By Lisa Guetzko, MD, HealthPartners Central Minnesota Clinic
Diagnosing and reporting suspected child abuse or neglect is one of the greatest challenges a pediatrician must face. Besides the obvious primary concern for the child’s welfare, there are numerous other considerations that can affect our decisions about whether or not to file a child protection report. Time constraints, diagnostic uncertainty, logistical barriers, lack of knowledge about proper reporting protocol, and fear of alienating the patient’s family or losing them to follow up may all play a role in the clinician’s decision. Although we are all aware that we are mandated reporters, it is often unclear exactly when, why, and how to report a suspicion of child abuse.
As a pediatrician who practices in a city that spans three different counties, I have encountered significant variability in the reporting, investigation, and responses to child abuse reports. One county is particularly efficient in filing reports over the phone, processing written documentation, and notifying the clinician after an outcome has been determined. Other counties have presented additional barriers that have made the reporting process more difficult for families and clinicians.
For example, I was told by one child protection employee that they could not file my report of suspected sexual abuse of a 12 year-old boy who had repeatedly sexually abused his two younger siblings and attacked his older sibling with a weed whacker. The children had been seen by law enforcement in the home, and by physicians in the ER repeatedly, where it had even been documented that the 12 year-old who perpetrated the sexual abuse was showing red flags that he, too, had been abused. But because I could not tell child protection services exactly who was the suspected abuser, the county refused to file my report. I subsequently spent another four hours on the phone, being redirected to various agencies until I reached someone in law enforcement who appropriately filed and responded to my report.
I am thankful that my persistence paid off, as none of the other medical providers who had seen the 12 year-old ever reported their concerns that he was the victim of abuse. This was especially surprising to me because I had spoken directly with ER staff during one of his visits there, and they had assured me that their suspicion of abuse against the child would be reported. The child has since been removed from the home and placed with his grandparents while the case is under investigation. After intensive psychotherapy and numerous legal proceedings, the child did finally identify his abuser and additional protective measures can now be implemented.
Although the reporting process can be daunting and frustrating at times, there are some helpful guidelines I would like to offer to the clinician who suspects child abuse or neglect:
- Trust your clinical judgment. If you suspect child abuse or neglect, make a verbal report to the appropriate agency within 24 hours. Follow up with a written report as soon as possible. It is better to report your concerns than to ignore them or talk yourself out of them.
- Consult with an expert if needed. If you are uncertain about your concerns or what to do next, consult with a child abuse specialist. Their wealth of expertise can help guide you through the process. Contact information is available at: https://www2.aap.org/sections/childabuseneglect/Minnesota.cfm
- Don’t assume that anyone else has filed a report. Even when a patient has been seen by multiple providers before you, there is no guarantee that any of them have reported a concern of child abuse. You may be the child’s only hope in obtaining the necessary investigation, intervention or services.
- Document your findings and impressions thoroughly. Your history, physical, assessment, and even photographs of your patient are extremely valuable in the investigative process.
- Utilize a team approach. While you are carefully documenting your findings and concerns, you can enlist your nurse or rooming staff to assist with contacting the authorities. Although you have to make the actual report yourself, your staff can assist by contacting the appropriate agency and providing them with basic information such as patient demographics.
- Communicate with the patient’s family. We all worry that we may alienate a patient’s family by filing a report of suspected child abuse. But parental estrangement is not inevitable. When appropriate, you can express your concerns to the child’s caretaker and explain why these concerns need to be addressed. You may be surprised at how grateful they are for your care.
- Make sure to follow up. You should expect to receive written communication from the county regarding the outcome of any inquiry or investigation resulting from your report. You may also be asked to provide additional feedback or documentation, depending on the situation. Child Protection Services personnel have told me on more than one occasion that most physicians are hesitant to stand by their original concerns by providing additional written documentation such as letters or more detailed impressions to be used in court. Remember that you might be your patient’s sole medical advocate in these situations, and your medical opinions are both valid and absolutely necessary.
Above all, remember that any suspicion of child abuse or neglect should be reported. You are protecting both yourself and your patient by doing so. You may even be saving a child’s life.
