Pediatric Primary Care Case Studies (52 page)

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watchful, as though preparing for something bad to happen; lacks adult supervision; is overly compliant, passive, or withdrawn; and comes to school or other activities early, stays late, and does not want to go home.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

Brady, M. A., & Dunn, A. M. (2009). Role relationships. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser (Eds.),
Pediatric primary care
(4th ed., pp. 366–394). Philadelphia: Saunders Elsevier.