AAP Voices Blog

It's normal for kids to pick up bumps and bruises, but some injuries cannot be explained away. A baby who is not crawling or cruising yet should not have bruises on her arms or shins or broken bones. A healthy infant, alone in a room, does not suddenly go limp from catastrophic brain trauma.

Faced with cases like these, which raise concern about possible abuse, a pediatrician’s first response is often a combination of fear, denial, and decision paralysis. No one wants to believe that parents or caregivers could harm a child. Doctors don’t either. Physicians naturally look for a medical problem, something they can treat to make the child healthy again.

The reality is that as many as 25% of children in the United States has experienced some form of maltreatment. Tragically, sometimes children whose “sentinel” injuries are not adequately assessed, are later abused to the point of death or permanent, debilitating injury.

Healing bodies – and relationships – in a stable medical home

As a pediatric child abuse specialist, I see infants and young children with abusive head trauma during a weekly clinic that’s part of a multidisciplinary follow up program. In this setting, I get to see a wide range of developmental outcomes from this preventable but still common form of abuse. Many are doing well with therapy and attention to some complex issues like seizures, visual deficits, and motor disabilities.

When a child is unsafe or has been maltreated, relationships between primary care physicians and parents can be strained or disrupted by human services involvement. It’s never an easy situation. However, pediatricians are in the the incredibly important position to rebuild the relationship, maintain the medical home, and continue both medical care and advocacy for the child’s safety and health.

While I get to revisit with families with social work and therapist colleagues and walk this journey of recovery with them, I still feel challenged--even as a child abuse pediatrician--to understand why the abuse occurred. But I am motivated to stay connected to the children and support their families. These children, some too young to speak, desperately need physicians trained in the medical and psychosocial aspects of this far-too-common condition of childhood.

"As we evaluate and treat young patients with suspicious injuries, trying to make the difficult determination of whether human services should be involved, our overarching goal should be to prevent further harm.”

A commitment to prevent further harm

How do we do that when emotions are high, the cases are tragic, and the outcomes for the child and family unknown? We return to who we are as pediatricians and ground ourselves for this unique and difficult journey.

Stay focused and committed.

Remember that our training in pediatrics has prepared us for this challenge. Taking care of kids is what we are committed to do in our careers, and we do it well. As we evaluate and treat young patients with suspicious injuries, trying to make the difficult determination of whether human services should be involved, our overarching goal should be to prevent further harm.

Stay evidence-based and educated.

The diagnosis of child abuse requires a meticulous and methodical approach following evidenced-based guidelines and consult with specialists, including a multidisciplinary team of medical experts. A new clinical report from the American Academy of Pediatrics (AAP), Ongoing Pediatric Health Care for The Child Who Has Been Maltreated, published in the April 2019 Pediatrics, offers guidance on how to best oversee and foster the optimal physical health, growth, and development of children who have been maltreated and remain in the care of their biological family, or are returned to their care by Child Protective Services agencies. It describes the pediatrician’s role in helping to strengthen families’ and caregivers’ capabilities and competencies and connecting them with high-quality parenting support services for families in their communities. Child Abuse: Overview and Evaluation is another new AAP resource that should be kept at hand, and continuing education opportunities on this topic, toxic stress and trauma informed care, and many others are available through AAP. Child abuse pediatricians, who can be located through the Council on Child Abuse and Neglect (COCAN), are also here to help.

Stay open minded and connected.

One of the challenges with working with child welfare is the uncertainty of the responsibilities and the mechanics of that complex system. Finding shared language under the same mission of keeping kids safe and healthy is important. Child welfare is inherently solution- and safety-focused: determining risk, insuring safety, and engaging with families to promote safe parenting and maintain nurturing environments for children. Medical providers are diagnosis and treatment focused: confronting diseases, investigating causation, and determining a best-informed treatment plan for the patient. We can learn from child welfare just as they can--and do-- learn from us. Developing professional trusted relationships with child welfare professionals and viewing them as true partners in the care of children is crucial.

Stay courageous and curious.

I learned early on that if I don’t stay curious and ask even more difficult questions about what I see or suspect, I might never know how to best intervene or help. Maintaining a nonjudgmental and supportive approach is important. Not infrequently, I have to step back, pause, take a deep breath, and jump back into the fray. The child and family need me. I am a pediatrician. I can do this. Resiliency and the care of the child who has been maltreated can be hard. When I struggle, or I see colleagues who are struggling, I also stay courageous and recognize the need to ask for help. Never hesitate to reach out to your local child abuse pediatrician or to COCAN to locate a supportive expert colleague. Healthy and resilient physicians as a work force are essential to the future of pediatrics.

More than anything, children who are abused and neglected need a stable medical home to foster healthy physical, emotional and behavioral development. As pediatricians, we can build it.