Most ED visits for intentional, interpersonal violence-related injuries to youth ages 10 to 15 years resulted from family violence (as opposed to peer violence), according to a recent analysis.1
Of 2,780 ED visits for injury by youth ages 10 to 15 years, 819 of these presented with intentional violence-related injuries. Researchers chose to look at this age group in particular because most previous research involved older teens, says Leticia Manning Ryan, MD, MPH, the study’s lead author and division chief of pediatric emergency medicine and medical director of injury prevention at Johns Hopkins Children’s Center.
Peer violence-related injuries comprised 19.2% of the injuries, but 54.7% involved family violence. This reflected instances of both child maltreatment and physical fighting. More than half of violence-related injuries happened at home. Ryan and colleagues also found more involvement of alcohol, drugs, and weapons in violent events during the COVID-19 pandemic. “Social work consults may be needed to further evaluate the safety of the child’s home environment. ED providers must also consider involving child protective services,” Ryan says.
ED-based efforts to screen and intervene “can be critical to preventing future violence,” Ryan says. The study’s findings show this is important not only for family and peer violence, but also for contributory factors — mainly, access to alcohol, drugs, and weapons.
“In addition to obtaining thorough patient and family interviews, the use of standardized instruments to screen for these factors can help identify youth at risk, and link them to appropriate interventions and care,” Ryan says.
EPs are deemed mandatory reporters under the federal Child Abuse Prevention and Treatment Act. “This indicates a legal requirement to report any suspicion of child abuse to the relevant authorities,” Ryan notes.
Generally, healthcare providers are legally obligated to report suspicion of abuse and neglect “in a timely manner and in good faith,” says Amy Evans, JD, executive vice president of business development and liability claims division at Intercare Insurance Services in Bellevue, WA.
State laws vary as to the particulars. “It is important that providers know the specific legal obligations where they practice,” Evans says. In some states, simply notifying the hospital is not enough to comply with reporting requirements. If EPs fail to make required reports or knowingly make an untimely report, warns Evans, “they could face criminal, civil, and/or licensure actions.”
All states provide reporters with immunity against criminal prosecution and some form of protection against civil liability, provided there is “good faith” basis to suspect abuse. “With that framework in mind, it is important for ED health professionals to remember that the public policy is one that supports their assessment if child abuse is suspected,” says Anna Berent, JD, MBA, senior director of claims at MCIC Vermont in New York.
Berent says worried or angry ED providers should remember their institutions, along with federal and state legislation, are behind them. “This helps stave off the panic and charged emotions that typically accompany cases where child abuse is suspected.”
It is best for ED documentation to be as objective as possible. “Mandatory reporters are required to include facts and circumstances in their reports,” Berent says.
Examples of good documentation: Quotes with statements from caregivers that EPs deemed suspicious, and detailed observations of the child’s injuries or general appearance.
If providers learn violence was perpetrated by a caregiver, or if the caregiver put the child in an unsafe situation, “then, in addition to the potential need for a police report, a child protective services report is necessary,” according to Genevieve Santillanes, MD, an associate professor of clinical emergency medicine at Keck School of Medicine at USC. “If the patient is going to be discharged, the team must ensure that the child or teen is being discharged to a safe situation.”
- EDs must assess if the perpetrator will continue to be in the home or will otherwise have access to the child.
“For example, if the child was injured by a non-custodial parent, ask if the child can be kept away from that parent until child protective services completes their assessment,” Santillanes suggests.
Likewise, if the child was injured by an adult sibling or a parent’s partner, EDs should determine if that person will be in the household once the child returns.
- Any agreed-upon safety measures (e.g., the adult sibling will not be allowed in the house) should be documented in the medical record.
“Even if the perpetrator is arrested, they might be released from custody quickly. A plan to ensure the youth’s safety is critical,” Santillanes says.
Child protective services’ planned response should be documented. For instance, the chart should specify the time frame (i.e., is the response going to be immediate, or will it happen within a certain number of days), whether child protective services will respond to the home, or if they would like the patient held in the ED. “Ultimately, for in-home violence, if the patient is medically ready for discharge, child protective services will determine if the child can return to the home,” Santillanes says.
ED staff can advocate for an alternate plan if they believe this is unsafe. “These discussions should be clearly documented in the medical record,” Santillanes adds.
- ED providers should speak to the child or teen alone to determine if they feel safe in their home and if there have been other incidents of violence perpetrated by the same individual or others.
“This risk assessment should be documented,” Santillanes says. “Any other incidents of violence by a family or household member must also be reported to the appropriate authorities.”
- Screening for trafficking and sex work should be considered in teens presenting with a violence-related injury.
For teens injured by an intimate partner, the age of the partner should be ascertained. “Unfortunately, a number of teens experience trafficking and other exploitative situations,” Santillanes laments.
REFERENCE
- Ryan LM, Irvin N, Miller M, et al. Characteristics of pediatric emergency department visits for youth 10-15 years old with injuries due to interpersonal violence. Int J Inj Contr Saf Promot 2021;1:1-6.
ED-based efforts to screen and intervene can be critical to preventing future violence. This is important not only for family and peer violence, but also for contributory factors — mainly, access to alcohol, drugs, and weapons. In addition to obtaining thorough patient and family interviews, using standardized instruments to screen for these factors can help identify youth at risk, and link them to appropriate interventions and care.
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