Case Scenario

While I was reviewing the chart of a two-year-old girl brought into the clinic by her mother, a medical assistant pulled me aside and said, “That woman was really rough with her child in the waiting room. You might want to ask about abuse.” My small patient had a rash, but I tried to weave the subject of discipline into the conversation with her mother. “Gee,” I said, “having an energetic, enthusiastic child like this one must really challenge you! How do you handle her high spirits?”

“Yes,” said the mother, “She does get out of hand once in a while, and then I have to give her a time out.” The mother's response seemed perfectly appropriate.

After they left the examination room, I heard the mother shout at her daughter, “Don't you ever embarrass me in public like that again.” Next I heard a loud smack, followed by crying. I entered the waiting room, soothed the little girl and said to the mother, “It's hard having to take your kids to the doctor.” I didn't know what else to say. I hadn't actually been an eyewitness to this or the prior episode reported to me by the medical assistant. I didn't want to jeopardize the clinical relationship I had with the mother for fear that she might punish the child more harshly once they left the clinic. At the same time, I suspected that the mother had dealt with accusations of child abuse before because she knew how to answer my questions.

Commentary

Physicians face a daunting task when they have to report allegations of child abuse. Sometimes abuse situations are clear-cut, such as a child who appears with multiple bruises or broken bones. However, that is usually not the case. Most situations are clouded and often present the physician with a real legal and ethical dilemma. In the case presented here, the mother disciplined her child harshly and used corporal punishment, but did her behavior constitute abuse?

This scenario raises several important questions. First, how does a physician determine if a situation constitutes abuse? Second, how does a physician protect the child without interfering with or disrupting the clinical relationship with the parent(s), and is this even possible? Third, what if you report an incident of abuse that is eventually found invalid? How do you deal with the aftermath of this? Fourth, what obligations do physicians have if a staff member reports possible abuse to them?

The Federal Child Abuse Prevention and Treatment Act of 1974 defines child abuse as “the physical or mental injury, sexual abuse, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for that child's welfare under circumstances which indicate that the child's health and welfare is harmed…”¹ Physical abuse is a nonaccidental injury or an injury that is not compatible with the history of the injury, as offered by the caretaker, or with the child's developmental level.

All 50 states have passed some form of legislation mandating that professionals who come into contact with children report any suspected abuse. Professionals with such legal obligation are called mandatory reporters. The scope of these regulations includes, but is not limited to, health care providers. Some states have broader statutes mandating “any person” to report suspected abuse. Each state is unique in the language contained in its individual statutes. It is, therefore, vital that physicians know their practicing state's reporting requirements.

Most states mandate that reporting be based on suspicion of abuse or neglect. In Minnesota, not only must recent or current abuse be reported, but also any that occurred within the preceding three years and any “threatened” injury or sexual abuse. A threatened injury includes any statement, overt act, condition or status that represents a substantial risk of physical or sexual abuse.² Failure to report suspected child abuse can result in criminal and civil liability.

All states require that the suspected abuse be reported to either law enforcement or a local child protection agency. Typically, a verbal report must be made to the proper authority immediately or within 24 hours. Most statutes require that the verbal report be followed by a written report. Each state's statutes specify the required content of the report and the timeframe in which it must be presented.

How do physicians know when abuse occurs? The laws absolve physicians from the responsibility of “knowing” that abuse has occurred because reports can be based on “suspicion” or “reasonable cause” alone. Still, it is sometimes difficult to know if what physicians are seeing or hearing (or what is reported to them) crosses the threshold of discipline to abuse.

One concern among mandatory reporters is the unintentional false report, one that was made in good faith. The Child Abuse Prevention and Treatment Act mandates that states enact legislation providing that reporters of suspected abuse are exempt from prosecution. In most states, a person who has reported suspected child abuse in “good faith” is immune from criminal and civil liability. This, however, does not prevent disgruntled parents who feel they have been wrongfully accused of abuse from filing a lawsuit. Although unlikely to be successful, fighting a lawsuit can be expensive and time consuming.

Investigations by child protective services can be disruptive to a family. Such issues were addressed in Zamstein versus Marvasti, a Connecticut case.³ In this case, a psychiatrist was retained to evaluate children to determine whether their father had sexually abused them. Their mother, in the context of a bitter divorce and custody dispute, had made abuse accusations. Custody of the children was granted to the mother. Although the father was eventually acquitted of criminal charges, he unsuccessfully sued the psychiatrist, claiming that because of the psychiatrist's report of suspected abuse, he had been criminally prosecuted and alienated from his children.

In Zamstein versus Marvasti,³ the Supreme Court held that abuse reports made in good faith are immune from civil or criminal liability. “Almost all health care attorneys will advise a client that it is far better to be faced with defending a civil action for reporting suspected abuse than with the bleak alternative of defending a civil (and/or criminal) action if a child is injured or killed because of failure to report.”⁴ This does not mean that we as physicians should zealously report every situation. Rather, we are faced with the task of weighing situations and deciding if the level of suspicion rises to the need to report.

Last but not least in this case is the issue that the physician did not actually witness the alleged abuse, that it was only reported by office staff members. If the physician even suspects abuse, it must be reported. The law does not require that the abuse be witnessed. In fact, in most cases, the reporting person does not actually witness the abuse.

The case scenario presented here does not exhibit a clear case of reportable abuse. In this case, the physician might attempt to foster a relationship with the mother and obtain more information by interviewing her alone before deciding if this is a reportable situation. This step would allow for inquiries about current stressors, marital status, emotional well-being, etc., which may help the physician to determine if this is an isolated incident or a chronic pattern. The physician also should perform a thorough physical examination of the child, looking for any unusual marks or bruises. For further clarification about what constitutes a reportable act of abuse, the local office of child protective services could be contacted.

Although this physician expressed concern about the relationship with the mother and the possible consequences of interfering with it, the law states very clearly that the safety of the child is paramount. Confidentiality is waived when suspected abuse is reported. It is indeed possible—and highly likely—that if a report is filed with child protective services, the relationship between the parent and the physician will be irreparably damaged.

More information must be obtained and a relationship established with the mother before this physician can proceed with a report. Interviewing the mother supportively would allow the physician to directly discuss his or her concerns with this parent. It is possible that although intervention is necessary (i.e., is the mother a victim of spousal abuse? Is she depressed?), it doesn't involve child protective services. If, after gathering objective information, child abuse continues to be suspected, a report would have to be made. It is well for us to remember that parents have the right to discipline their children as they deem appropriate, even when their approach to discipline contradicts our own.

This scenario illustrates just one of the many complex situations physicians face. It is important that the necessary resources and information are made available to physicians. Abuse situations are important clinical problems that should be addressed initially during residency training and bolstered through continuing medical education. We can never have too much information or training in the face of such a difficult dilemma.