PolicyLab

Guest blogger: Stephanie A. Deutsch, MD, is a Child Abuse Pediatric Fellow at The Children's Hospital of Philadelphia. Find her New England Journal of Medicine Perspective article here.  

Assessing suspected victims of child maltreatment can be challenging. Even for the most astute, seasoned clinicians who have built decades-long careers assessing child abuse, imparting a diagnosis of non-accidental trauma is often complex. Beyond recognizing the myriad, sometimes vague clinical signs and symptoms that victims of child maltreatment may present with, clinicians must grapple with the absence of any specific radiologic or laboratory test that yields a definitive diagnosis of “abuse.” Unlike other fields of medicine, there’s no single clinical test to “prove” or “disprove” child abuse. Rather, the diagnosis becomes one of probability, and based upon whether mechanistic and historical explanations are incongruous with clinical reality and exceed the threshold of suspicion for reporting to child protective services. Context is crucial, and no single injury, clinical sign or symptom itself is synonymous with abuse.

The child abuse pediatrician’s role is to objectively weigh the medical evidence against an understanding of the child’s underlying health, development, and the safety risks conferred by the social environment in order to formulate an opinion of the likelihood of abuse.

Sometimes there is even a degree of trauma we, as child abuse pediatricians, can personally experience when assessing our cases. Our emotions span a full spectrum, causing even the most unequivocal radiologic and laboratory studies to prove challenging. Feelings – sadness or anger over the injuries being assessed – may threaten to sway clinical judgment, while frustration with an overburdened child protective services system – perhaps dissatisfaction with a prior case outcome – pits the scientific, medical evidence against the reports and investigations that should ensure the safety and well-being of the most vulnerable. Our actions can feel conflicting. The inherent biases that shape all human interaction, those subconscious parts that define us as individuals and shape our reception, expression, and interactions with other people, can pervade our thinking about a case. When we can imagine bumping into the caregiver at our local supermarket, it may be harder to conceive of them, this “likeable person,” as responsible for the child’s injuries. And memories of when our opinion was incorrect, when we deemed an injury likely accidental, only to witness the fallacy of our judgment – a battered child under our care, yet elusively missed our clinical detection – what does this do then, to our opinion of abuse?

Although I once felt alone in this struggle for certainty, this quagmire of probabilities, imminent risk, and children’s best interests, I take solace in knowing that I, as a young child abuse pediatrician, am not alone in this confusion. Many of these challenges are universal to the profession of medicine, with our struggle for certainty and our common goal of wanting to ensure the safety and well-being of our patients. We work as a team, our medical opinions juxtaposed with the independent assessments of social workers, caseworkers, and police who collectively determine the probability of future harm and the necessary steps to safety. The definitions, criteria, and practices we each use to stratify levels of concern and involvement entangle us in a marriage of necessity, with the goal of doing what’s best for children. This partnership buffers against the rawness of these investigations – a vulnerability that can affect all of us as we uncover what lies behind the walls of a home where a child may grow up, safely or unsafely, on the basis of our judgment.

To me, acknowledgement of this common struggle has strengthened my resolve: child abuse pediatricians must strive to embody the “tabula rasa,” approaching each encounter free from preconceived notions, stereotypes, or judgments informed by zip code, income level, or skin color. We must instead strive to recognize, manage, and understand these influences on our actions and thoughts. We are society’s sentinels, tasked with identifying children who’ve been injured by those responsible for their care, and we must start the process of protection.