1. Child Neglect— Medical and Legal Implications
April 18, 2019
Jeffrey Bomze, MD, FAAP
200 N. Wynnewood Ave.--# B Wynnewood, PA 19096

2. Most preventable form of child abuse:
--Greater than 1500 fatalities/yr in US
--Victims commonly under age 3 years
--Victims commonly live in poverty

3. Definition of Child Neglect: Any action or failure to act which causes serious physical or emotional harm or puts the child at imminent risk for such harm
--Multiple forms of abuse and maltreatment can coexist

4. Many forms of neglect: --Physical --Supervisory --Emotional
--Educational --

5. Forms of neglect:
--Nutritional
--Medical
--Dental

6. Physical neglect: Supervisory neglect:
--failure to provide adequate food, clothing, shelter or hygiene
Supervisory neglect:
--inadequate supervision placing child at risk of physical, emotional and/or psychological harm

7. Emotional neglect:
--failure to provide love, security, emotional support, psychological care when needed
--failure to protect from exposure to domestic violence

8. Nutritional neglect:
--failure to provide adequate nutrition to maintain physical growth and development
--failure to prevent overnutrition-obesity and complications

9. Medical neglect: Dental neglect:
--failure to prescribed medical care or treatment
--failure to seek appropriate medical care in a timely manner
Dental neglect:
--failure to provide adequate dental care or treatment despite access to care

10. Educational neglect:
--failure to enroll in school and ensure regular attendance
--address special education needs

11. Factors impacting neglect:
--accepted standards of care for children
--role of communities
--harm to child

12. Factors impacting neglect:
--parents’ ability or intent
--family’s resources—community resources
--community norms

13. Family risk factors: --poverty, domestic violence
--family stress, mental health/substance abuse
--decreased social support, lack of knowledge

14. Evaluation: --Types of neglect --pattern of events
--possible harm to child or potential harm
--risk of imminent harm

15. Clinical presentations of neglect:
--depends on type of neglect and any other types of abuse
--occurs on a continuum

16. Physical neglect: --hygiene, lack of adequate clothing
--injuries from lack of shelter—heat illness or frostbite

17. Supervisory neglect: --repeated burns, lacerations, fractures
--serious injuries-MVAs, drownings, falls
--burns, poisonings—“accidental trauma”

18. Emotional neglect: Educational neglect: --lack of emotional security
--lack of follow up with psychological care
Educational neglect:
--truancy, poor attendance, homeschooling

19. Nutritional neglect: --malnutrition—undernutrition-failure to thrive
--overnutrition—obesity with medical complications

20. Medical neglect:
--serious illness and not signs not recognized or care sought
--serious or life-threatening health conditions with lack of compliance with treatment plan or follow up
--lack of primary care visits for at risk/complex children

21. Evaluation of neglect:
--comprehensive history
--social history: financial, education
--psychosocial history: mental health, substance abuse
--family history: domestic violence, criminal

22. Medical neglect: --most complex
--continuum based on risk of harm and role of caregiver in neglect
--? repeat neglect or risk to recur

23. Physical exam: --hygiene, clothing
--nutritional status-hunger, diet-caution
--height, weight, BMI, head circumference(< 2yo)
--skin, muscle mass, hair, edema

24. Physical exam: --hair—infection, malnutrition, intentional
--mouth—dental caries, abscesses
--skin and nails—multiple scars and past injuries, ulcers, cracked or thin nails
--unmanaged infections-scabies, lice

25. Additional studies-based on history, exam and concern
--underweight-failure to thrive
--obesity-complications-lipids, diabetes, liver
--look for signs of physical abuse

26. Key factors in diagnosing neglect:
--harm or imminent harm by caretaker’s action or inaction
--type, severity, and frequency the neglect-minor injury from brief distraction
--suspicion for physical, sexual and emotional abuse
--? Continued deterioration despite education and family engagement in care

27. Differential diagnosis:
--social factors versus physical or supervisory neglect
--failure to thrive-can lead to cognitive bias preventing identification of medical illnesses
--look for medical causes-undiagnosed conditions

28. Management-Report suspected abuse:
--consult with child abuse team
--multidisciplinary approach
--report if suspicious for abuse, harm is done, interventions have failed, concern for other types of abuse

29. Management:
--ensure patient safety-voluntary interventions or report to child protective services
--hospitalization may be needed-dehydration, malnutrition/starvation, poisoning, burns, exacerbation of chronic disease, safety and discharge planning
--hospitalize-chronic neglect, further evaluation, observe caregiver-child relationship

30. Education and documentation:
--simple and clear treatment plan
--family education-engage caregiver
--follow up appointments
--provide resources-insurance, transportation, nutritional assistance

31. Report to Child Protection:
--child at risk of imminent harm
--serious injury or serious medical illness caused by caretaker neglect
--continued neglect despite resources
--gross failure to provide adequate food, shelter, clothing, protection or education

32. Photo-documentation:
--injuries, appearance, hygiene
--nutritional status, skin condition
--condition of any indwelling medical equipment

33. Religious objections to medical care:
--most states with exemptions because of religious beliefs
--respect parental religious beliefs and their role in child rearing
--collaborative decisions

34. Religious objections to medical care:
--legal issues when beliefs or practices interfere with appropriate medical care likely to prevent death or substantial harm or suffering
--may need legal consultation for court authorization to override parental authority
--may need to intervene if imminent threat to child’s life

35. Legal considerations:
--need medical evidence of risk to minor’s life or health and consent requirements would delay care
--need to report to child protective services
--may need to consider referral to child protective services as temporary custody and/or court orders for treatment if not immediate need to treat

36. Religious exemptions:
--American Academy of Pediatrics opposes religious exemptions when treatment is likely to prevent harm, suffering or death
--Review of fatalities associated with religion-motivated medical neglect—over 80% would have had over 90% chance of survival with medical care

37. Sequelae of Neglect:
--serious consequences in all domains of child development—physical, cognitive, emotional and social
--post-traumatic stress disorder
--effects in childhood on learning, parent-child interaction, high risk behavior, criminality
--negative adult outcomes (heart disease, cancer, obesity, depression)