Child Maltreatment Guideline Helps ER Doctors Evaluate Potential Child Abuse

Natalie Kissoon helped develop a guideline to standardize how doctors approach possible child abuse or neglect cases so that no victims are missed.


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By Katherine Corley
Population Health Scholar
University of Texas System
Dual Degree Master's Student in Journalism and Global Policy
UT Austin Moody College of Communication & UT Austin LBJ School of Public Affairs

In 2017, nearly 64,000 Texas children—enough to populate a large Texas town—were abused or neglected, according to the Texas Department of Family and Protective Services. One hundred and seventy-two of those children died due to abuse or neglect—approximately three times the number of victims in the 2017 Las Vegas mass shooting.

“I think the public thinks that child abuse is very rare. I also think that there's a misconception that it happens only in certain types of people,” said Dr. Natalie Kissoon, a board-certified Child Abuse Pediatrician who is a Clinical Assistant Professor at UT Health San Antonio. “In reality, child abuse [is] very common, and it doesn't have any socioeconomic or racial/ethnic boundaries. It can be anywhere.”

natalie kissoon
Dr. Natalie Kissoon

To help ER clinicians accurately recognize and evaluate abuse-related injuries, Dr. Kissoon, who is also at the Center for Miracles at the Children’s Hospital of San Antonio, helped the Southwest Texas Regional Advisory Council Pediatric Committee develop the the Child Maltreatment Work-up Guideline. Now used at 74 hospitals in Southwest Texas, this protocol guides doctors to child abuse experts and recommends key medical assessments for children who may have injuries due to abuse or neglect.

“The workup provides more information that can help [a clinician] rule in or rule out child abuse,” said Dr. Kissoon. “For example, a child comes to the hospital with bruises. I would first get studies to make sure that they don’t have a bleeding problem. We would also run tests or labs to rule out other past injuries and to help assess whether this injury is due to a medical problem or an accident or abuse.”

The guideline identifies types of injuries that are commonly seen in abused/neglected children, such as unexplained burns or patterned bruising, and it instructs ER doctors what to do when maltreatment is suspected. Depending on the injury, clinicians might order certain injury-specific scans and lab tests, take photographs of the injuries, consult with specialists, and contact child maltreatment experts at the Center for Miracles, social workers, CPS, and/or law enforcement as needed.

“Based on a list of diagnoses in the guideline, if a child fits into one of those categories, there’s a high risk that the injury is due to maltreatment,” Dr. Kissoon said. “If the provider is concerned, the next step in the guidelines is actually calling us at the Center for Miracles to discuss the case. “We may be able to help clinicians make better decisions when it comes to making a report to CPS [Child Protective Services] or not, though doctors can always decide to call CPS at any time during this process.”

The Center for Miracles always has a board-certified Child Abuse Pediatrician (CAP)—a pediatrician who completed an additional three-year fellowship on child maltreatment—on-call to provide expert consultation by phone for physicians who suspect child abuse or neglect. The CAP will talk with the provider about the child’s history, mechanism of injury, and physical exam findings, and may suggest that the child receive further lab work or imaging if more information is needed to determine if the child has been abused.

“We are building a whole puzzle—looking at the child’s history, physical exam, labs, imaging, literature on child maltreatment—all of these help me make an assessment about whether a child has been abused or maltreated,” Dr. Kissoon said. “At the end of that discussion, I as a child abuse pediatrician will be able to provide my opinion on my level of concern for abuse and/or neglect. In some cases, it's clear that my opinion is this is abuse and a report should be made to CPS. There are other times where I might say, based on the information I know now, my concern for abuse is very low.”

The main purpose of the guideline is to standardize the way doctors approach possible child abuse or neglect cases so that no victims are missed, according to Dr. Kissoon.

While this guideline focuses on helping doctors accurately assess child abuse, Dr. Kissoon notes that lots of different strategies can be used to prevent abuse and neglect in the first place.

“Sometimes kids are hurt because families have expectations that are developmentally inappropriate for children, like expecting a baby to sleep all night long and not cry,” Dr. Kissoon said. “We need to provide good education to parents, because that decreases stress. We can also help them to find and pay for good childcare, because child maltreatment happens in child care settings too.”

“Don’t turn your back when you see someone who is having difficulty with their children,” she continued, “because that might be a stressful situation that puts them over the edge. We all need to work together to try to keep kids safe.”