Beth Moore
Margaret A. Brady
Sometimes unanticipated psychosocial issues present themselves when children come in for well or sick child examinations. Because the role of the provider includes the protection of children, the provider needs to take the time to collect appropriate data about the child’s emotional and physical well-being during the history and physical examination. This includes a thorough social/family assessment to identify potential risks to the physical and psychological well-being of the child.
Educational Objectives
1. Identify the common behavioral signs and symptoms associated with child abuse.
2. Understand how the underlying dynamic factors of culture and socioeconomic status can contribute to child abuse and neglect.
3. Recognize how the age of the child and his or her developmental stage impact the presentation of sexual abuse and what signs the healthcare provider must be alert to when delivering health care to children.
4. Apply the guidelines for the reporting of potential child abuse or neglect.
Case Presentation and Discussion
You are a healthcare provider (HCP) in a busy pediatric practice and are running behind schedule. You enter the room of a family that has waited there for about 45 minutes for routine pediatric health supervision visits for two children. Fortunately, there were some interactive toys and some paper and crayons in the examining room to occupy the children while they waited to be seen. The mother, Susan Jenkins, is there with her 5-year-old son, Tommy, and her 7-year-old daughter, Lucy. She is talking on her cell phone but hangs up when you enter the room. She obviously is a bit irritated and states “I’m going to be late meeting my boyfriend. Can you get us out of here quickly?”
In an effort to build rapport, you apologize for the wait and start to look at the picture her son drew. The boy drew a picture of his house with the mother and the sister in the kitchen and the boy in the bedroom with a man. In the picture the man was very large compared to the boy. The man had a scary face, with large hands. The boy in the picture was quite detailed with a sad face and what clearly looked like genitals. You ask the boy about the picture, and he states that the man is “Roy, my mom’s new boyfriend,” and identified the boy as “me.” The mother becomes upset and passes the picture off as her son’s “wild imagination.”
Before proceeding, you need to think about the possibility of child abuse for this little boy.
Child Abuse and Neglect
Child abuse includes physical abuse or neglect, sexual abuse, emotional maltreatment, or threats of injury or harm. Each state has laws that individually define the various types of child abuse and how they are to be interpreted in their state. Acts of commission (inflicting injury) or omission (failure to protect from harm) related to child abuse are both punishable in every state’s child abuse statutes. Typically, physical abuse is judged to be the use of unlawful corporal punishment or injury to a child; almost 16% of reported child abuse cases involve the physical abuse of children. General and severe neglect typically account for more than 64% of child victims. Cases of child sexual abuse, sexual assault, or exploitation are responsible for approximately 9% of reported cases. Willfully harming or endangering the mental health of a child is considered emotional maltreatment; approximately 7% of cases fall into this category (U.S. Department of Health and Human Services, 2008).
In 2006, an estimated 3.3 million referrals involving approximately 6 million children were made to Child Protective Services agencies throughout the United States. Approximately 30% of those reports were substantiated, meaning that at least one child was found to be a victim of abuse or neglect (U.S. Department of Health and Human Services, 2008).
Cultural and Socioeconomic Risk Factors for Abuse
Children who live in homes where domestic violence and/or alcohol or drug abuse occurs are at increased risk for abuse and neglect. Stressors for families in crisis can contribute to violence against children, such as struggling to meet financial demands, living in violent communities, or having few social resources. If one child in the family has been abused, it greatly increases the likelihood of siblings also being abused (U.S. Department of Health and Human Services, 2008). Children less than 2 years old and children with physical or mental handicaps are at increased risk for child abuse and are particularly vulnerable populations for physical abuse. In 2006, more than 80% of children who were killed through abuse were younger than 4 years old; 12% were 4 to 7 years old; 14% were 8 to 11 years old; and 3% were 12 to 17 years old (U.S. Department of Health and Human Services). Likewise, a developmentally challenged teenager, particularly a girl, can become the target of sexual assault.
Because physical abuse commonly leaves visible signs, many individuals who are not healthcare providers consider that physical abuse has the greatest negative implications for the child victim. In addition, the lay public often expresses difficulty in believing that a child could be sexually molested by a family member or trusted adult and, instead, thinks that young children, in particular, fabricate stories of sexual molestation. In actuality, emotional maltreatment and sexual molestation serve to corrupt a child’s self-esteem. Thus, the long-term implications for emotional and sexual abuse are just as traumatic for the child as physical abuse.
Who Are the Perpetrators?
Data from reported cases reveal that approximately 75% of perpetrators were parents (40% mothers, 17% fathers, and 18% both parents). Other relatives accounted for 7%, and unmarried partners of parents accounted for 4% of perpetrators. The remaining perpetrators included persons with other or unknown relationships to the child victims. Of all parents who were perpetrators, fewer than 3% committed sexual abuse compared to nearly 75% of sexual perpetrators who were friends or neighbors (U.S. Department of Health and Human Services, 2008).
Roy is the new boyfriend of Ms. Jenkins. Because Tommy’s drawing of his family depicts his sad face and reveals his genitals, and Roy’s features are scary, you must consider the possibility of sexual abuse. Your priority concern for this visit has switched from a routine health supervision visit for Tommy to one that will focus on questioning about the possibility of sexual abuse. This drawing and its meaning merit further investigation.
Assessing for Possible Child Abuse
The diagnosis of sexual abuse and the protection of the child from additional harm depend, in part, on the provider’s willingness to consider abuse as a possibility. Parents may arrange for their child to be seen in a primary care setting because they have concerns about abuse. More typically, a child is brought in for a routine health supervision visit or minor ill visit and then abuse concerns emerge from either historical information or clinical findings. Primary healthcare providers who suspect that child abuse is occurring or has occurred should conduct a complete healthcare history and elicit key historical information about the presence of behavioral symptoms and signs associated with maltreatment or abuse. Whenever feasible, they should inform the parents of their concerns in a calm, nonaccusatory manner. However, if the parent/caregiver becomes violent or verbally confrontational during the questioning, the clinician may defer informing the parent/caregiver that a suspected child abuse report is being called to child protective services or law enforcement and instead, call these agencies prior to addressing the concerns with the parent (Kellogg & Committee on Child Abuse and Neglect, 2005).
A decision to call law enforcement rather than child protective authorities for an immediate evaluation should be based on whether the child will remain in a continuing abusive or dangerous situation if allowed to return home with the parent or caregiver or if the parent/caregiver is a flight risk. Reporting concerns to the child abuse hotline (Brady & Dunn, 2009) while the child remains in the ambulatory setting allows the provider to receive direction and guidance from child protective services.
What questions will you ask the mother to further evaluate for the potential of child abuse? 
You determine the need to interview Ms. Jenkins without the children present, and she is in agreement. You tell Tommy and Lucy that you and their mother will be in the next room and then alert the medical assistant to check on the children while you are interviewing their mother. You explain to Ms. Jenkins that you are going to obtain a health history about both children because this is your first visit with this family and you start by obtaining information about Tommy.
In particular, you need to conduct a detailed social history related to living conditions, supervision of the children, and Tommy’s school performance. You ask the following questions and receive these answers from Ms. Jenkins:
Who lives in the home, where do the children sleep, and who supervises their activities when Ms. Jenkins is not home? Ms. Jenkins replies “It is just the three of us, Lucy, Tommy, and me. We live in a two-bedroom apartment: Lucy and Tommy share a room. They go to an after school program until I pick them up at 5:30 p.m. I’m with my children all the time.”
What, if any, is the involvement of Tommy’s dad in his life, and do Tommy and Lucy have the same father? “Lucy and Tommy have the same father, who ran off with another woman about 1 year ago. We never see that jerk!”
How is Ms. Jenkins doing financially (does she have a job, does she receive child support from the father) and is she having difficult financial times? “We get along OK with my job, which just covers the bills. I get an occasional token check from the kids’ deadbeat dad. Roy is good and has been giving me some money to help with the kids.”
When did she first meet Roy, what is their relationship, is he living in the home, and if so when did he move in and what is his relationship with the children? She replies, “I met Roy in a bar about 3 months ago. He’s new to town.” She does admit upon further discussion that Roy stays overnight with her, but says, “We’re always discrete.” She tells you that Roy took care of the kids a couple of times when she went out with her girlfriends to celebrate birthdays. He last babysat about 1 week ago.
How is Tommy doing in school and have there been any changes in his grades, performance at school (can’t concentrate or is easily distracted), or other behaviors? Has his teacher noted any changes?“Tommy has been having some problems in kindergarten and the teacher wants me to talk with her. Tommy’s been hitting kids lately.”
The healthcare provider should seek out information from the parent as to whether there has been a change in the child’s general attitude, demeanor, or behaviors at home or with his friends or family members and whether this change was associated with a particular event. In this case, did Ms. Jenkins notice any changes in Tommy or Lucy since Roy entered their lives and home situation?
In addition, the provider should seek information about the presence of behavioral signs that are associated with the various types of child maltreatment, not just sexual abuse, because multiple types of maltreatment may be being inflicted upon the child (Brady & Dunn, 2009). Key questions to ask include:
Has Tommy become overly fearful, clingy, shown indiscriminate attachment, or compliance? Ms. Jenkins replies “No, that has never been a problem for Tommy.”
Have you noticed extremes or drastic changes in his behavior such as extreme passiveness or aggression lately? She says, “I’ve had to give him more time outs the last 2 weeks because he is fighting more with his sister.”
Does Tommy appear wary of physical contact with adults or frightened of anyone? In this instance, ask Ms. Jenkins how he relates to Roy. She states, “He isn’t frightened of anyone I know. He doesn’t seem to like to be around Roy. Tommy is just jealous of Roy now that Tommy doesn’t have all of my attention.”
Has he exhibited signs of being depressed, hypervigilant, withdrawn, or apathetic? “That’s not my Tommy.”
Have there been any changes in Tommy’s bowel or bladder patterns (loss of control such as bed wetting or stool soiling), sleep issues (e.g., nightmares or inability to sleep alone) or eating disorders? Ms. Jenkins seems to hesitate and says, “He wet the bed last week while I was out with my girlfriends.” Upon further questioning, she tells you that Roy was babysitting the kids and she didn’t get home until 2 a.m. She noted that Tommy was awake in his bedroom when she went in to check on him. He was crying and said that he was sorry that he wet his bed. This was the first time he had wet his bed at night in the last 12 months.
Has Tommy talked about suicide plans or thoughts or made any suicide attempts? (Suicide and running away are more frequently seen in adolescents. This question is more relevant for the older school age and adolescent age group. Therefore, you focus on issues of depression and sadness). She replies, “No, Tommy’s not a sad kid.”
Does he have any unusual fears, phobias, or compulsive behaviors or has there been a recent negative change in peer relationships? Ms. Jenkins again ponders for a short time and says, “He got into a fist fight with his best friend at school the other day but wouldn’t tell me what it was about.” (Ms. Jenkins also said earlier that the teacher wants to talk with her about Tommy’s behavior at school.)
In addition, consider the possibility of sexual abuse when the child (Child Welfare Information Gateway, 2007):
• Has difficulty walking or sitting
• Suddenly refuses to change for gym or to participate in physical activities
• Reports pain on urination, urethral discharge, or bleeding or genital bruising
• If female, has atypical vaginal discharge, bleeding, genital bruising, or rashes
• Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior
• Becomes pregnant or contracts a venereal disease, particularly if under age 14
• Runs away and/or reports sexual abuse by a parent or another adult caregiver
The healthcare provider must always remember that such behavioral changes are not diagnostic per se of sexual abuse but are often indicative for further thorough investigation by a child abuse expert.
You ask questions that might pertain to Tommy’s issues, and Ms. Jenkins denies any such issues with Tommy.
Ms. Jenkins tells you at the end of the interview, “I love my boy, and now wonder if Roy molested him. That drawing of Tommy’s isn’t like him, and at first I just wanted to ignore the fact that something might have happened. I’ll do anything to protect my kids.” She then starts crying. You reply, “I’m glad that you are willing to put Tommy’s welfare as your first priority.”
What other questions do you need to ask Tommy?
You talk to Tommy in private. He is reluctant at first and you affirm to him that he has done nothing wrong and is not in trouble. You start off by asking about school, sports, and then ask him to tell you about his drawing. You ask him about the boy, and he says, “It’s me.” You ask him to tell you about the boy and the people in his picture. He looks down at the floor and says while pointing at the picture, “That’s my pee pee, where I go pee.” He then identifies Roy, his mother, and sister Lucy. You ask him to tell you about each one of them. He starts with his mother and then his sister; he describes their facial appearance and talks about them in a positive manner. He says nothing about Roy spontaneously, so you ask, “Tommy, who is this person (while pointing to the figure of the adult man).” He says “Roy” and again looks at the floor and avoids eye contact. You start by saying, “He’s a tall man. Tell me about your picture of Roy.” He says, “Roy scares me when he looks at me. I don’t like him. He’s got big hands and does bad things with them.” You reply, “Oh? Tell me about those bad things.” Tommy then continues and says, “Roy came into my bedroom while I was sleeping and pulled down my pjs (pajamas). I woke up, and he was rubbing my pee pee. I didn’t like it at all and told him to stop. Roy said, This is good for you. It’s our secret.’ ” Tommy pauses, so you ask, “What was he rubbing your pee pee with?” Tommy states, “His big hands.” You ask, “And then what happened?” “I told him to stop but he wouldn’t.” You say, “Oh, and then what happened?” Tommy stated, “He pulled down his pants and told me to kiss his pee pee. I said ‘no’ and started crying and wet my bed. Lucy woke up and Roy ran out of our room.” You end this discussion and ask, “Is there something more you think I should know?” Tommy says, “Roy smelled like beer.”
Based on what Tommy said, you have enough data to initiate a report. Tommy will be further examined and interviewed by child protective services and professionals who are expert in the field. Another approach to interviewing children about possible sexual abuse is to talk about “good” and “bad” touches that involve touching the child’s private parts. You would use this approach when talking with Lucy to see if she too was a victim.
Should the primary care provider interview the child about the abuse or let the experts do this?
Children who are sexually abused are often coerced by the abuser to “keep it a secret.” The child must be appropriately questioned without the parent or caregiver present to minimize emotional damage and maximize information retrieval. Although investigative interviews should be conducted by social workers or practitioners specifically trained in child abuse, this should not keep primary care providers from asking relevant questions to obtain a detailed pediatric history and a review of systems. A medical history, past incidents of abuse or suspicious injuries, and menstrual history should be documented (Kellogg & Committee, 2005). Line drawings, dolls, or other aids can be effective tools to help the child to talk about the abuse. It is important for the clinician to avoid leading and suggestive questions or showing strong emotions. Instead maintain a “tell-me-more” or “and-then-what-happened” approach. Document the questions asked and the child’s responses as well as his or her demeanor and emotional responses to questioning. Use quotation marks to document the child’s exact words and/or your questions. For example, Tommy said, “Roy came into my bedroom and pulled down my pajama pants. I [the HCP] replied, “And then what happened, Tommy?”
The general rule of thumb to remember is that children younger than 3 years of age are generally not interviewed (Kellogg, 2005). Tommy is 5 years old and should be interviewed, beginning by asking him to tell you about the people in his drawings.
What data do you want from the physical examination?
Physical Examination
If the routine physical examination of potentially sexually abused children cannot be conducted without additional physical or emotional trauma, the examination should be deferred to professionals from child protective services, who will schedule a detailed forensic examination with a health provider expert in the field of child sexual abuse. If the primary care provider is able to secure the child’s cooperation for a physical examination, he or she should conduct the examination mindful of the child’s developmental needs for sensitivity, particularly when inspecting the genital and rectal areas. Document all physical finding that are obtained during the regular well or sick child examination. A total body assessment of the skin is important to document. In particular, you are looking for signs of physical abuse such as scarring, burns, or bruising that are suggestive of nonaccidental injury because of their pattern or placement on the body. Features of nonaccidental trauma include any injury that leaves a pattern consistent with an agent of injury (belt or bite marks, rope abrasions, or sock/glove injury pattern with a burn injury) or when the type or degree of injury is inconsistent with the child’s developmental capability.
Likewise, the rectal and genital/urinary system should be inspected as you would do for any child. Be sure to have a good light source. Look for any signs of bruising, tears, scars, discharge, or lesions. As is the case for all genital/ rectal examinations, inform the child of what you are doing. For the female who is not yet a teen, a frog leg position is the easiest for the child to assume. It allows the girl to comfortably spread her legs apart. With your gloved hand, gently spread the labia majora apart and conduct your inspection. A side-lying position with legs bent at the knees is easiest to inspect the rectal area.
If there has been genital contact by the perpetrator, it is important that forensic evidence, including labs and diagnostics, be collected within 24 to 72 hours after the sexual incident, but only by a forensic expert. This forensic exam will be arranged by child protective services (Kellogg & Committee, 2005). Such examiners frequently use a colposcope to magnify the genital and rectal areas, looking for signs of rectal or genital injuries such as tears, lacerations, abrasions, bruising, scars, scratches, atypical laxity of the anus, anal tags, hymenal trauma, or lesions (e.g., herpes or warts). The examiner will collect specimens for sexually transmitted infections, semen, and pubic hairs depending on the history and age of the child.
Tommy allows you to conduct a complete physical examination, including examining his genital and rectal areas. He doesn’t want his mother in the room when this is done. You explain to Tommy that you will need your medical assistant to be there to help you. (This is also done to provide a second person in the room who can verify what occurred during the examination if issues of inappropriate conduct by the provider arise.) Tommy says, “OK, she can be in the room.” You do your physical examination, which is essentially normal. You are careful to note, “No bruising, unusual scars, lesions, rashes, or abrasions on the skin or rectal/genital areas. His genital/rectal examination is normal with no anal laxity noted.”
Lack of physical findings of sexual abuse is common in young children because of the nature of the abuse (nontraumatic fondling), such as occurred with Tommy. Furthermore, delayed disclosure, quick healing times, and the fact that most sexual abuse of young children does not involve penetrating injury are points the HCP needs to remember (Brady & Dunn, 2009). At this point, no diagnostic laboratory testing for sexually transmitted diseases is needed.
Indicators of Potential Child Abuse in Children’s Drawings
When investigating possible abuse in children, art functions as a nonthreatening tool for communication between client and clinician (Stember, 1980). The size and placement of the figure(s) relative to the space available may be indicative of the child’s perception of self-importance. Also, many or few details, parts of the drawing emphasized or deemphasized (e.g., heavier or lighter or darker or fainter lines) can indicate how the child feels about him- or herself. The drawing being more advanced or immature than is appropriate for the child’s developmental age may be indicative of emotional disturbances. Tears and frowns on a child’s face are common indicators of sadness or depression. Smiles may be indicators of happiness, but also may be indicators of repression if inappropriate to the context of the scene. Huge circular mouths are often drawn when oral sex is involved. Similarly, Wohl and Kaufman (1985) suggested that hair is a common representation of masculinity, and that overemphasis on or omission of hair may represent feelings related to sensuality, or sexual anxiety, confusion, or inadequacy. Hands are the most frequently omitted human body part in drawings by persons experiencing significant emotional difficulties. Presumably, omission of hands reflects perceived lack of control.
The assumption underlying the use of art is that, because emotionally disturbed children are believed to reflect their problems in their drawings (Yates, Beutler, & Crago, 1985), the drawings of children who have been abused will differ from those of nonabused children. Free drawings, as well as the House-Tree-Person, Draw-A-Person, and Kinetic Family Drawings are used by psychologists in their assessment of a child who may have been abused. In free expression drawings, the child is asked to make a drawing about whatever he or she wants. The House-Tree-Person Test was originally developed by John Buck as an outgrowth of the Goodenough scale utilized to assess intellectual functioning. The child is asked to draw a house, a tree, and a person the best they can. The child’s figure gives some indication of how the child perceives himself or herself in the world (Burns & Kaufman, 1972). For the Goodenough-Harris Draw-A-Person Test, the child is asked to draw a man, a woman, and themselves on separate pieces of paper. Scoring scales are used to examine and score the child’s drawings (Harris, 1963). The Kinetic Family Drawings, developed in 1970 by Burns and Kaufman, requires the child to draw a picture of his or her entire family including themselves. The drawing is meant to elicit the child’s attitudes toward his or her family and the overall family dynamics (Burns and Kaufman).
The qualitative features of the drawings, such as the colors used, the size and detail of body parts, and the shape of the figures may be interpreted in terms of the presence or absence of sexual abuse. Cantlay (1996) claims that distress and trauma, including sexual abuse, are reflected in drawings. The presence of genitalia is often considered a sign of sexual abuse because it is considered rare for normal, nonabused children to include genitals in their drawings (Di Leo, 1996).
Making the Diagnosis
What is your diagnosis?
You determine the following diagnosis for Tommy:
• Suspected sexual molestation by the mother’s boyfriend.
• Mother believes son and is willing to cooperate with law enforcement and child protective services.
Based on Tommy’s drawing and disclosure of genital fondling and oral copulation by Roy, you suspect that he is the victim of sexual molestation.
You ask your medical assistant to carefully watch the family to ensure that Ms. Jenkins doesn’t leave or call anyone while you call child protective services. The supervisor there instructs you to call law enforcement immediately and says the police will come to your office to talk with Tommy and his mother and that they will likely arrest Roy. She also tells you that Tommy and his family will be referred to the local child protection team for further evaluation and follow-up.
Recognizing Child Abuse
You decide to review the signs and symptoms of physical abuse, neglect, and emotional abuse to be sure you have not missed any other forms of child abuse that may be simultaneously occurring with Tommy (Child Welfare Information Gateway, 2007). These include the following: a child shows sudden changes in behavior or school performance; has not received help for physical or medical problems brought to the parents’ attention; has learning problems (or difficulty concentrating) that cannot be attributed to specific physical or psychological causes; is always watchful, as though preparing for something bad to happen; lacks adult supervision; is overly compliant, passive, or withdrawn; and comes to school or other activities early, stays late, and does not want to go home.
You need to consider the possibility of physical abuse when the child has unexplained burns, bites, bruises, broken bones, or black eyes; has fading bruises or other marks noticeable after an absence from school; seems frightened of the parents and protests or cries when it is time to go home; shrinks at the approach of adults; or reports injury by a parent or another adult caregiver. Think about the possibility of neglect when the child is frequently absent from school; begs or steals food or money; lacks needed medical or dental care, immunizations, or glasses; is consistently dirty and has severe body odor; lacks sufficient clothing for the weather; abuses alcohol or other drugs; or states that there is no one at home to provide care (Child Welfare Information Gateway, 2007).
Finally, consider the possibility of emotional maltreatment when the child shows extremes in behavior such as overly compliant or demanding behavior, extreme passivity, or aggression; is either inappropriately adult (such as parenting other children) or inappropriately infantile (such as frequently rocking or head-banging); is delayed in physical or emotional development; has attempted suicide; or reports a lack of attachment to the parent (Child Welfare Information Gateway, 2007).
Management
What are the laws regarding reporting of child abuse and neglect?
Key Components of Child Abuse and Neglect Reporting Laws
Mandated reporters are any person providing services to a minor child. If a child is not in imminent danger, the individual should call the local child abuse hotline. If the child requires protection and is in imminent danger, both the police and the child abuse hotline should be called. Healthcare professionals such as nurse practitioners, physicians, physician assistants, and nurses are mandated reporters and are protected against civil and criminal action if acting within their professional role (U.S. Department of Health and Human Services, 2008). Every clinical setting that serves children should have the toll-free telephone number of the local child protective services department in an easily accessible location.
More than half of all reports of alleged child abuse or neglect are made by professionals such as educators, law enforcement and legal personnel, social services personnel, medical personnel, mental health personnel, child daycare providers, and foster care providers. Friends, neighbors, relatives, and other nonprofessionals submitted approximately 44% of reports (U.S. Department of Health and Human Services, 2008).
Making a Child Abuse Report
Reports about abuse can be made in all states by calling Childhelp (800-4-A-Child) or the local child protective service agencies. The Childhelp National Child Abuse Hotline is available 24 hours a day, 7 days a week. Counselors are available to answer any questions about child abuse or child neglect. This number can be used by all persons who live in the United States, Canada, Puerto Rico, Guam, or the U.S. Virgin Islands. Mandated reporters must accurately fill out the state-required Suspected Child Abuse Report form online, if available, or mail a hard copy to the address on the form within 36 hours of verbally reporting the abuse (Childhelp, 2006).
Therapeutic plan: What will you do therapeutically to help this child?
All children who have been sexually abused should be followed up by a team of healthcare professionals who specialize in child maltreatment. Child protective services and the mental health professionals involved in the care of Tommy will assess the need for mental health treatment and will determine the level of family support needed for the Jenkins family. Unfortunately, there are limited mental health treatment services for abused children. The parents and siblings of the victim may also need treatment and support to cope with the emotional trauma associated with Tommy’s sexual abuse. A referral to a mental health professional is essential to the emotional recovery for all child victims such as Tommy (Kellogg & Committee, 2005).
Consequences of Child Abuse and Neglect
Eighty percent of young adults who have been abused meet the diagnostic criteria for at least one psychiatric disorder at the age of 21 years. Abused children are 25% more likely to experience teen pregnancy. Children who experience child abuse and neglect are 59% more likely to be arrested as a juvenile, 28% more likely to be arrested as an adult, and 30% more likely to commit violent crimes. Nearly two thirds of the people in treatment for drug abuse reported being abused as children (Child Welfare Information Gateway, 2008). Thus, failure by the HCP to investigate when there are physical, behavioral, or historic indicators of child abuse and failure to report suspicions to child protective services or law enforcement are breaches of professional ethical conduct. Similarly, these children need to be brought into the social services network so they can secure appropriate mental health counseling that they will need both during the crisis period of disclosure and long term.
What will child protection services do?
A child protective services worker comes to the practice setting with a local police officer who works with child abuse victims. They talk with Ms. Jenkins and explain that they will take the family to the local child protective center for a forensic interview by an expert in the field. They plan to talk with both Tommy and Lucy about Roy. Based on what you and Tommy have told them, the police officer is making arrangements to arrest Roy.
You briefly talk to Ms. Jenkins and she is willing to help in any manner she can. She is upset with herself for what has happened to Tommy. The children are told that they need to talk to some people with their mom about what has happened and have been given assurance by their mom that she is not angry at them, loves them, and will be going with them. The police officer and child protection worker also assure the children that they will be helping the family.
You end by saying that the children will be rescheduled for the routine health supervision examination. Ms. Jenkins tells you that she is glad that you talked to Tommy about the picture because she hadn’t really looked at what he was drawing until you asked him about it. She indicates that she will return to you for their health care and will cooperate fully to keep her children safe. You also mention the need for individual counseling for Tommy as well as the need for her to seek mental health assistance, and that the child protection center staff will assist the family in this matter.
Key Points from the Case
1. Recognition of child abuse is dependent on the primary healthcare provider being knowledgeable of the signs and symptoms of abuse and reporting procedures.
2. The primary care provider’s initial emotional response to the suspected abuse and finesse in handling the situation with the caregivers and the child can greatly influence whether intervention by child protective services is positive or negative.
3. Accurate documentation of medical history, past incidents of abuse or suspicious injuries, and the child’s demeanor and emotional responses to questioning is essential to establishing patterns of abuse.
4. Treatment of child abuse victims by mental health professionals is essential to the child’s emotional recovery. The parents of the victim may also need treatment and support to cope with the emotional trauma of their child’s abuse.
REFERENCES
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Burns, R. C. & Kaufman, S. H. (1972). Action, styles, and symbols in Kinetic Family Drawings (K-F-D): An interpretative manual. New York: Brunner/Mazel.
Cantlay, L. (1996). Detecting child abuse: Recognizing children at risk through drawings. Santa Barbara, CA: Holly Press.
Child Welfare Information Gateway. (2007). Recognizing child abuse and neglect: Signs and symptoms. Retrieved October 5, 2008, from http://www.childwelfare.gov/pubs/factsheets/signs.cfm
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Childhelp. (2006). Get help now. Retrieved December 5, 2008, from http://www.childhelp.org/get_help
Di Leo, J. H. (1996). Young children and their drawings. New York: Brunner/Mazel.
Harris, D. B. (1963). Children’s drawings as a measure of intellectual maturity. New York: Harcourt, Brace, and World.
Kellogg, N., & Committee on Child Abuse and Neglect. (2005). The evaluation of sexual abuse in children. Pediatrics, 116(2), 506–512.
Stember, C. J. (1980). Art therapy: A new use in the diagnosis and treatment of sexually abused children. In K. McFariane (Ed.), Sexual Abuse of Children: Selected Readings (pp. 59–63). Washington, DC: National Center on Child Abuse and Neglect.
U.S. Department of Health and Human Services, Administration on Children, Youth and Families. (2008). Child maltreatment 2006, the National Child Abuse and Neglect Data System. Washington, DC: U.S. Government Printing Office.
Wohl, A., & Kaufman, B. (1985). Silent screams and hidden cries. New York: Brunner/Mazel.
Yates, A., Beutler, L., & Crago, M. (1985). Drawings in child victims of incest. Child Abuse and Neglect, 9(2), 183–189.