By Alice Swenson, MD, FAAP, Children’s Hospitals and Clinics of Minnesota; Chris Derauf, MD, FAAP, Mayo Clinic; and Sarah Lucken, MD, FAAP, Hennepin County Medical Center
One of the toughest challenges that primary care physicians face is what to do when confronted with a child who may have been maltreated. This may occur in the inpatient setting when a child is hospitalized with suspicious injuries or failure to thrive. Or it may occur in an outpatient setting, such as an emergency room or clinic, derailing an otherwise routine day and requiring immediate action.
Physicians often have questions about who is mandated to report, which acts trigger mandated reporting, and to whom a mandated report must be made. These topics are addressed in more detail in the Minnesota Reporting of Maltreatment of Minors Act in Minnesota (Statute 626.556).
Who is a mandated reporter?
Anyone can voluntarily report suspected maltreatment. However, physicians, medical care providers, and other professionals who work with children are legally required to report cases of child maltreatment or neglect that are suspected, ongoing, or have occurred in the past three years. They also must report cases involving maltreatment of two or more children unrelated to the perpetrator that have occurred in the past 10 years.
Those making reports in good faith are legally immune from criminal and civil liability. However, a mandated reporter who does not report a case of suspected child maltreatment or neglect is guilty of a misdemeanor.
Which acts trigger mandated reporting?
Acts that would be considered reportable under the statute are broadly defined as physical abuse, sexual abuse, and neglect.
Physical abuse means “any physical injury, mental injury, or threatened injury inflicted by a person responsible for the child’s care.” This may include, but is not limited to, throwing, kicking, burning, biting, cutting, striking with a closed fist, shaking a child under 3 years of age, inflicting any injury on a child 18 months old or younger, interfering with a child’s breathing, threatening a child with a weapon, striking a child under 1 year old in the face or head, and unreasonable physical confinement. It is noted that abuse “does not include reasonable and moderate physical discipline of a child administered by a parent or legal guardian that does not result in injury.”
Sexual abuse includes sexual assault, rape, prostitution, and statutory crimes in which a child who is under the age of 16 becomes involved in sexual activity. Although specific laws governing sexual conduct for teens may be confusing to the mandated reporter, it is clear that an adult who is in a caregiving role is guilty of sexual abuse if he or she engages in sexual conduct with the child, regardless of age.
Neglect includes medical, nutritional, educational, and other forms or acts of omission or commission that result in inadequate care and potential or actual harm. Minnesota is one of many states that allow for religious exemptions from routine medical care, but not if the lack of medical care may cause serious danger to the child’s health.
To whom must a mandated report be made?
When maltreatment is suspected, a verbal report should be made to the local child protective services (CPS) and/or the law enforcement agency. A follow-up written report must be submitted within 72 hours (exclusive of weekends and holidays). CPS then takes on the responsibility for investigating the report, ascertaining the child’s safety, and implementing a safety plan during the investigatory period.
If CPS cannot be reached and there is immediate concern about the patient’s safety or the safety of other minor children in the home or daycare setting, the physician should call 911; ask for the police, in particular the child abuse unit; and make a report.
What should a physician consider before reporting child maltreatment?
Try to determine whether the child has been abused or neglected. Take a careful history from the child’s caretaker, carefully delineating this firsthand account from other histories that may have come secondhand. The physician also should use trained interpreters when taking histories from non-English speakers in order to be as accurate as possible. If the child is developmentally capable and medically able, the physician also should ask the child directly what happened; depending on the situation, this may occur either with or without the caregiver present. Children often can spontaneously give many corroborating details about how their injuries occurred. A physician also may partner with an experienced social worker to help obtain this information.
A thorough physical exam should be done to look for any injuries/physical findings in addition to the presenting complaint. Additional lab tests and X-rays may be ordered if indicated.
The physician then must attempt to determine if the physical findings and test results fit with the history given by the caregiver. In some cases this may be easy. For example, a nonmobile infant would not sustain a broken femur and posterior rib fractures from rolling off a bed. In other cases it may be more challenging. A pattern injury, such as an iron burn, may occur when a toddler trips over an iron left on the floor or it may have been inflicted.
The physician also should look for other red flags. Has the child had suspicious injuries before? Was there a delay in seeking care and why? Are there different histories about how the injury happened, including a changing history from the caregiver?
The most important question the physician then must address is: What are the immediate safety needs of the child? Can the child safely be discharged home with the parents/guardians, particularly if they are possible perpetrators of the injury? If they are not the perpetrators, can they protect the child?
The safety and health of the child must come first. It must take priority over consideration of the family’s and provider’s reputations, and the family’s relationship with the physician.
Is there a protocol to follow when evaluating a possibly maltreated child?
Depending on the type of abuse and age of the child, there are standard workups that occur for children who may have been physically abused. For example, an infant with suspected abusive head trauma would typically have a careful history and physical exam, head CT, skeletal survey, and ophthalmologic exam performed, as well as liver function tests, amylase, lipase, and urinalysis to screen for possible abdominal trauma.
A child suspected of having been sexually abused would typically undergo a careful history and physical exam, and evaluation that might include laboratory tests for sexually transmitted infections, and a colposcopic and forensic exam depending on the age of the child, the type of sexual abuse, and how long ago it occurred.
For the child with “failure to thrive,” most often the causes are multifactorial. A careful history and physical exam, examination of growth charts, and diagnostic testing can help rule out significant medical etiologies at the same time the physician initiates close monitoring of feeding practices of the child, including calorie counts.
The latter workup can occur in an outpatient setting but may require inpatient admission for management. In these cases, it is the cooperation and concern of the caregiver and their ability to follow up with medical recommendations that determines whether neglect is present.
What options do physicians have if they suspect that abuse and/or neglect may have occurred, but cannot make a definitive determination with the information at hand and do not know whether to file a report?
The physician can always call the appropriate social services agency, such as Child Protection Services (CPS), and run the case by a screener for advice—in essence, to find out whether CPS would most likely open a case and to help determine whether the child can safely go home.
For situations in which there is concern for serious injury, threatened harm, child abduction, flight, or where the child needs ongoing medical care, the provider can send the child to the nearest emergency room or admit the child to the hospital for treatment and further medical evaluation and testing.
How should parents be informed?
Many parents, though upset, are able to understand if one explains to them the laws about mandated reporting and the need to put the child’s safety first when uncertainty about the circumstances of an injury occurs. When the time is right, caregivers can be informed of the need to make a report to CPS using some variant of the following: “Ms. Johnson, I want to thank you for all your patience this afternoon—I know it has been a long day for you and that you have been really concerned about Jenny. I’m concerned, too. As you know, we discovered that she has a broken arm. Unfortunately, we don’t know how this happened, and when I see an injury like this in a child her age, one of the possibilities is that someone might have caused this injury to her. Because of this, I’m required to make a report to Child Protective Services so that together we can do our best to make sure she is safe. I know you want the best for her; so do I. And, I’m going to do my best to help you and Jenny through this situation.”
The caregiver then should be told what to expect from the CPS worker, and that the physician’s role will be to help CPS understand the medical findings and provide any needed medical background or pertinent social information. Using language like the above usually (but not always) sets the stage to allow the physician to maintain an ongoing working relationship with the family.
What if the family is not cooperative and wishes to leave immediately with the child?
If there is concern that the child is potentially in immediate danger, hospital/clinic security should be called if available and a 911 call placed to police, who can then place a 72-hour police hold on the child. The child may either then be admitted or put into foster care while awaiting the CPS/police investigation.
Does patient confidentiality enter into reporting abuse?
The Health Insurance Portability and Accountability Act (HIPAA) allows for the disclosure of protected health information without the consent of the child’s caregiver or legal guardian in situations where abuse or neglect is suspected. Ideally, the parent or guardian should be made aware of this disclosure unless the disclosure could place the child’s safety in jeopardy.
Can the reporter of the abuse remain anonymous?
Technically, yes—the reporter’s name is confidential unless she/he consents to be named; however, CPS and police will most likely need to receive additional historical and medical information from the physician after the initial report and the physician can ultimately be subpoenaed to testify if the case goes to court.
Caring for children who are suspected of being abused or neglected can be challenging even for experienced practitioners. Physicians should understand mandated reporting laws, know how to contact CPS, prioritize child safety, and when needed, seek consultation from a physician trained in child abuse pediatrics.
