You are a nurse working in an urgent care clinic. A 2-year-old boy is brought in by his mom and the boy’s father. The mom reports that her son won’t stop crying. The father interrupts the mother, saying the boy is clumsy and is always falling. The father seems overly protective and won’t allow the mom to answer any questions.

During your examination, you notice bruising of various sizes and colors on the boy’s trunk, including the abdomen and back. He has swelling on his left leg and a bruise on her forehead. When you try to examine his left leg, he withdraws, cries out, and reaches for his mother.

The father reports that the child fell off his highchair earlier in the day while the mother was at work. When the father reaches for his son, the child begins crying uncontrollably, screams, and pulls away from his father.

You send a nurse and the mom for an x-ray of the boy’s leg and hip, which shows a buckle fracture of the tibia. You ask the boyfriend to wait in the room, but he is becoming increasingly agitated and impatient and says he is going to take his son home. When the boy returns from his x-ray, the doctor recommends that he be admitted for more tests.

Discussion

You have a reasonable cause to suspect that the child is the recipient of abuse due to the leg fracture, bruising of different levels of healing, depth of bruising, and bruising in atypical locations*, as well as the child’s fearful reaction to the father.

Your suspicions are aroused further when the father tells you he is going to get a cup of coffee. On his way out he says, “there’s nothing wrong with the kid—he’s just being a baby.” The father does not return. You correctly decide to make an immediate report to ChildLine.

The bottom line: Treat the child and make your report to ChildLine.

You are an occupational therapist assigned to work with a 66-year-old woman who had a hip replacement about 2 weeks ago. When you arrive at 3 pm, the blinds are closed. A man answers the door who appears to be drunk. His speech is slurred and there is a strong odor of alcohol.

You introduce yourself to your client, who is lying on a couch in the front room. As you cross the room, you notice an infant lying in a crib in the corner of the room. You notice a heavy urine and feces odor urine coming from the crib. You also notice that the baby’s clothes and bedding are stained and dirty. Beside the crib is an overflowing dirty diaper bin and you note at least a dozen empty beer bottles on the coffee table. Meanwhile, a man disappears into a back room.

You’re there to treat the grandmother, who relates to you that her son is looking after her and her grandchild. You assess her situation and begin your treatment, but you are concerned about the cleanliness of the baby’s environment and the apparently drunk caregiver. You review in your mind the 3 key components of child abuse in PA CPSL: 1) a child, 2) an act or failure to act, and 3) intentional, knowing, or reckless behaviors that give you a reasonable cause to suspect the child is a victim of child abuse.

Discussion

What is your role in this situation? You are there to treat the assigned client—not to assess the child for neglect. You suspect the child may be the victim of abuse or neglect based on the condition of the house, the child’s appearance, and the drunken caregiver. At the very least, the child appears to be physically neglected.

The Bottom Line

Treat your client. However, you cannot ignore the situation with the child. Based on your knowledge of the three components of child abuse, you have a reasonable cause to suspect and, as a mandated reporter you must report your suspicions to ChildLine personally and immediately.

Do not assess the child yourself—your responsibility is to the assigned client. You must make your report to ChildLine, stating your objective findings.

You are a physical therapist working in a rural part of Pennsylvania. You have been assigned to evaluate an older woman following a knee replacement. Your patient lives in the living room of a the one-bedroom, one-bath trailer. Her daughter and son-in-law share the bedroom. The inside of the trailer is unkempt and crowded but not overly dirty. There is running water, but the only heat is from a small floor heater.

During your visit, you notice a tent in a partially fenced front yard. You are told that there are 2 school-aged children that sleep in the tent. You are concerned about the kids sleeping in the yard during bad weather and are told by their mother that they sleep in the tent when the weather allows and come inside and sleep on the floor of the bedroom when it gets too cold or rainy. They have a large dog that sleeps in the tent with them.

You note that the kids appear to be well-fed, are not withdrawn with adults, and seem comfortable and relaxed when interacting with their mother. Their clothes are seasonally appropriate but in disrepair. You’re not sure if there is reasonable cause to suspect child abuse or neglect.

Discussion

You decide there is a reasonable cause to suspect the children are the victims of neglect and make a report to ChildLine. CPS sends a social worker to assess the situation, but she does not feel the children are victims of abuse or neglect. The CPS worker feels that, with support services and an evaluation of the family’s strength and weakness, the negative factors can be successfully resolved. She arranges for support services and ongoing visits to monitor the situation.

You are working in an emergency department. A woman arrives in acute distress, complaining of abdominal pain. Upon examination, you note that she is pregnant. The baby is successfully delivered and immediately starts having seizures. The baby was born premature at 34 weeks (per mother’s determination of when she became pregnant). It is under-weight for its gestational age.

The mother reports to you she used drugs throughout her pregnancy and her last use of drugs was 24 hours ago. She reported to you that she did not see a healthcare provider at all prior to the delivery. During physical exam you note that the mother has injection scars on both her arms. She reports that she is without medical insurance and doesn’t know how she’s going to look after the baby.

The mother also reports to you that she doesn’t want to see the baby and wants to know when she can have something for pain.

What indicators are present?

• No medical care during pregnancy.
• Continued use of drugs during pregnancy.
• Disinterest in seeing her baby.
• No plan for the baby’s care.
• Physical signs of injection drug use.
• Patient’s request for pain medication.

In your role as a mandated reporter, do you have reasonable cause to suspect child abuse?

• Yes

What are your next steps?

• A mandated reporter enumerated under section 6311(a) of the PA CPSL (relating to persons required to report suspected child abuse) must immediately make a report of suspected child abuse to ChildLine, Pennsylvania’s 24/7 Child Abuse Hotline and Registry, by calling 1-800-932-0313 or electronically through the Child Welfare Portal, if they have reasonable cause to suspect a child is a victim of child abuse.

A 10-year-old girl comes to the doctor’s office for a school sports physical for soccer. She has bruises on her lower left leg, scratches along his left arm, and a bruise on her forehead. When questioned, the girl reports she was injured while playing soccer on Saturday afternoon. She proudly states that she was tackled while making a goal that won the game.

She lives with her mother, a single parent. Her mother says she is very active and athletic. You understand that, when there is a reasonable cause to suspect child abuse, mandatory reporters are protected from retaliatory employment actions as long the report was made in good faith.

What indicators are present?

• Bruises and scratches along one side of the child’s body consistent with a sports injury.

Is there reasonable cause to suspect child abuse or maltreatment?

• In your professional opinion, is the story is consistent with a soccer injury? What were the injury patterns?
• Was the child’s condition the result of an act or failure to act on the part of the parent?

In your role as a mandated reporter, do you have reasonable cause to suspect child abuse?

• No

What are your next steps?

• Continue the physical and treat the child’s injuries as needed.