The Canadian Incidence Study of Reported Abuse and Neglect[1] estimates that 135 573 child maltreatment investigations were conducted in Canada in 1998—an incidence rate of 21.52 investigations per 1000 children. A historical general population study conducted in Ontario in 1990 found the prevalence rate of childhood physical abuse in males to be 31% and childhood sexual abuse of females to be 12.8%.[2] By comparison, the estimated prevalence rate of childhood asthma in Canada is 13% for males and 9% for females.[3] This suggests that child abuse may present to health care professionals more frequently than expected.

Investigating child abuse

In 1999–2000, British Columbia child welfare authorities completed 24 321 child protection investigations. The number has steadily increased from 18460 investigations in 1996. Not every concern reported to child welfare authorities is investigated. Roughly only 70% of the total reports result in a child protection investigation.[4]

In BC, child welfare definitions, reporting laws, and investigation procedures are outlined in the Child, Family and Community Service Act (1995), which is the responsibility of the provincial Ministry of Children and Family Development (MCFD), previously known as the Ministry of Social Services (MSS) and the Ministry for Children and Families (MCF). The minister delegates responsibility for child protection services to trained social workers throughout the province. Sections of the Criminal Code of Canada also apply to child abuse, such as those sections dealing with failure to provide necessities of life, assault, and sexual interference. Therefore, both social workers and police officers may be involved in a child maltreatment investigation. Child protection social workers might determine whether a child is safe to continue to reside in his or her home, while police might determine whether a criminal offence has taken place.

Role of the medical profession

Both law enforcement and child welfare authorities may call on the medical system to provide opinions required as part of protection and/or criminal investigations. Although only one piece of a much larger puzzle, medical opinion often carries significant weight. In addition to providing the overall medical assessment and treatment recommendations, health care practitioners may be asked to collect forensic evidence and to offer opinions on a variety of concerns, from unexplained fractures or skin markings to the significance of genital trauma.

Aside from providing an opinion when requested, medical professionals may also initiate investigations by reporting suspected cases of child maltreatment to authorities. In BC, the Child, Family and Community Service Act requires all persons, whatever their profession, to report suspected cases. The B.C. Handbook for Action on Child Abuse and Neglect[5] recognizes the important role health care professionals play in the identification of abuse by specifically outlining the legal reporting requirements of physicians (“the duty to report overrides the confidential requirements of the physician-patient relationship”). The handbook also includes guidelines for hospitals that state “each hospital must develop a protocol for the identification, assessment and management of abused children… in some instances, referral to a larger and more comprehensive centre is advisable.”

Role of SCAN units

British Columbia is home to four fully functioning Suspected Child Abuse and Neglect (SCAN) units (Table). Primarily, SCAN teams at these units exist to provide specialized medical assessment for cases of suspected child abuse and neglect. The Child Protection Service Unit (CPSU) at BC’s Children’s Hospital has existed since the mid-1970s. It initially operated at Vancouver General Hospital and moved to the Children’s Hospital site when the facility opened in 1982. In the late 1990s, the Ministry of Children and Family Development initiated the development of multidisciplinary SCAN teams throughout the province, including the Fraser Valley, Vancouver Island, and Northern BC. (Sites in the BC Interior are under development.) Today the medical practitioner is only one member of the multidisciplinary SCAN team that can include professionals from the nursing, social work, and mental health fields.

All SCAN team members regularly receive updated, specialized training in the medical evaluation, investigation, and assessment of child maltreatment. In turn, SCAN teams provide education to a variety of community professionals through seminars and presentations. SCAN team physicians also provide training to community physicians interested in child abuse evaluation. Team members at BC’s Children’s Hospital CPSU participate in training residents and medical students through the UBC medical school.

For every child evaluated at a SCAN unit, a medicolegal report is prepared and made available to professionals according to current BC Freedom of Information guidelines. Only in a fraction of cases will expert medical testimony be required (see View from the witness box: Testifying in court [8]). Costs for court testimony by a SCAN physician are covered by the Ministry of Attorney General, the Ministry of Children and Family Development, or the party issuing the subpoena. All SCAN physicians receive expert witness training and keep up-to-date with the latest research.

Barriers to child abuse evaluation

Given that specific guidelines exist to assist in reporting child maltreatment, and that most physicians practising in British Columbia have some knowledge and training in the area, why are SCAN teams necessary? Physicians have identified several barriers to providing a thorough evaluation of child abuse in traditional settings.[6,7] These include too little time, poor remuneration, inadequate knowledge, and a low comfort level.

Physicians practising in emergency departments, offices, and walk-in clinics often do not have the time to conduct more than a cursory examination, let alone a thorough review of the case history. If, on rare occasions, time is available for rigorous history-gathering from multiple sources, fee-for-service billing does not usually provide adequate remuneration. Some physicians say the degree of child maltreatment training they have received is limited and they do not feel comfortable providing an “expert” opinion, especially in complicated situations. Many consider child abuse to be an area of subspeciality. Lack of comfort with the subject matter and the possibility of having to provide court testimony can also be a barrier for some practitioners. Working without the support of a team, the physician can feel burdened with all interagency communication duties, crisis counseling, and service referrals.

There can be an emotional burden as well. As family physicians, general practitioners are often closely involved with members of the victim’s family. The serious nature of these cases and the significant family disruption that often ensues may leave the family physician feeling emotionally drained and reluctant to become involved in future cases. For these reasons, many health care practitioners prefer to refer children to a SCAN team for second-opinion evaluation.

Need for SCAN teams

“Specialized teams employing an interdisciplinary approach” have long been identified as the ideal mechanism for the provision of health care services for suspected child abuse cases.[8] The SCAN units in BC vary slightly in team composition and services offered, as these are dependent on the needs of the community, the resources available, and the stage of team development. However, all the SCAN teams employ an interdisciplinary approach. Social work, nursing, and mental health professionals with expertise in the area of child maltreatment gather and assess data on multiple levels to provide a comprehensive history. Medical evaluation can then be guided by the history collated by the team.

Frequently, medical examination alone is not sufficient to address all of the child’s or family’s needs. For instance, with child sexual abuse, positive physical findings are found in only 10% to 15% of the cases referred for examination. However, abuse may still remain a concern as a result of disclosures, behaviors, or confessions that must be pursued further. Also, regardless of the medical results, families may still require education, crisis counseling, and referral to community services. The team also identifies children who may need mental health intervention. For successful outcomes, coordination of information-sharing between the team, the investigators, and the family is essential, albeit time-consuming. Time-consuming tasks are shared, along with the burden of decision making. Team members provide support to each other, buffering the emotional impact of disturbing subject matter. “The management of child maltreatment cases involves complex decisions which reflect medical, legal, ethical, and social issues often beyond the expertise of a single individual.”[9]

Examples of this complexity are found in the 1995 Report of the Gove Inquiry into Child Protection in British Columbia,[10] which presents findings regarding the death of 5-year-old Matthew Vaudreuil. “Autopsy showed that Matthew weighed only 36 pounds. His face, arms, legs, and back were covered in bruises. There were what appeared to be rope burns on his shoulders and wrists…His buttocks were covered in bruises and welts. He had a fractured arm, 11 fractured ribs, and what looked like a foot print on his back.” Although the Gove inquiry’s main goal was to review the adequacy of services, policies, and practices of the Ministry of Social Services of the time, the role of the medical profession was also explored. Judge Gove found that Matthew “had been taken to the doctor 75 times and had been seen by 24 different physicians” during his short life. He also noted that “physicians did not pay sufficient attention to Matthew’s medical and social history. Some physicians who had basis for concern about Matthew’s safety and well-being did not make a report to the ministry, as they should have.” As background, Judge Gove reviewed the files of 29 other child deaths. From this he found “strikingly similar patterns.” One of these patterns was “a lack of interagency communication and cooperation, particularly between social workers and the medical community.” Included in Gove’s final recommendations was a section dedicated to medical and other health care professions, which highlighted the need for proper training in child abuse and neglect, and improvement of interagency communication and cooperation.

More recently, testimony during the criminal trial of the parents of Randal Dooley in Toronto, Ontario, revealed that in February 1998 Randal was admitted to the Hospital for Sick Children with a broken elbow and a mark on his eye. Randal’s stepmother told the hospital officials that her stepson had slipped on the ice. Randal was treated and released. Doctors who later testified at the trial said such a fall could not have caused both injuries. Randal died in September 1998 with “at least a dozen cracked ribs, a lacerated liver, and a tooth in his stomach. But what killed him was one of four brain injuries.”[11] Randal’s father and stepmother were found guilty of second-degree murder.

Would referral to a SCAN team (available in both Vancouver and Toronto at the time) have changed the outcome for Matthew in BC or for Randal in Ontario? We will never know. However, we do know that a thorough review of social history and interagency communication usually does make a difference, and that referral to SCAN teams should be considered in similar cases.

Referrals

The frequency of suspected child abuse, the possibility of severe outcome, and the potential liability for physicians makes it incumbent upon medical professionals to familiarize themselves with the specialized services that can assist them in identifying and assessing child abuse and neglect.

Referrals to SCAN units in BC are received from MCFD, law enforcement, and health care professionals. Depending on the resources of the individual SCAN team, between 200 and 700 referrals are received each year. Reasons for referral include sexual abuse, physical abuse, and neglect concerns. In BC generally, sexual abuse evaluation is consistently the most frequently requested service at SCAN units, even though sexual abuse is found to be the least common reason for investigation by Canada’s child welfare authorities. While neglect (40%), physical abuse (31%), and emotional abuse (19%) all rank well ahead of sexual abuse (10%) as causes for investigation,1 there are reasons why so many sexual abuse concerns are referred to SCAN teams. First, sexual abuse is often noted as the concern physicians feel least comfortable evaluating. Second, sexual abuse evaluation standards are continually being revised and updated, resulting in Crown counsel and law enforcement agencies often insisting on “expert” evaluation. Finally, it is now standard practice for sexual abuse examinations to include colposcopic evaluation.

Common struggles

Recruitment of new SCAN physicians and psychologists has been difficult. Generally, retention has not been an issue. Once exposed to the interdisciplinary approach, most team members find the experience rewarding and challenging. Financial commitment to BC’s SCAN teams appears to be decided on a year-by-year basis, which can make long-term planning difficult. However, feedback from families, investigators, and health care providers who have used the services of SCAN teams remains overwhelmingly positive.

Competing interests
None declared.

Table. Suspected Child Abuse and Neglect (SCAN) units in BC.*

*No formal team currently exists to take referrals in the BC Interior, although two pediatricians at Penticton Regional Hospital do provide child abuse evaluations through Acute Care General Pediatrics and the Emergency Department for the South Okanagan area.

Christine E. Jarchow, MSW

Ms Jarchow is a social worker with the Health Evaluation, Assessment, and Liaison Team at Surrey Memorial Hospital.