"If you take care of children in an acute care setting, there is a 100 percent chance that you will see physical abuse," says Mark S. Mannenbach, M.D., a pediatric emergency room physician at Mayo Clinic in Rochester, Minn. "And unfortunately, you will likely also miss a case of abuse. Not out of ignorance or incompetence but because of the nature of the problem." He adds that a missed case of his own still haunts him.
Dr. Mannenbach says one of the biggest obstacles to identifying maltreatment is that many people — providers included — don't want to believe it happens. "Children are vulnerable. They rely on us and trust us. That anyone, especially a parent, could betray that trust is inconceivable," he says.
What's more, many childhood injuries lie in a gray area between neglect and abuse. "The clear-cut, blatant cases are obvious," Dr. Mannenbach notes. "It's the subtle ones that go unrecognized and unreported."
Bias can cloud perceptions, too. Studies show that abuse is reported more often in children from low-income families and overlooked more often in children from high-income ones. "You can't lose sight of the fact that abuse crosses all socio-economic lines and that it can happen with people you know," Dr. Mannenbach stresses.
He emphasizes that whether abuse is suspected or not, a child's medical issues are the first priority. "Providing the family with an explanation of the extent and type of injuries, along with assurances that the best care will be provided, is the first step for any injured child," he says.
Obtaining appropriate X-rays, CT scans and lab tests is important — not only for proper treatment, but also to look for underlying medical problems that might explain findings such as extensive bruising.
Listening to the history is paramount. "You listen to the story and try to figure out if it makes sense within the context of the injured child," says Dr. Mannenbach. "Does what the caregiver is saying fit with what you're seeing? And does the story make sense for the child's stage of development? For example, the parents say the baby rolled off the bed. But is she old enough to roll?"
Putting the pieces together is complicated by each child's uniqueness. Not all children are the same, Dr. Mannenbach stresses, and a child who is developmentally slower might not have the same capacities as other children her age. That's why it's vitally important to take time to learn about a particular child.
"'Tell me what happened' is a good place to start," he says. "Then you listen and listen and listen some more. See if what you're hearing correlates with what you find on the exam and with the child's normal developmental capabilities. And if it doesn't, then you have to have that conversation with the caregiver. You have to say, 'This doesn't make sense to me. You tell me the child did this, but we don't see this type of injury from what you're describing. I'm not accusing you of anything, but I'm required by law to report my concerns.' "
Dr. Mannenbach says he has had every possible reaction from parents, including outrage, physical assault and total silence, so, he notes,"you can't base judgments on response."
Though childhood injuries can be ambiguous, some are more plausible than others. "Burns and scaldings are suspicious," Dr. Mannenbach says, "but you have to look at the pattern of injury. A scald burn that spreads from the scalp across the face to the chest suggests that a child pulled down a boiling kettle from the stove. But if both hands are scalded, with no splash marks and clear demarcations at the wrist — that was probably punishment."
Other red flags include:
In such cases, documentation through regular medical record keeping is especially important; medical photography can help capture specific wounds, burns or bruises.
Infants and toddlers suffer most from abuse, but Dr. Mannenbach also sees it in teens. Adolescents might not sustain the same degree of physical trauma because they can fight back or run, but the emotional scars run deep. "You have to ask older kids who are angry, depressed or suicidal if they are safe at home. They're likely to deny it when asked directly, but you have to be persistent. Often, after being asked four or five times, they'll admit they're in trouble," Dr. Mannenbach explains.
A 2010 study of more than 15,000 child-injury visits to doctors in 40 states found that 25 percent of providers who believed a child's injuries were abuse-related failed to report them. A decade earlier, Carole Jenny, M.D., who has done pioneering work in child abuse and neglect, found it took an average of seven days and multiple visits to multiple providers to diagnose abusive head trauma in toddlers.
Most states have mandatory reporting laws and hospitals and providers are immune from prosecution if suspected abuse is reported in good faith. So why don't more speak up? Fear of being wrong, of retaliation, of tearing families apart, of getting involved in the cumbersome workings of the law and social service agencies — any or all of these may play a role. But the responsibility to help children in danger is clear.
"Contact the appropriate social services agency as soon as possible, both verbally and in writing," Dr. Mannenbach advises. "It's very important to provide a clear explanation of what raises your concerns to allow for a thorough investigation."
Dr. Mannenbach confesses that caring for physically abused children is the most draining part of his job. "Any time a child dies, it's devastating. Any resuscitation is pretty draining, but it's what we're trained for, it's why we're here," he says. "The same is true of abuse. Not getting involved isn't an option. We need to enlist the help of others if we're not sure. But we can't separate abuse from asthma or broken bones or any other part of care."