Treatment of Child Abuse: Common Ground for Mental Health, Medical, and Legal Practitioners

27. Education of Emergency Department Physicians

ter a significant educational intervention, emergency departments often fail to document key aspects of childhood abuse–related injuries (Guenther et al., 2009). Emergency medicine training requirements include general knowledge of interpersonal violence, including child maltreatment, elder abuse, and intimate partner violence , but do not include any specific requirements for the recognition and management of specific syndromes associated with child abuse (Perina et al., 2012). In fact, emergency medicine residents receive relatively little training in child abuse pediatrics. In 2009, Starling et al. reported that less than 20% of emergency medicine physicians received eight hours or more of didactic instruction in child abuse and only 11% received eight hours or more of clinical teaching in child abuse, even though one-third of respondents had seen seven or more cases of child sexual abuse during their residencies. Given the high likelihood that physicians working in emergency department settings will encounter child maltreatment , it is critically important that emergency physicians receive specialized training on the recognition, evaluation, and management of common forms of child maltreatment. This training is even more important because of strong evidence for the presence of bias in the medical assessment of suspected child maltreatment. In a landmark study, Lane and colleagues (2002) showed that African American children were more likely to have a skeletal survey than white children in the same emergency department. Furthermore, Laskey and colleagues (2012) found that given a child with the same history and injury, pediatricians were more likely to consider child abuse in families of lower socioeconomic status, confirming earlier results obtained in a national prospective primary care study (Flaherty et al., 2008). Hence, objective evaluation at the time of a patient’s initial presentation is necessary to formulate a clinical rationale guided Emergency medicine physicians are at the frontline of caring for children with abusive injuries. This chapter focuses on the essential educational content that emergency medicine physicians require to identify, manage, and report child maltreatment in the emergency department. THE PROBLEM Injured children may be seen in emergency departments in children’s hospitals, in specialized pediatric emergency departments in general hospitals, or in emergency departments of hospitals without on-site pediatric expertise. In general, less than half of American children entering emergency departments are seen in pediatric specialty emergency settings. At the same time, many American children are evaluated in the emergency department for physical injuries that result from abuse or for concerns about sexual abuse. According to the Centers for Disease Control and Prevention ’s (2012) National Epidemiologic Injury Surveillance System, in 2010 more than twenty-six thousand children under the age of 5 years (132 per 100,000) were seen in emergency departments for violence-related injuries. The overall statistics most likely represent an underestimate of the overall number of children treated for abuserelated injuries, as recent research has shown that abusive injuries are frequently missed in emergency departments that do not have pediatric-specific services. For example, children with abdominal injuries resulting from abuse are less likely to be diagnosed if they are treated in a general emergency department than if treated at a pediatric emergency facility (Trokel, Discala, et al., 2006). Similarly, abuse-related fractures are more likely to be missed in a general emergency department than in a pediatric emergency facility setting (Ravichandiran et al., 2010). Even afEducation of Emergency Department Physicians ROBERT D. SEGE, M.D., PH.D. GENEVIEVE PREER, M.D. KIMBERLY A. SCHWARTZ, M.D., FAAP 27 280 Education, Training, Dissemination, and Implementation ears, bruises on the buttocks, and patterned bruises are particularly worrisome. In contrast, bruises on the shins and other bony prominences are common in toddlers and children and generally do not elicit concern for maltreatment. Head trauma raises specific concerns in young children. Children who are found obtunded or with injuries around the head and neck should be evaluated promptly and thoroughly . Abusive head trauma often includes subdural hematoma or other intracranial bleeding, evidence of diffuse axonal injury, retinal hemorrhages, and changes in neurological status. These may occur even in the absence of skull fractures or other external signs of injury. Child abuse must be considered in the evaluation of any infant who appears obtunded or presents with altered mental status in the absence of clear trauma history (such as a motor vehicle accident ) or acute medical problem. Indeed, even when another medical etiology may explain the child’s presentation, it is critically important to recall that children with chronic medical problems can also be the victims of child maltreatment and...