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Child Neglect: Signs, Symptoms and What to Do · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Music.
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Dates, and discussions for the busy pediatric practitioner. Click on the link
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in this podcast for MOC credit.
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Today, I'm bringing you a Grand Rounds talk.
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It's by Dr. Mary Ann Alvarez-Griffiths. She is a fellow in the Department of
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Pediatrics at UT Health San Antonio Division of Child Abuse.
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During her fellowship training, Griffiths has provided community education regarding
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child maltreatment to various audiences, from pediatric residents to the San
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Antonio Police Department.
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She recently participated in updating the AAP Point of Care Quick Reference
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section on physical abuse and neglect.
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She's a member of the Child Abuse and Neglect Committee of the Texas Pediatric
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Society and is also a member of the Council on Child Abuse and Neglect.
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Her fellows' research project focuses on the importance of obtaining head circumference
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in infants to prevent missed abusive head trauma.
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Let's listen in to her talk on child neglect.
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Neglect is usually typified by an ongoing pattern of inadequate care,
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and it can actually do as much damage as physical abuse.
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The neglect depends on the age of the child and can also result in a long-lasting
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impact on them, their peer relations, and their school function.
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There's also the possibility of impaired problem solving, delayed language,
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and lower academic achievement, which we know is going to affect them later on in life.
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So, the National Child Abuse and Neglect Data System, or NCANDS,
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collects data on the types of reports that have been made to CPS,
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so this is CPS data, and how the percentages of what has been founded or has been confirmed.
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So, So just looking at the national statistics, neglect is the most common types
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of reports made to CPS, which makes about two-thirds of the reports made.
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And about 74% of these reports made have been confirmed for concern for neglect.
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Just looking at these statistics, these are the most recent ones that we have.
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In Texas and Bexar County, we could see that in Texas, there was about 2,000,
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a little over 2,000 cases of physical neglect.
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In Bexar County, constituted 165 of those. And then for medical neglect, we had a little over 900.
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And in Bexar County, we had 97 of those cases. So, as we can see in the total
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numbers below, that we do make up quite a percentile, about 10% of these confirmed
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cases of neglect, unfortunately.
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So, when people think of fatalities, most often the most common thought is,
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oh, this child was abused and therefore died as a result of ongoing abuse or an abusive event.
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But actually about 73% of child fatalities involve some form of neglect.
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In our 22 data, we found that there was about 43% that were exclusively due
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to physical and medical neglect.
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Neglectful supervision is actually the most common neglect fatality,
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but for the purposes of this talk, we're focusing on physical and medical.
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We know that children with special needs are an increased risk for maltreatment.
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And 31% of child maltreatment fatalities actually involve a child with special
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medical needs or concerns.
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So, this could be something as your bread and butter asthma to those that are
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physically disabled, have CP, those that have feeding tube or medically complex children.
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So, we all know about the social determinants of health and risk factors that
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are associated for maltreatment and how they are all different levels of it.
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So, it can be in the individual setting.
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So, a baby that is born premature or has disabilities or special needs, has low birth weight.
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It could also be risk factors within their relationship with their caregivers.
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So if it's like a single parent, young parent, young maternal age,
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if their caregivers have mental health issues or substance use,
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also in their community, if there's a lack of social support or if there's increased
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crime rate or stress or lack of social support.
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So, we know that these are risk factors for maltreatment, and it's our job as
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physicians to identify these risk factors in order to help and support and provide
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resources to our families to prevent maltreatment.
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So just because there are risk factors for maltreatment doesn't mean that every
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case of abuse and neglect has one of these risk factors.
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And the opposite is true. Many children and families may have one or several
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of these risk factors, but it does not necessarily mean that they will be maltreated later on.
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So, due to the medical literature that we have, the greatest risk factor for
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neglect, as we know, is poverty or low socioeconomic status,
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which is the most directly associated with neglect.
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Children living in high-poverty areas are six times more likely to experience neglect.
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There are high levels of unemployment. There's population loss where they reside,
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or there's overcrowding in the impoverished neighborhoods.
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There's fewer opportunities to meet their child's needs, including like health
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care, fewer resources, including nutrition, clothing, hygiene,
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playgrounds, transportation.
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And poverty exacerbates other risk factors, such as like food insecurities,
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poor material nutrition, caregiver depression, stressful life events,
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living in higher crime or unsafe neighborhoods. hoods.
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So really, the greatest risk factor is the low social support resources and
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education that ties in with poverty and low socioeconomic status.
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So again, a family may be low income, but it does not necessarily mean that
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they are neglectful of their children.
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We have also identified that there is, in addition to all the risk factors,
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like the individual with the caregiver and their social status,
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there's also risk at the professional level with that.
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That being problematic communication, whether it be between the caregiver and the provider,
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maybe the parents aren't understanding the child's condition or the treatment
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plan, why their kid needs XYZ treatments or surgery or procedures.
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And there's also with problematic communication between providers themselves,
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not communicating properly regarding recommendations or treatment plans.
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And this is seen more often with the children that are slow waking or failing
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to thrive and the medically complex children.
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So we've identified four possible options as far as consequences for neglect.
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So there is no current harm done and no future harm is anticipated.
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One of the examples would be leaving a child asleep in a crib who does not require
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nighttime care while their caregiver is out partying on a Saturday night.
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So no harm is done. The kid is in the crib, safe and secure,
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even though unsupervised.
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And they don't need any nighttime care like diaper changes, bottle changes,
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and then no future harm is anticipated.
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The other one is no current harm, but future harm is anticipated, such as co-sleeping.
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Some families may co-sleep with their child and their child wakes up okay the
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next morning, but there's always that risk of future harm that they may have
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an asphyxia event due to a co-sleeping incident.
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There's where the child experiences current harm, but no future harm is anticipated,
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such as when a caregiver turns back for a few minutes and the child falls into to the pool.
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So the child experienced that near drowning event, so that current harm,
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but because of that event, caregivers tend to do all the things,
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put up the gates, put in cameras or lock the doors, and then no future harm is anticipated.
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There's also children that experience current harm and future harm as anticipated,
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such as the failure to thrive kiddos.
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So if we know that they're experiencing physical neglect, the caregivers aren't
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feeding them adequately and aren't understanding the treatments or the feeds,
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or just plain don't want to do it. So they're right now, failure to thrive, will wait.
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And then there's that increased harm, increased risk for harm that they may
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not continue giving them the appropriate caloric intake. type.
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So, we have the raw outcome for neglect.
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So, it varies between the age group. So, in infants, we usually see this as poor growth.
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They'll have cognitive delays, poor social skills, and other psychosocial problems.
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And this is usually seen, one of the studies showed that this is seen before the age of three.
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And then with the school-aged children or adolescents, they're more likely to
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develop developmental problems such as poor cognitive and school performances,
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emotional and behavioral problems.
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And then the behavioral problems, it's a spectrum. No one child is going to
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act the same way to say, oh, pinpoint this child's neglected because they are withdrawn.
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The opposite may be true. They may be more aggressive or they may be engaging
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in high-risk behaviors, such as early initiation of sexual activity or substance use.
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And as we know, neglect plays a part in our adverse childhood experiences.
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It is one of the aces, and these increased aces may predispose for chronic health
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problems, mental health problems, and increased risky behaviors.
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So, as mentioned before, there are many types of neglect, including physical,
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medical, dental, which is sometimes lumped into medical, depending on the medical
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legal definition or the agency using these definitions.
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Supervisional, emotional, and educational.
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So, for physical neglect, this occurs when a parent or a caregiver does not
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provide the child with basic necessities, which could be adequate food,
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clothing, shelter, hygiene,
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or really the lack that would cause a serious injury or illness.
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So, people commonly think about a child not having adequate food to grow and
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failure to thrive, and that's just one of the examples.
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So, for physical neglect, there are some physical indicators and some behavioral
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indicators. So, some physical indicators.
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The child may have, you can see it through the growth parameters,
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that if they're not getting adequate nutrition at home, that their weight starts
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to drop, and then their height starts to drop off, and then their head circumference starts to drop off.
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They may be consistently dirty or have a severe body odor.
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So whenever I get consults and they tell me this child is dirty and uncancelled
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or has like dirt under the fingernails, it's not really about having dirt under
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their fingernails or on their feet because for all you know,
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they may have been just laying outside before coming to visit you in your office, clinic, ED,
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whatever setting you're at.
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But we're talking about just consistently dirty, caked on, and with a severe odor.
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And then another physical indicator is the lack of adequate clothing.
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Here in San Antonio, this is kind of a little bit more difficult to gauge.
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We don't have these strong winters where we would need puffy coats,
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but usually that's one of the, usually what we think about is when it's winter
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and these children don't have coats or it's summer and then these children are
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still in like heavy clothing.
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Some of the behavioral indicators could be that they're asking or begging for money, food.
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They may stay extended time at school just for food and nutrition.
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I know growing up in the valley at my school, we had a food program including after school.
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So they may be doing that just to get another meal.
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They may tell you, oh, that no one's at home and this is why they prefer to
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stay at school or they'd rather be elsewhere.
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They may be frequently absent. You may get calls from school saying,
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hey, this kid is absent or from the nurse, or they may tell you,
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the parents may tell you that they're just constantly fatigued.
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So whenever you notice that there are some indicators, just know that it is
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okay to ask the hard questions to understand the problem.
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For the example of the child with like dirt taped on or under their fingernails,
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it's okay to ask them or the caregivers, hey, I noticed this.
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How are things going at home or is everything okay at home? So...
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Talk to them in an unjudgmental way to see if there's something unidentifiable
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problem in which we could help or provide resources.
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So once we understand the problem, we can get the appropriate resources to them
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and always use our wonderful social work and care coordination teams for these resources.
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So maybe the parents may say, oh yes, the water stops working.
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They cut off the water. I didn't have enough money to pay the water bill this month or something.
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So there may be a reason as to why they are presenting that way.
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So if you notice something, please provide the resources for them.
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So some other indicators that may present, think about a child that has a chronic illness.
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They have a Broviac placement or maybe a port-a-calf, and then they're supposed
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to be maintaining it clean.
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And then you see them come walking into your office or you go into the ED and they're just dirty.
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The tegaderm is all soiled and they're coming in with frequent infections.
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So that may be an indicator that, hey, maybe something is going on at home as
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well, that maybe the home life is unhygienic for them,
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for their level of immunocompromised level.
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And then we find that once we get into the home, CPS or law enforcement,
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sometimes, unfortunately, they do live in unhygienic conditions.
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So you may not be seeing this yourself as physicians.
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This isn't going to walk into their office. Families might not show you these
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pictures, but just having these children coming in with frequent infections,
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or they may be coming frequently unkept and with odor,
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and they may be coming for multiple ailments.
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And just some specific items that may be an indicator that maybe something is going on at home.
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The most common physical neglect presentation in infants is failure to thrive
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or slow weight gain as we're trying to move away from this term.
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There are many aspects to consider when managing a child with failure to thrive.
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It is multifactorial and it encompasses a lot of spheres.
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So for us, It can encompass biologic, where growth failure is related to a medical
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illness, whether acute or chronic.
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So they may have feeding difficulties secondary to poor caloric intake.
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Maybe they have some oral motor dysfunction or dysphagia, a neuro impairment.
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They have inadequate absorption or excess loss, such as pyloric stenosis or CF or infection.
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Or they may have something that has an increased caloric requirement such as
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a congenital heart disease or chronic lung disease or an important area of metabolism.
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The psychological component revolves around the mental health of the caregivers
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and their competence including their IQ level.
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The social sphere as we know poverty and low support system and low resources
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is the most pervasive risk factors, and this also takes in part the food insecurity,
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family stressors, and problematic interpersonal relationships between the caregivers.
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So, an extensive workup, including thorough history,
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seating history, family social history, review systems, labs,
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exams, imaging, if needed, are recommended for these cases to roll out or to
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parse out what could be causing the slow weight gain in these infants.
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So here's an example of a failure to thrive baby.
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So we can see that they have on the face lanugo.
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So this is the body's reaction to kind of maintain no thermia.
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And we can see their skin folds around the necks and how there's the loss of
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the subcutaneous fat over in the buttocks. This is another example of failure
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to thrive when this child is one who had not seen a doctor since two months of age.
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And then when they were admitted, we can see some lanugo going on in the back
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and the loss of subcutaneous tissue.
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And then three weeks later, with adequate caloric intake, they regained that
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fat as well. So this is one of those obvious cases on how adequate caloric intake
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made a noticeable difference in change.
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So we're going to go through some cases. And since we're not in person,
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I'm not going to ask the hypothetical questions.
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But for this example, how old would you think this child is based on these characteristics?
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They're three feet tall, 30 pounds.
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So, this is the average size of a two-year-old, and this child is actually six years old.
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So, in this example, providers, this is just to show an example how providers usually see,
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victims, so weight gain or failure to thrive is typically seen in infants,
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but it can also happen in older children who are victims of physical neglect as well.
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Sometimes the families may come in and say, oh, the child may have a poor appetite
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or they have a bleeding disorder or an eating disorder, sorry,
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that hasn't been confirmed when food may actually be withheld.
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Now, in this case, for the six-year-old, it's an extreme example.
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And he also has psychosocial dwarfism due to the extent of maltreatment he underwent,
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which included physical and emotional neglect.
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So we can see how his weight was affected, his height was affected,
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and obviously we know his circumference falls as well.
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And this is why he looks similar to a two-year-old more than a six-year-old.
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Another example for physical neglect and risk factors at the professional level.
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So there was the case of a one-month-old admitted for failure to thrive.
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Their birth weight was 2.19 kilos and admission weight was 2.2 kilos.
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When they were born, they were discharged from the hospital.
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They follow up with their PCP appropriately the three days after delivery.
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And per documentation, they were 1.84 kilos or 21% below birth weight.
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The instructions were to follow up in one month.
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And from their visit from the PCP's office to admission, this child had actually
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gained about 16 grams per day.
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So as we know, newborns may lose up to 10% of their birth weight and may take
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7 to 14 days to regain it, which is slower in breastfed infants than formula fed.
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And for the AAP, a loss of more than 10 to 12 percent should be investigated.
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20 percent is significant, and these typically require hospital readmission,
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if not very close follow-up.
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And while the child was gaining weight, we know that it's suboptimal weight
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gain, as average weight gain in this age group would be 20 to 30 grams a day.
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So in this case was a risk at the professional level.
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Just looking at the growth chart, looking at plotting these things can help
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us identify if there's any risk factors that are needed.
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So this child was admitted for failure to thrive with concern for failure for
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physical neglect, but the child was gaining weight adequately and the weight
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was not addressed at this visit, unfortunately.
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Another example, a baby 9.2 months of age was seen in the ED and they were 7.8 kilos or 10 percentile.
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They came back a little a few weeks later and they were 6.85 kilos or not the 0.5 percent.
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For this one, on the day of admission, they were described as hectic with loose
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skin around the neck, sunken eyes that were pale.
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But interestingly enough the
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day before admission they were described as
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well-peering and non-toxic and that was the 6.85 kilo and they were there the
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day before and the day of admission with same weight so in this case they had
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gone to the ed for an outside and unrelated issue followed
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up with a PCP per ED instructions the next day,
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and the PCP was concerned that they were 67% at the six-month well-child check
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and was now at the 0.5%, so they sent them to the ED for evaluation and admission.
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So, here we have a copy of the growth chart. So, this is what was seen in the
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ED, these first two points.
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These other points were inpatient after the child gained getting linked with
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the adequate nutrition.
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So in this case, the weight issue was just recommended to be followed up in
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the office and not necessarily addressed in the ED with this growth chart.
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And it turned out that the mother was pregnant, didn't know that her supply
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had dropped, and there was also concern for caregiver level cognition.
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So it's really important to, you know, just take a moment, take a look at the
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growth chart, address these issues as we see them and to provide your documentation
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for everyone following up.
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Another example, this child has several ED visits and in all of these,
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between the ages of five and seven, almost seven years old, six and a half, they were noted.
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The exam wasn't documented as unremarkable and the weight was not addressed. dressed.
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This child's weight had been decreasing in the last one and a half years.
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And there was no mention of the weight trend.
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And then we see how the height over here on the right side has started to stall.
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And then this child was starting to grow and then stall again.
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So these pictures were taken one year apart.
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And then this was the one to the right is one closer to admission.
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I think this was the day they were admitted when they took this photograph.
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So now the child had noticeably sunken eyes and appearance.
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And this case is an extreme case of starvation and psychological maltreatment.
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But here, what's important is just stressing the importance of looking at the growth chart.
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Just take two seconds to take a look to see if there's anything identifiable,
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any form of maltreatment that may be going on or any concerns or something that
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we may prevent or help the family with.
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So, for shifting gears to medical neglect now, medical neglect can take one of two forms.
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It can be the failure to act on an obvious sign of serious injury or illness,
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or it could be a failure to follow medical providers' There's instructions once
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care and advice has been sought.
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So traditionally, people think of those with asthma, diabetes,
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or infections for the second bullet point.
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And we will go through those shortly.
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So an example of an acute setting.
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So there is an 18-month-old that's coming in refusing to bear weight for two
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days after splitting while running and landing in a split position.
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On exam, there's an obvious deformity noted. They are non-variant.
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They're attended to palpation. They're noted to be in mild distress.
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You decide to get imaging, and this is what you see.
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So you have minimally displaced, angulated spiral fracture of the feet.
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So in this case, the child required surgery. So while this could have been an
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accidental mechanism, there was a delay in care.
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And while the delay in care did not change the medical management,
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this child would have required surgery even if they came in within 30 minutes of their fall.
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This child had obvious findings like that obvious deformity and they were obviously
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in significant pain and did require a surgical intervention.
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So this is the case where caregivers failed to act on an obvious serious injury.
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And therefore concerning for medical neglect. Another example may be an eight-year-old
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breaking leaves in a rural area.
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There was an ash pile that they stepped through.
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Caregiver saw them, heard them yell, took off their boot, and found this.
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So here we know that there is a large burn, at least partial thickness burn
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due to the blisters and bubbles.
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And here the caregiver did not take them to the hospital until two days after the incident.
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So it is not unreasonable for caregivers to try to manage sunburns at home.
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In this case, medically speaking, it's a large area. It's crossing joints.
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But the issues here are more with the child and what the child was experiencing.
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So the child was in distress and pain. So there was inadequate pain control, limited mobility.
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The child couldn't walk. They couldn't do ADLs or range of motions.
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They couldn't put shoes on. And then they started to feel warm and tender.
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Or so an infection was studied.
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So, without the proper care, there's an increased risk for infection,
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and now they may need surgical intervention.
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Besides the debridements, they may need grafting, and there's also the risk
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for decreased permanent decrease mobility without the appropriate therapies
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like physical and occupational therapies that our burn children usually have.
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So, in this instance, it's because it's medical neglect due to the significant
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pain and the inability for the child to do any ADLs, including walking or putting boots on.
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So in this case, it was an example of medical neglect.
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So what about a seven-month-old presenting for a soft, squishy spot on their head?
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The history their caregiver tells you is that they fell from a bed three days ago.
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Caregiver witnessed it. There was no loss of consciousness. They cried right
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away. They were asymptomatic.
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And then they presented because now, fast forward three days,
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they noticed the soft, squishy spot on their head two hours before getting to
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you in the office or the ED. and there was no other history of trauma.
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So, when you examine them, the exam is notable only for the scalp swelling.
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So, you send them to the ED if they're not already there and then you scan them
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and you see a right parietal skull fracture with an overlying scalp hematoma
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and underlying minimal subdural hemorrhage.
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So, in this case, this case is not concerning for medical neglect.
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Yes, we do have an injury and a finding, but this child had an incident three
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days prior, was asymptomatically otherwise appropriate and at their baseline,
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and their caregiver sought care when there was a change in symptoms.
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So as soon as the caregiver saw the squishy spot, they sought the medical care
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right away. And then we know that these scalp hematomas after something like
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this, like a fall, may present several days.
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So scalp hematoma, the soft swelling of the scalp, may not happen right away.
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It may take a few days to develop.
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So in this case, this is why it is not really concerning for medical neglect.
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So, we've talked about some of the acute, some of the children in the acute setting.
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So, some examples of medical neglect with children with chronic conditions.
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So, you have a known asthmatic is on their regimen.
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They require a controller plus a rescue inhaler. They have their asthma action plan.
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So, you know that they've had that education provided to them and the resources to them.
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They haven't had their controller for three years. They've been going frequently
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to the ED or urgent care for shortness of breath every two weeks.
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The winter season, this is usually where things trigger up and get worse for
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them, but they still don't have their controller and just ran out of their albuterol,
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and now they're admitted for status asthmaticus.
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So this is concerning because they had that education, they had the resources,
29:34
and the family did not follow through with the recommendations provided to them,
29:40
nor did they seek earlier care to get that controller.
29:45
Another example is a known diabetic with a long-acting and short-acting insulin
29:49
for control who's admitted for DKA.
29:52
They didn't have their insulin for about two months and were attempting dietary
29:55
management because guess what?
29:58
The kid doesn't like needles or shots.
30:01
I don't either. I tell my patients I'm the doctor and I don't like them either.
30:05
I have to take my shots when I have to, but hey.
30:08
So in this case, it's concerning for medical neglect because their caregiver
30:12
didn't use their resources, like going back to their providers,
30:16
whether it be the PCP or the endocrinologist for assistance,
30:20
like, hey, my kid does not really does not like needles. What can I do?
30:24
So because they didn't go back to those resources for assistance,
30:30
it's concerning for medical neglect.
30:33
Also, an example like a known epileptic with Keppra and they got their rescue.
30:39
They have their seizure action plan. So it's clear documentation of education and a plan.
30:44
But lo and behold, caregivers don't believe in medicine anymore.
30:49
Modern medicine, they're trying to leave the keto diet on their own and they're
30:53
using CBD because they read something online that it could help.
30:57
And now this child is admitted in status.
30:59
So, this is another great example of medical neglect because they had the education,
31:05
they had the resources, and it was documented.
31:08
And caregivers failed to provide that to their child, and now they were put in a harm's way.
31:15
So, now we get to dental neglect. Is dental neglect part of medical neglect?
31:21
It can be. So, dental neglect can be medical neglect.
31:25
It doesn't have to stand alone on itself and is usually in the same category.
31:30
It's a form of medical care and treatment.
31:33
So for our other example, you have a seven-year-old that has multiple caries and dental abscesses.
31:41
They're bringing her in due to three days of tooth pain.
31:45
They're bringing her into the pain and you get the history that they've never seen a dentist before.
31:51
So is this neglect? like? Well, there are several factors that we need to address.
31:57
So let's go ahead and assess the situation.
32:00
So we have to determine what has prevented the family from getting the appropriate
32:04
care. Maybe they didn't know the importance of dental care.
32:08
I know personally growing up in the Valley, my family probably didn't know the
32:13
importance of getting the annual checkups.
32:16
We certainly didn't go at the newborns. As soon as the first two came out and
32:20
every six months and then yearly, I just went across the border to Mexico.
32:24
That's what we do in the Valley.
32:26
Once it came time for braces as a teenager. So maybe they didn't know the importance of dental care.
32:30
Maybe there's transportation issues, finance issues, or maybe they just plain
32:36
didn't want to bring them in.
32:39
So in our example, the caregiver tells you, well, they don't brush her teeth.
32:43
I knew she had cavities, but I figured the teeth would fall out anyways.
32:49
We don't have dental insurance, but they did bring them in when the child was complaining of pain.
32:56
So is this neglect? So here we've identified multiple barriers and knowledge gaps.
33:02
So and the caregiver sought care when the child became symptomatic,
33:07
when they realized, hey, we need to seek care. So is this neglect?
33:12
Maybe not. Maybe not right now, since we know there was a lot of barriers.
33:17
So what do you do? You prescribe your antibiotics,
33:20
you provide the education on oral care and completing the course of antibiotics,
33:25
and then you instruct the caregiver to come back in three weeks for a follow-up,
33:31
and you document this conversation, and you document your plan of care.
33:35
And then since you've also identified that finances is an issue for this family,
33:40
you can enlist the help of social work to assist with helping them find dental coverage.
33:47
So you've done all the things you've identified the
33:50
gaps and the the risk factors you get
33:53
the help you document it clearly and then
33:56
she comes back two months later this time she's got an abscess that is more
34:02
painful than before you find out that she only took the antibiotic for four
34:07
days because because she felt better and that's why they didn't follow up as instructed because
34:13
it was better and they couldn't pay for another visit anyways.
34:17
So is this neglect now? Well, it depends.
34:22
Did we address the knowledge gap? Yes. Did we address the financial issues?
34:28
Will we enlisted the help of social workers who provided the resources for them
34:33
to get to get the finances that the insurance needed?
34:37
So, yes. Did we document those conversations?
34:42
So, in our example, it was clearly documented the education and the need for
34:48
the medication and the follow-up.
34:50
Caregiver had verbalized understanding, it had no questions,
34:54
and they didn't show up for the follow-up, they didn't complete the medication,
34:57
which resulted in further complications.
35:01
So now in this case, there is concern for medical neglect and is our duty to report it.
35:08
So when risk factors are identified, please, please, please,
35:13
it is very important for us to provide the resources when we see these things.
35:18
And that includes our social workers, our case management, our care coordination.
35:23
Some that I learned throughout my residency here was catforkids.org, San Antonio chapter.
35:29
This is an advocacy project and they have different tabs for different things,
35:34
which include like legal or if it's like the different illnesses or elements
35:38
that they need, or if it's resources for like food or something else,
35:42
they have different tabs,
35:44
which are easy to go through and they have the different resources per each category.
35:49
Any baby can also help with resources for family and also respite care if needed,
35:56
especially when we have our chronic kiddos.
35:58
And then the SA Food Bank, which assists families, which I found out during
36:03
my advocacy rotation, the residency, it's not just food, but they also assist
36:07
families in accessing state and federal benefits, including SNAP, Medicaid, and CHIP.
36:12
And then since we talked about the asthmatics, we also have our wonderful SA Kids Breathe program.
36:18
So use your resources when the risk factors are identified to help prevent the
36:26
risk of maltreatment later on.
36:28
So what's something else that we can do to prevent risk at the professional level?
36:33
So we can ensure that we address any barriers to understanding.
36:38
Look out for the vocabulary that we're using with the families,
36:41
making sure that it's at a level that they understand. Have them verbalize their understanding.
36:47
You can ask them, hey, can you repeat back to me what I just said?
36:50
Making sure you're talking in their preferred language and having interpreters
36:55
who interpret well if needed. in chart review for the prior visits or growth charts.
37:03
So really please pay attention. It takes two, three seconds just to click the
37:09
box, look at the growth points and review them. Make sure we're not missing anything.
37:14
Is there weight and height and head circumference? Are they all okay?
37:18
Is there something that we may potentially be missing?
37:20
They may not always come for weight concerns or or GI concerns.
37:24
And then you just by, they may be coming for a rash or a bump or something.
37:30
And then you find out later on just by chart reviewing that maybe they have
37:34
been going down, down on their weight point.
37:37
And also clear documentation to provide that assistance,
37:43
documenting the education that you've provided to the family, your treatment plans,
37:47
and also to help the providers later on that may see these children and also
37:52
clear communication with other providers so we can make a difference with these
37:56
families and help our colleagues out as well.
38:00
So when should you report? You should report if there's a suspected concern
38:04
for neglect or even any form of maltreatment.
38:07
And this is for the safety of your patient. And maybe there's other children
38:11
at home that may be neglected as well or maltreatment and you don't know because you're not seeing them.
38:16
So if you have a suspicion for neglect, please report it.
38:20
CPS is actually a very helpful resource. A lot of times people have a negative
38:26
connotation of CPS that, oh, if I call CPS and they're going to take their kids
38:30
away. They're never going to see them again.
38:32
But actually they are mandated by law to try to keep children with their families
38:38
together unless there's a clear reason not to or other avenues have been exhausted
38:42
to keep the children safely with their caregivers.
38:46
So there are cases that children need to be removed from their home for their
38:49
own safety, but this is very few cases.
38:51
CPS has resources for these families.
38:55
So maybe the family is going through a divorce, their primary breadwinner is leaving the home.
38:59
Maybe utilities stopped, someone lost a job, their car is not working,
39:04
that's why they can't make it to the appointment, or they have other life stressors.
39:08
So again, they try to work with families. They can use classes such as parenting
39:13
classes, substance abuse classes.
39:16
They can provide them with community resources, help them attain insurance,
39:20
provide transportation.
39:21
Sometimes Sometimes they can even provide assistance with daycare if needed.
39:26
So if a report is made, try to be transparent with a family if it is safe to do so.
39:33
So whenever there are issues.
39:36
Whenever you identify some risk factors or you think that there's a concern,
39:41
when you're trying to gauge safety, please check your biases.
39:45
Is there a tangible reason to fear the family if you tell them about CPS,
39:50
such as were they aggressive during your interview with them?
39:54
Were they threatening or menacing during the exam?
39:57
Or is it something that's your inherent bias of what you think of the family
40:02
based on what they look like or your own personal self?
40:06
Try to be empathetic and supportive and explain their concerns and try to be non-judgmental.
40:11
So you can say, you can tell them, hey, so I noticed, for example,
40:16
this bruise, and this is not a typical location for a bruise in a child this
40:21
age or a child this age shouldn't bruise.
40:23
I'm concerned that your child may have some underlying disorder that we just
40:30
want to roll out, or I may be concerned that something that's happening to your child.
40:34
And you can express them that this is for the health and safety of your child
40:38
and come to that joint consensus.
40:40
Like we both want your child to be safe and healthy, right?
40:43
If you don't feel that's good to do so, you can always say, well,
40:47
I have to make a report. I'm a mandated reporter.
40:49
This is our hospital policy or protocol or procedure to do so, to make these reports.
40:56
And then a disabled family is not necessarily a neglectful family.
41:01
If you see that a family is really riled up or being a little difficult,
41:07
take time to ask what their concerns are, what their needs are, what can we do to help?
41:13
I know when I was a resident, I was asked by trauma service.
41:18
Do consults on a difficult family, but something wasn't sitting right.
41:22
And then we'll tell you the demographics of the person consulting me and the
41:27
families, but you can just imagine.
41:29
But just medically speaking, this child was run over by a known drunk driver
41:34
who cops had released within 24 hours, drank again and got behind the wheel again.
41:40
So the family was, you know, obviously and noticeably distressed,
41:45
and they were being a little difficult because how could this happen?
41:49
The cops should have done better. This should have happened.
41:52
That should have happened.
41:53
So that's why they were being, quote unquote, difficult, because of their concerns
41:57
of other factors, not necessarily being aggressive towards the providers themselves.
42:02
It was just the situation that they were upset at. So take the time to really
42:07
talk to them and listen. So thank you all for your time.
42:11
And this is us at Set Up for Miracles. Our office is located over at Christus.
42:17
And please, if you ever have a concern for any form of maltreatment,
42:22
or if you're thinking of consulting CPS, please let us know.
42:26
We have a provider on call 24-7.
42:29
And we are more than happy to walk things through with you guys.
42:33
If you don't know if you should or shouldn't make a report, we're more than
42:37
happy to talk it through and assess the case with you.
42:40
But if you are making a report, please let us know. We would like to be involved
42:44
from the get-go in case there's other recommendations needed.
42:50
Music.
42:56
Fascinating talk. Click on the link in this podcast for MOC credit.
43:01
Coming up next week, a wake-up call.
43:04
Melatonin is incredibly important at this time.
43:09
The CDC reports that there were 11,000 infants and children who visited the
43:16
emergency room after accidentally taking melatonin.
43:21
This is a wake-up call for all of us. That's from sleep specialist Dr. Karen Hensel-Franks.
43:29
Also in this Pediatrics News Feed, we have an episode called The New Asthma
43:35
Guidelines, What Were They Thinking?
43:37
I interview a doctor who was on that expert panel who explains the guidelines.
43:45
Our sister podcast is Pediatrics Now for Parents.
43:49
That website is pediatricsnowforparents.com. That podcast can also be found
43:55
wherever you get your podcasts.
43:57
We cover a lot of the same topics that we cover here in Pediatrics Now for the
44:03
Practitioner, but it's in small bites for the busy parent.
44:06
We hope it's one less thing you have to say in the exam room.
44:10
That's our sister podcast, Pediatrics Now for Parents.
44:14
Music.
44:20
If you know someone who would be interested in this podcast, please share.
44:24
And I want to thank you all for all of the hard work that you're doing.
44:28
And I so appreciate you listening.
44:32
Our website is pediatricsnowpodcast.com. My email address is on there.
44:38
Please send me comments or episode ideas.
44:42
I'm Holly Wayment. Thank you so much for listening. And thank you for making a difference.