Pediatric Primary Care Case Studies (49 page)

Leslie, L., Weckerly, J., Plemmons, D., Landsvere, J., & Eastman, S. (2004). Implementing the American Academy of Pediatrics attention deficit/hyperactivity disorder guidelines in primary care settings.
Pediatrics, 114
, 129–140.

Michelson, D., Allen, J., Busner, J., Casat, C., Dunn, D., Kratochvil, C., et al. (2002). Once-daily atomoxetine treatment for children and adolescents with attention-deficit/hyperactivity disorder: A randomized, placebo-controlled study.
American Journal of Psychiatry, 159
, 1896–1901.

MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder.
Archives of General Psychiatry, 56
, 1073–1086.

Perrin, J., Friedman, R., & Knilans, T. (2008). The Black Box Working Group and the Section on Cardiology and Cardiac Surgery. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder.
Pediatrics, 122
, 451–453.

Pliszka, S., & American Academy of Child and Adolescent Psychiatry, Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 46
(7), 894–921.

Quinn, D. (2005). Poster presented at the 45th annual meeting of New Clinical Drug Evaluation Unit. Boca Raton, FL.

Vetter, V. L., Elia, J., & Erickson, C. (2008). Cardiovascular monitoring of children and adolescents with heart disease receiving stimulant drugs: A scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Heart Defects Committee and the Council on Cardiovascular Nursing.
Circulation, 117
(18), 2407–2423.

Wernicke, J. F., & Kratochvil, C. J. (2002). Safety profile of atomoxetine in the treatment of children and adolescents with ADHD.
Journal of Clinical Psychiatry, 63
(Suppl 12), 50–55.

Chapter 13

The Boy Who Draws a Picture Suggesting an Abuse Situation

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!”