managing-child-abuse-screening

# Managing Child Abuse Screening

Guides the systematic identification, documentation, and reporting of suspected child maltreatment (physical abuse, sexual abuse, emotional abuse, and neglect) using validated screening frameworks, forensic documentation standards, injury pattern recognition, and mandatory reporting procedures. Covers the medical evaluation, imaging workup, and multidisciplinary team coordination.

## Why This Skill Exists

Child maltreatment is vastly underreported: an estimated 1 in 8 children experience confirmed maltreatment before age 18, yet many cases are never identified by healthcare providers. Sentinel injuries (minor injuries in pre-mobile infants) are missed in up to 25% of cases that later present with severe abuse. Healthcare providers are mandatory reporters in all 50 U.S. states — failure to report is both a legal violation and a patient safety failure. This skill ensures that concerning presentations trigger systematic evaluation, forensic-quality documentation, and timely reporting to Child Protective Services (CPS).

---

## Checkpoint A — Intake Verification

### Required Intake Questions
1. What is the child's age and developmental stage (particularly: pre-mobile vs. mobile)?
2. What is the presenting injury or concern?
3. What history has been provided for how the injury occurred?
4. Is the history consistent with the child's developmental ability and the injury pattern?
5. Has the history changed between different historians or over time?
6. Are there prior ED visits, hospitalizations, or fractures?
7. Who are the child's caregivers and who was present when the injury occurred?
8. Are there any social risk factors (substance abuse, domestic violence, CPS history)?

### Required Documents
- Detailed physical examination with body diagrams
- Photographs of injuries (with ruler for scale, patient identifier, date/time)
- Prior medical records (ED visits, hospitalizations, growth charts)
- Radiology reports (if imaging obtained)
- CPS history (if accessible)
- Verbatim statements from caregivers and child (if verbal)

> Document using exact quotes whenever possible. Record each historian's account separately. Do not synthesize or reconcile conflicting histories.

---

## Step 1 — Sentinel Injury Recognition

### What Are Sentinel Injuries?
- Minor injuries (bruises, oral injuries, fractures) in pre-mobile infants (typically < 4-6 months)
- "Those who don't cruise rarely bruise" — bruising in a non-mobile infant is abuse until proven otherwise
- TEN-4 FACES rule: bruising to Torso, Ear, Neck in a child < 4 years; or to Frenulum, Angle of jaw, Cheek, Eyelid, Subconjunctiva at any age → high specificity for abuse

### Concerning Injury Patterns
| Pattern | Concern |
|---------|---------|
| Bruising in non-mobile infant | Abuse until proven otherwise |
| Patterned bruising (belt, loop cord, hand, bite mark) | Inflicted injury |
| Multiple bruises in various stages of healing | Repetitive inflicted trauma |
| Burns with sharp demarcation (stocking/glove, "donut" pattern on buttocks) | Inflicted immersion burn |
| Posterior rib fractures in infants | Highly specific for abuse (squeezing mechanism) |
| Classic metaphyseal lesions (CML / "bucket handle" fractures) | Highly specific for abuse |
| Multiple fractures at different stages of healing | Repetitive trauma |
| Subdural hematoma in infant (especially bilateral) without major accidental mechanism | Abusive head trauma (AHT) |
| Retinal hemorrhages (multilayered, extending to periphery) | Abusive head trauma |

### Red Flags in History
- Injury inconsistent with developmental stage (e.g., "rolled off the couch" in a 2-week-old)
- Changing or inconsistent history among caregivers
- Delay in seeking care
- Caregiver blames sibling who is developmentally incapable of causing injury
- "No history" for significant injury

---

## Step 2 — Physical Examination and Documentation

### Forensic-Quality Examination
- Examine child completely (undressed) in a warm, well-lit room
- Examine ALL skin surfaces including scalp, behind ears, oral cavity, genitalia, buttocks
- Document every finding with:
  - Anatomic location (use body diagrams)
  - Size (measure with ruler in cm)
  - Shape and color
  - Tenderness
  - Stage of healing (if assessable)
- Photograph with:
  - Overview shot (body region in context)
  - Close-up shot (with ruler and patient ID visible)
  - Document camera type, date, time, photographer identity

### Oral Examination
- Frenulum tears (labial and lingual) — from forced bottle feeding or direct blow
- Palatal petechiae — from forced oral penetration
- Dental injuries inconsistent with developmental stage

### Genital/Anal Examination (If Sexual Abuse Suspected)
- Refer to Child Advocacy Center (CAC) or trained forensic examiner when possible
- Acute assault (< 72 hours): forensic evidence collection kit ("rape kit")
- Document: hymenal configuration, tears, bruising, discharge, anal findings
- Normal genital exam does NOT exclude sexual abuse (most exams are normal)

---

## Step 3 — Imaging Workup

### Skeletal Survey (Mandatory for < 2 Years with Suspected Physical Abuse)
Complete skeletal survey per ACR standards:
- AP and lateral skull
- AP chest (with dedicated rib views or oblique views)
- AP pelvis
- AP humeri (bilateral)
- AP forearms (bilateral)
- PA hands (bilateral)
- AP femurs (bilateral)
- AP tibiae/fibulae (bilateral)
- AP feet (bilateral)
- Lateral thoracolumbar spine

### Follow-Up Skeletal Survey
- Repeat in 2 weeks for: any positive finding, or clinical concern remains high despite negative initial survey
- Healing fractures become visible at 10-14 days (periosteal reaction), increasing sensitivity

### Head Imaging (For Suspected Abusive Head Trauma)
- Non-contrast CT head: initial screen for acute hemorrhage
- MRI brain: more sensitive for parenchymal injury, diffusion restriction, dating of injuries; obtain within 24-72 hours
- Ophthalmology consult: dilated fundoscopic exam for retinal hemorrhages (document number, layers, extent)

### Laboratory Evaluation
- CBC with differential and platelet count (to exclude thrombocytopenia as cause of bruising)
- PT/PTT/INR (to exclude coagulopathy; consider von Willebrand panel)
- LFTs (AST, ALT — screen for occult abdominal trauma; sensitivity for liver laceration at AST > 200 or ALT > 125)
- Lipase (screen for pancreatic injury)
- Urinalysis (hematuria from renal injury)
- If abdominal trauma suspected: CT abdomen/pelvis with IV contrast

---

## Step 4 — Mandatory Reporting

### Legal Obligation
- ALL healthcare providers are mandatory reporters in all 50 U.S. states
- Reporting threshold: "reasonable suspicion" — NOT certainty, NOT confirmed diagnosis
- Reports are made to Child Protective Services (CPS) and/or law enforcement per state-specific statute
- You do NOT need permission from the family, attending physician, or institution to report
- You are legally protected from liability for good-faith reports (immunity)
- Failure to report is a misdemeanor or felony depending on state

### Report Documentation
- Report must be made immediately (typically by phone) followed by written report within 24-48 hours (state-specific)
- Document in the medical record:
  - Date and time of report
  - Agency reported to and intake worker name/ID
  - Report reference number
  - Summary of information provided
  - Who made the report (by name and role)

### What to Report
- Name and age of child
- Nature and extent of injuries
- History given by caregivers (including inconsistencies)
- Names and contact information for caregivers
- Information about siblings (they may also be at risk)
- Provider's level of concern and basis for suspicion

---

## Step 5 — Multidisciplinary Team Coordination

### Key Team Members
- **Child Abuse Pediatrician (CAP)**: board-certified subspecialty; consult when available
- **Child Advocacy Center (CAC)**: forensic interviews, medical exams, victim advocacy
- **Social work**: psychosocial assessment, safety planning, CPS liaison
- **Law enforcement**: criminal investigation (coordinate through CPS, not independently)
- **Mental health**: trauma-focused cognitive behavioral therapy (TF-CBT) referral for child and non-offending caregivers

### Hospital-Based Response
- Admit child if: safety cannot be ensured at discharge, medical treatment required, or CPS investigation pending
- Place safety hold per hospital policy and CPS guidance if immediate danger exists
- Do NOT confront the suspected abuser — this is the role of CPS and law enforcement
- Do NOT perform a forensic interview — refer to CAC; multiple interviews cause retraumatization

### Sibling Safety
- If abuse is confirmed or strongly suspected, assess safety of ALL children in the household
- Siblings may need skeletal surveys (especially if < 2 years) or other evaluation
- CPS should be informed of all children in the home

---

## Checkpoint B — Child Abuse Screening Review

- [ ] Physical exam completed with full skin survey documented
- [ ] All injuries documented with body diagrams, measurements, and photographs
- [ ] History recorded verbatim from each historian separately
- [ ] Developmental assessment documented (mobile vs. pre-mobile)
- [ ] History-injury consistency evaluated and documented
- [ ] Skeletal survey ordered (if < 2 years) with follow-up survey planned
- [ ] Head imaging obtained if head trauma suspected
- [ ] Labs ordered to exclude bleeding disorder and screen for occult injury
- [ ] CPS report filed with reference number documented
- [ ] Multidisciplinary team notified (CAP, social work, CAC)
- [ ] Sibling safety assessed
- [ ] Disposition addresses child safety (admit if safety uncertain)
- [ ] All [VERIFY] flags resolved or escalated

---

## Quality Audit

| Item | Requirement | Pass? |
|------|-------------|-------|
| Full skin exam | Complete undressed exam documented | |
| Forensic documentation | Body diagrams, measurements, photographs | |
| Verbatim history | Each historian's account recorded separately | |
| Developmental context | Pre-mobile vs. mobile stated | |
| TEN-4 FACES applied | Bruising pattern assessed against validated criteria | |
| Skeletal survey | Complete per ACR standards for < 2 years | |
| Follow-up survey | Planned at 2 weeks when initial survey obtained | |
| Bleeding workup | CBC, PT/PTT, ± vWF panel obtained | |
| CPS report | Filed immediately with reference number documented | |
| No unexplained [VERIFY] tags | All flagged items resolved or escalated | |

---

## Guidelines

- Follow AAP clinical report "Evaluation of Suspected Child Physical Abuse" (2015, reaffirmed)
- Apply TEN-4 FACES bruising clinical decision rule (Pierce et al.) for identifying abusive bruising
- Follow ACR Appropriateness Criteria for skeletal survey imaging standards
- Follow AAP/AAN guidelines for evaluation of abusive head trauma
- Mandatory reporting: per state-specific child abuse reporting statutes; threshold is "reasonable suspicion"
- Child Abuse Pediatrics (CAP): board-certified subspecialty — consult whenever available
- Refer to Child Advocacy Center (CAC) for forensic interviews and coordinated response
- "Those who don't cruise rarely bruise" — any bruising in a pre-mobile infant requires evaluation for abuse
- Normal genital exam does not exclude sexual abuse — most abused children have normal exams
- Retinal hemorrhages: obtain formal ophthalmology consult with indirect ophthalmoscopy; document layers, number, and extent
- Do not delay CPS report while awaiting test results — report on suspicion, update as information becomes available
- This skill produces clinical and legal documentation; it does not replace clinical judgment or legal counsel