ABSTRACT: Managing suspected child abuse cases in the primary care setting is difficult. These cases are typically time consuming, and the prospect of having to testify in court can be daunting. As well, many physicians feel they lack the necessary expertise to render an opinion on possible child maltreatment. The challenges may be mitigated by involving local child abuse experts more familiar with these difficult situations. Fortunately, child abuse pediatrics is an emerging subspecialty in pediatric medicine and an evolving specialty in social work, psychology, and nursing. In British Columbia, five Suspected Child Abuse and Neglect (SCAN) teams with access to pediatric, social work, and mental health resources are available to help medical professionals engaged in the complex decision-making process of investigating and reporting child abuse.
Child maltreatment continues to be a serious problem in Canada today. The most recent Canadian incidence study of child abuse and neglect (2008) identified 235 842 child maltreatment investigations. Of these, 74% focused on possible incidents of abuse or neglect, while 26% concerned risk of future maltreatment. Investigations led to 36% of the cases being substantiated. Of the substantiated cases, 34% involved exposure to intimate partner violence, 34% involved neglect, and 20% involved physical abuse.
In British Columbia, the Ministry of Children and Family Development receives approximately 30 000 calls per year concerning children at risk. Not infrequently, abused children present to medical professionals for care. The opinion of the treating physician often carries significant weight with child welfare authorities and law enforcement, with some reports leading to social service or criminal investigations. Physicians may be asked to offer an opinion on the cause of a child’s injuries and, in some cases, to collect forensic evidence.
It is difficult for physicians to deal with suspected child abuse cases in their medical offices. These cases are typically time consuming, and the prospect of having to testify in court can be daunting. Many physicians feel they lack the necessary expertise to render an opinion on possible child maltreatment. Cases where abuse is suspected may be more effectively and efficiently managed by a multidisciplinary team with access to additional expert pediatric, social work, and mental health resources. In BC, five Suspected Child Abuse and Neglect (SCAN) teams are available to assist medical professionals in managing these complex and challenging situations.
Provincial SCAN teams
The Child Protection Service Unit (CPSU) was founded at Vancouver General Hospital in the mid-1970s and moved to its current location at BC Children’s Hospital when that facility opened in 1982. In the late 1990s, the Ministry of Children and Family Development supported the formation of other similar multidisciplinary teams for investigating suspected abuse and neglect throughout the province. Today the team at BC Children’s Hospital is one of five teams in the province, with the other four located in Surrey, Kamloops, Nanaimo, and Prince George (Table).
The SCAN teams vary in their makeup and expertise, meaning that each one provides slightly different services. The team may include general practitioners, pediatricians, nurses, psychologists, psychiatrists, social workers, play therapists, and administrative support staff. Because the team at BC Children’s Hospital is located at the province’s tertiary pediatric facility, it provides both acute and on-call service. All teams provide nonacute referral services by outpatient appointment for children and youth with concerns of physical, sexual, or emotional abuse or neglect. A thorough medical assessment at a SCAN clinic includes physical examination, consultation, and medical chart reviews. Some teams provide development assessments by appointment.
Because physicians and nurses on SCAN teams possess specialized training in the medical and forensic examination of young children suspected of being sexually abused, the referral focus for most clinics is the prepubertal age group. Some teams are able to see older victims of historical sexual abuse. Currently, only the team at BC Children’s Hospital is able to provide acute, emergent sexual abuse assessments.
When a child presents to a SCAN clinic, a full medical and psychosocial history is taken and a complete physical examination is performed. Forensic evidence is also collected when the need for this is indicated. Some children may require further comprehensive mental health and developmental assessments by team psychologists or psychiatrists; however, ongoing therapy is generally not available. After a child is examined, a medicolegal report is prepared and made available to other professionals under the terms of BC Freedom of Information guidelines, and referrals are made to community support services as required.
SCAN teams are well placed to facilitate interagency communication and cooperation, and to provide support, advice, and information. All team members receive specialized training at regular intervals and participate in a quality review process. The teams meet annually to discuss challenging cases, common issues, and new developments in the field. SCAN teams also provide education to other professional and community groups in the province through workshops, seminars, and presentations.
Reporting suspected abuse and neglect
Failure to report injuries that suggest abuse can result in further injury or death. In a recent study by Sege and colleagues, primary health care providers and child abuse experts were found to agree generally about which cases suggested abuse was possible, but not about which cases should be reported. Primary health care providers would not have reported 21% of suspected maltreatment cases that child abuse experts would have reported—leaving children potentially at risk.
A physician may fail to report a case of suspected abuse or neglect for several reasons, including lack of training, discomfort about addressing the issue with families, and previous negative experiences with the child welfare system. Nevertheless, health care professionals are required by law to report any reasonable suspicion of abuse or neglect. Physicians who need advice or guidance in this regard can contact the child maltreatment experts in their local community or health authority.
The information provided to social workers by physicians can be critical when substantiating child maltreatment. On the one hand, a physician’s conclusion that an injury suggests abuse may lead directly to a child’s removal from parental care, further police investigations, or both. On the other hand, a physician’s conclusion that an injury is consistent with the history provided and does not suggest abuse may eliminate the need for lengthy and disruptive investigations. The work is complex and the stakes are high, so it is important to get it right.
Child abuse pediatrics
In the United States, child abuse pediatrics is a new subspecialty with board certification by the American Academy of Pediatrics. More recently, the Royal College of Physicians and Surgeons of Canada approved child maltreatment pediatrics as a discipline and is developing competency training requirements and setting program accreditation standards.
The medical investigation of child maltreatment as a subspecialty service will continue to evolve within the multidisciplinary team structure. Sexual assault nurse examiners (SANEs) have been practising in BC for many years, and are often consulted about acute sexual assault in women and girls older than 13. Recently, a pediatric specialization has emerged as a subset of offerings within forensic nurse examiner programs in BC.
The establishment and funding of child advocacy centres in North America has been shown to help the families and child victims of abuse by providing a coordinated, multidisciplinary approach to the investigation, prosecution, and treatment process. Currently, there are three advocacy centres in BC, with a fourth in development in Vancouver.
Health care providers face many challenges in both the identification and management of cases where child maltreatment is suspected. Early recognition and reporting are critical if children are to be protected from future harm. Effective and timely communication and collaboration among disciplines is essential to optimize both service to families and safety for children.
Child abuse pediatrics has emerged as a subspecialty in pediatric medicine and an evolving specialty in social work, psychology, and nursing. BC’s five multidisciplinary SCAN teams provide expert support, advice, and information that can help in the complex decision-making process of investigating and reporting child abuse.
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3. Sege R, Flaherty E, Jones R, et al. To report or not to report: Examination of the initial primary care management of suspicious childhood injuries. Acad Pediatr 2011;11:460-466.
4. Pietrantonio AM, Wright E, Gibson KN, et al. Mandatory reporting of child abuse and neglect: Crafting a positive process for health professionals and caregivers. Child Abuse Negl 2013;37:102-109.
5. Giardino A, Hanson N, Seaver Hill K, et al. Child abuse pediatrics: New specialty, renewed mission. Pediatrics 2011;128:156-159.
Dr Hlady is a clinical professor in the Department of Pediatrics at the University of British Columbia. Ms Allchurch is the nurse clinician in the Child Protection Service Unit at BC Children’s Hospital.