History Physical exam Radiology/Laboratory
Scene Investigation
Interviewing others
Background “checks”

12. WHAT I WANT TO KNOW What happened (without interruption)
Specific details:
-- When were first symptoms or worry noted about the child?
-- How did symptoms develop over time? (level of alertness, breathing problems, seizures)
-- Who was present?

13. WHAT I WANT TO KNOW
-- How did the parent respond? (unusual activities)
-- Whom did the parent call?
-- Who decided to bring child for medical care (who called 911)?
-- What was the decision based on?
-- Was there a delay in seeking care?

14. WHAT I WANT TO KNOW Details of the day (and previous day(s))
-- who else saw or played with child
-- who provided care to the child
-- when was child acting normally
Child’s developmental skills
Any recent trauma or falls
History of injuries, bruises, bleeding from mouth or nose (sentinel injuires)
-- was child brought for medical care

15. ADDITIONAL HISTORY Past Medical History -- Birth history
-- Pediatric care; immunization status
-- Growth and development
-- Medical problems

16. FAMILY/SOCIAL HISTORY
Relevant family hx
Mental health hx
Previous DCF involvement
History of drug or alcohol use
History of domestic violence
Troubles with the law

17. PHYSICIAL EXAMINATION
Head: HC, anterior fontanelle, hematoma of scalp
Eyes: subconjunctival hemorrhages, retinal hemorrhages
Mouth: tear of frena
Abdomen: enlarged liver, tenderness
Genitals and anus
Skin: bruises (TEN-4)(FACES)

18. Blood count Bleeding Studies Screening blood tests for liver injury
LAB DATA
Blood count
Bleeding Studies
Screening blood tests for liver injury

19. DIAGNOSTIC IMAGING CT of head MRI of head and spine
Skeletal survey (and repeat in 2 weeks)
CT with contrast of abdomen (if screening blood tests abnormal)

20. WHAT TO SAY IF WORRIED ABOUT ABUSE OR NEGLECT
When I see an injury like your son’s, I need to worry about the possibility of child abuse, that he has been hurt by an adult, and I am obligated by state law to report the case to DCF.
(The hospital requires that I report the case to DCF.)
Do you know what that agency does?

21. DECISION-MAKING RELATED TO ABUSE
Link history provided to child’s findings:
-- mechanism
-- severity
-- timing
Use Leventhal’s Triangle to plot:
-- decision about reporting of suspected abuse
-- diagnostic likelihood of abuse/maltreatment

22. LEVENTHAL’S TRIANGLE Accident Report Abuse Neglect
Asnes & Leventhal. Pediatr Rev. 2010;31(2):47-55

23. LEVENTHAL’S TRIANGLE
Accident
Probable Maltreatment
Abuse
Neglect

24. SUMMARY
Collect appropriate information to fit the pieces together and understand what happened
Carefully consider the differential diagnosis
Be clear about decision-making