Child Abuse – PediaCast 183
Welcome back to another episode of PediaCast! Today Dr. Mike tackles the very serious topic of child abuse with special guest Dr. Jonathon Thackeray, the Interim Medial Director of the Center for Child and Family Advocacy at Nationwide Children’s Hospital. Don’t forget to submit your questions or concerns to Dr. Mike and tune in to hear them answered on a future PediaCast.
- Child Abuse
- Dr Jonathon Thackeray
Announcer: This is PediaCast.
Announcer: Welcome to PediaCast, a pediatric podcast for parents. And now direct from the campus of Nationwide Children’s, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast, a pediatric podcast for moms and dads. It’s Dr. Mike, coming to you from the campus of Nationwide Children’s Hospital here in Columbus, Ohio.
And we have a little bit of a different program for you today. It’s not really a disease process per se or a listener question. But we’re going to talk about child abuse. It’s an important topic and I think you’ll be surprised at just the scope of the problem. And here to talk with us today in the studio is Dr. Jonathan Thackeray. He is the Interim Medial Director of the Center for Child and Family Advocacy here at Nationwide Children’s. So we’re going to get to him in just a minute.
I want to remind you that if there’s a topic that you’d like us to discuss or if you have a question for us, it’s easy to get a hold of me, just go to pediacast.org and click on the Contact link. You can also email email@example.com or call the voice line at (347) 404-KIDS, that’s (347) 404-KIDS or 5437.
And also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
Alright, so let’s turn our attention to our studio guest. Again, Dr. Jonathan Thackeray is Interim Medical Director of the Center for Child and Family Advocacy here at Nationwide Children’s Hospital.
So it’s sort of a long and convoluted way of saying he’s a child abuse expert. Dr. Thackeray is also an Assistant Professor of Clinical Pediatrics at the Ohio State University College of Medicine and serves as Associate Program Director for the Pediatric Residency at Nationwide Children’s.
So welcome to PediaCast, Dr. Thackeray.
Dr. Jonathan Thackeray: Thank you. Good morning, Dr. Mike.
Dr. Mike Patrick: Appreciate you stopping by. Before we get started talking about child abuse, I want to focus really quickly on the Pediatric Residency here at Nationwide Children’s. I know we have a lot of medical students in the audience and a lot of them listen to PediaCast because they’re interested in becoming pediatricians. So I guess, how does our residency training program here at Nationwide Children’s stand out from the crowd? Why should they consider coming here?
Dr. Jonathan Thackeray: We have an outstanding Pediatric Residency program. We want to brag just the programs in the nation and we train over a hundred pediatricians in both General Pediatrics and Sub-Specialty Pediatrics and some of them are really all over the country to take care of children.
What sets us apart is a diverse curriculum, exposure to sub-specialists of every existing sub-specialty which residents don’t get at every program, and really a broad and diverse training in both community and sub-specialty pediatrics. So what I like to explain to medical students is no matter what you’re going to decide to do as a career pediatrician, you will come out of our residency program with an outstanding training and preparedness to do it.
Dr. Mike Patrick: Yes, yes. I agree and I can say that from a experience because I trained here back in the ’90s. And I wouldn’t have traded it for anything. I mean really just a great experience here and exposure to everything. I mean it’s just such a large tertiary care center. I mean there’s not a lot of things I didn’t see when I was here.
Dr. Jonathan Thackeray: Absolutely.
Dr. Mike Patrick: And its supportive environment with cutting edge technology including podcast.
Dr. Jonathan Thackeray: Exactly.
Dr. Mike Patrick: Alright, so let’s talk about child abuse, a much more serious topic. Let’s just start with what would be a good definition of child abuse?
Dr. Jonathan Thackeray: You know, child abuse is a broad term. It really includes several different types of maltreatment that children experience and so that could include physical abuse which could be an act or even a failure to act that results in the harm of the child or even risk of harm to a child.
It includes sexual abuse, which we would define as a child engaging in any type of sexual activity for which he or she is not developmentally prepared for, for which here she can’t legally consent to do or things that would violate laws or societal taboos.
Child abuse also includes emotional abuse which isn’t as visible as sort of the physical or the sexual abuse but it can still be very damaging. The law defines it as mental injury to a child and that’s again, a very sort of vague term but it could include a child who’s repeatedly belittled or ignored or blamed in the family setting.
Child abuse can include children who are exposed to traumatic situations, so children who are exposed to domestic violence within the home. So it’s a very broad and all encompassing term.
Dr. Mike Patrick: Sometimes we hear the term neglect. Is there a difference between neglect and abuse?
Dr. Jonathan Thackeray: Neglect is a form of child maltreatment and so when we talk about the broad umbrella of child maltreatment, you have physical abuse, sexual abuse, emotional abuse. And then within that, we’d include neglect.
Again, neglect can be very broad. It can include medical neglect, educational neglect, nutritional neglect, social neglect.
Dr. Mike Patrick: And with neglect, it’s more of failing to provide needs as opposed to actively, I guess if you wanted to say the difference between abuse and neglect, just because that terminology is out there.
Dr. Jonathan Thackeray: Yes, that’s correct.
Dr. Mike Patrick: And so how big of a problem is this?
Dr. Jonathan Thackeray: It’s a huge problem. It’s a larger problem than I think most people care to acknowledge or may even know about. Abuse results in the death of three children every day in this country. And if you look at national statistics, there are over 3 million children in this country who were referred to a child protective services agency for some concern of abuse or neglect.
And anytime we talk about statistics looking at abuse and neglect, we refer to it as the tip of the iceberg. And I say that because for each case that gets reported to a CPS agency, we suspect there are abused children who, for whatever reason, are never reported to the agency and even more children still that are probably never even identified as having been maltreated.
In Franklin County, there’s more than 9,000 investigations completed for suspected abuse each year. And at Nationwide Children’s Hospital each year, we’re asked to evaluate about 12,000 children for concerns of sexual abuse and another 200 or 300 for concerns of serious physical abuse.
Dr. Mike Patrick: And that’s over the course of the year that we’re talking?
Dr. Jonathan Thackeray: That’s each year.
Dr. Mike Patrick: Boy, that is a lot. And when you think too that so many of these kids are how long did this abuse or neglect go on before it was reported, I mean that also pretty mind-boggling really.
Dr. Jonathan Thackeray: Yes, that’s frightening.
Dr. Mike Patrick: Now I guess a lot of parents who hear these numbers, the first question they ask is why. I can’t imagine that someone gets up in the morning with the intent of hurting a child. I’m sure there are people out there but the vast majority of these cases that we’re talking about aren’t necessarily premeditated abuse. So why does that happen? Why would someone maltreat a child?
Dr. Jonathan Thackeray: So the why is an incredibly difficult question to answer. And I use that example you gave. When we’re talking about physical abuse, for example, I don’t think most caregivers wake up in the morning and say, today’s the day I’m going to harm my child.
We do see some caregivers who engage in a repeated patterns of violent behaviors towards her child, but I think for the most part, we’re talking about caregivers who snapped, for lack of a better word, under stress and end up harming their child.
And they’re the same stresses that many of us as parents deal with everyday, a baby who cries, a child who’s learning to toilet-train, a child with normal behavioral issues. They’re not listening, they like to use the word no.
And for whatever reason, the caregiver doesn’t have the social support or the education or the ability to cope with that stress in a healthy manner. And so you add to those normal stresses, what I call external life factor.
So you’ve got a child with a disability or you have a caregiver who has a mental health or a substance-abused problem. You have relationship stress, you have job stress, you have economic stress, you’re a single parent, you have domestic violence at home. Whatever it is, but you can imagine how these stresses would accumulate to a point where the caregiver snapped and in an instantaneous moment, they harm their child.
Dr. Mike Patrick: Right. Why don’t we just cover a new story and a recent episode of the podcast about the increase in head injuries since the, if you look before the economic downturn of 2008 and afterward and it was staggering how that increase, I guess that’s one sign of that stress and sort of snapping.
Dr. Jonathan Thackeray: Yes, and that study just came out this month and it confirmed what we’ve been seeing anecdotally. And in fact, Nationwide Children’s was part of the group that conducted that research.
And we noticed from 2007 to 2008 with the onset of the recession, our abuse of head injuries nearly doubled. And unfortunately, we’ve seen that number remain at a pretty constant rate in the last couple of years.
Dr. Mike Patrick: Now I think most of us recognized that there are certain people who have a responsibility and in some case, a legal responsibility to report when they suspect that there’s child abuse going on. So we think about doctors and teachers and even day care workers, but are there others who have the responsibility to be on the outlook – or on the lookout for childhood maltreatment?
Dr. Jonathan Thackeray: Yes, I would suggest that basically, we all have the responsibility to be aware that a child can be and is abused. Any person who suspects a child of having been abused, whether it’s your relative or your friend’s child or a neighbor child that you don’t know, I would encourage anyone who has a suspicion. They should report those concerns to the appropriate agency.
Dr. Mike Patrick: Yes, and we’ll get to exactly who that is and how you go about doing that. I think this is really an important thing because a lot of times, it’s easy just to turn your head the other way. But you maybe the only person who recognize this and may be that child’s chance of avoiding a serious injury or even death.
Dr. Jonathan Thackeray: Absolutely.
Dr. Mike Patrick: So what do you look for? I mean how do you spot potential abuse and in particular, just for parents out there who have just random interactions with kids, I mean how do you identify this?
Dr. Jonathan Thackeray: So again, it’s a tough question to answer. Children don’t come with a sign around their neck that says, I’ve been abused.
With that being said though, there are children who, for whatever reason, at a specific moment in time, they feel comfortable telling somebody that something’s happened to them. Somebody’s touched me, somebody’s hurt me.
And so any caregiver, any adult who hears the child make the statement, no matter how vague, no matter how brief it is, I would encourage that person to act on that statement and report it and get it investigated because that may be the only clue you will get from that child that’s something is happening in the home.
Dr. Mike Patrick: Right. What now for people who have a little more access to kids such as physicians and teachers, bus drivers, daycare centers, that sort of thing, what are some of the, I guess, classic things to look out for in terms of it should really be a major warning sign that something abusive is happening?
Dr. Jonathan Thackeray: Yes, we recognized that certain patterns of injury in children are highly concerning. So anytime we see a young infant, an infant who can’t yet get up and walk on their own, anytime we see a child that age with the bruises or fractured bones, that raises our level of concern. Any child with a concerning burn injury or significant burn injury, that raises our concern.
In general, we’re looking for injuries that don’t have a history to explain their presence or looking for injuries that don’t have an adequate history to explain why they’re there. Sometimes caregivers would give changing histories or different histories. Those are all things that would raise my concern that the child potentially has been abused.
Dr. Mike Patrick: Or if the history is inconsistent with the injury that just doesn’t make sense when you try to put two and two together that, that accident would cause this injury.
Dr. Jonathan Thackeray: Exactly. So part of our assessment is going through a thorough developmental assessment of the child’s abilities and seeing what they can do and then try to match that up with the history that the caregiver’s given us.
Dr. Mike Patrick: I think it’s easier for folks to think I’m going to report this if they see something blatant like that. But what if you just have this suspicion that may be there is that gut feeling that something’s not quite right here. Should folks be afraid of incorrectly accusing someone?
Dr. Jonathan Thackeray: Absolutely not. The laws of Ohio are designed to protect the child and to protect somebody who has a suspicion of child abuse. So it means you don’t have to know that a child’s being abused before you report. You only have to have a reasonable suspicion. It’s called reporting in good faith. And as long as you do this, you’re immune from liability and you’re protected. And even if turns out you’re 100% wrong and the child wasn’t abused in any way, shape or form, the person making the report is protected.
The other nice things that child protective services agencies do is they allow the general public to make a report confidentially. You don’t have to give your name, you don’t have to give your number and that provides some assurance that the person making the report can be comfortable and feel protected.
Dr. Mike Patrick: To be anonymous basically.
Dr. Jonathan Thackeray: Exactly.
Dr. Mike Patrick: So let’s say that you do have a suspicion, how do you go about reporting it?
Dr. Jonathan Thackeray: Well, as a general rule, so if it’s a less emerging situation, what you can do is you should contact, here in Franklin County, you can contact Children Services. Their number is (614) 229-7000. They have a 24-hour hotline that fill reports of child abuse.
And another option is somebody can actually present to the Children Services Offices on 525 East Mountain St. and discuss their concerns and person with a caseworker there. In the rare situation that somebody’s actually witnessing a child being abused, I would encourage them to call 911 and report the concern immediately.
The question I probably get asked most often is the sort of gray area in between, what do I do if I’m in the grocery store, for example, I see somebody yelling at their child or hitting their child.
Dr. Mike Patrick: Or a kid not in a car seat when you’re near the stoplight.
Dr. Jonathan Thackeray: Yes, exactly, sort of neglect and supervision issues. Here’s what you can’t do. You can’t out of nervousness, simply smile or nod or walk away. When you’re silent like that, you’re implying that you approve of whatever is going on.
I think an effective strategy for people, so if you’re in a grocery store and you see someone yelling at their child or spank their child, an effective strategy is to intervene and to walk up to that person and consider saying something to them. Something reassuring and normalizing, such as I’ve got two kids and each of them went through phases just like this. Don’t worry, it gets better.
Something just reassuring and normalizing like that might be enough to deescalate that parent at that moment. If you know the parent, obviously, you can offer to watch that child for a few minutes and let the parent calm down.
If the parent’s not responsive to your comments, then I think your next best step is to get someone from the store, an employee and involved and discuss your concerns with them. Most stores should have a policy for how to respond to violence in the store.
Dr. Mike Patrick: Yes, you know it’s tough as a physician. So I see a kid at the grocery store who’s not, they’ll be standing up in the cart. And the level of the cart is right at the waist level and it is so easy just to turn your head and not want to be involved in that situation. But really, we have the duty to say something.
Dr. Jonathan Thackeray: Yes, and I think you can do it in a very tactful and respectful way that educates the parent and doesn’t imply that you’re judging them in any way, but maybe is a very safe thing for a child.
Dr. Mike Patrick: Yes, and say hey, I work in the emergency department and I see what happens.
Dr. Jonathan Thackeray: I see children fall out of shopping carts all the time and bad things happen.
Dr. Mike Patrick: Right. Now you gave the numbers and information for Franklin County. We do have a lot of listeners in other places, but they should be able to find fairly easily their local child protection agency phone numbers or just call law enforcement.
Dr. Jonathan Thackeray: Absolutely. You can go to the phone book, you can get on the internet and just literally type in the name of your county children services and then you will see a number pop up.
Dr. Mike Patrick: So once something is reported, kind of step us through the evaluation than action process, I guess you’d say. Because I think too, there’s a lot of parents out there who things are reported because someone was suspicious and nothing really was going on. As you said before, it really was a mistake but you’re better off making that mistake than not, but some parents may find themselves on the other end of it, sort of going through the evaluation process even though perhaps nothing really happened. What can they expect?
Dr. Jonathan Thackeray: Yes, the Children Services process can be a mystery for people. Once they received a report of suspected abuse, the person who’s answering the phone, they’re known as the screener, they will talk to the person who’s calling and review the details of the report and they will decide if the case meets criteria for further investigation. And if it doesn’t, then they’re done and the case is closed.
If it does, then the case is open for further investigation and Children Services then, depending on the type of case has between 30 and 45 days to complete and investigation. And as part of this investigation, they will work with child abuse pediatricians, emergency physicians to review the child’s injuries and other medical findings.
And maybe of interest to your audience to know that over a third of a case is that we’re involved with medically for potential abuse end up being diagnosed with some type of medical condition or an accidental injury. So there are many cases that we see that we determine to not be abusive.
Children Services also works with the family to identify the child’s and the family needs. Oftentimes, the family will be referred to community resources for assistance. Occasionally, a protective name will be identified and in those situations, the case will be open for what’s called ongoing services work, case work or we’ll work with the family on an ongoing basis to help them.
And then occasionally, there will be a threat identified to the child’s safety. And in those situations, the child gets removed from a home and put into a safe environment until things can be worked out.
And Children Services over time, unfortunately, I think they’ve developed a bad reputation that they are the group that pull children from their home. When in fact, their mission’s really the exact opposite of it. They recognized the children are best served within their family, within their community and the agency does everything they can to maintain that relationship and to keep that child with his or her family.
Dr. Mike Patrick: And even when they’re apart, I mean they encourage still healthy communication as long as it’s safe, visitations and trying to get reunification as fast possible.
Dr. Jonathan Thackeray: Exactly. That is their primary goal.
Dr. Mike Patrick: Yes. Now what if your child has an accident? A lot of parents that I see who come in the emergency department, you know, something happened and they’re afraid they’re going to be reported and they may not give you the correct information, then you start to get more suspicious but they just don’t want to admit. You know their child had an accident but kids have accidents and it’s not always a maltreatment that’s involved. I mean what if a child has an accident, what should parents do?
Dr. Jonathan Thackeray: So parents should seek medical attention for their child when they believe it’s necessary and never ever let a concern for a report of suspected abuse stand in their way.
And I think what’s important for families to know is that again, the system’s designed to protect the child. And so occasionally, a child with an accidental injury is going to get reported to Children Services. It’s the way the system is designed. But a report doesn’t mean that there’s going to be criminal charges. It doesn’t that the child’s going to be removed from the home.
What a report does is it allows Children Services, in conjunction again with emergency physicians, specially trained child abuse pediatricians to thoroughly evaluate the children’s injuries, to talk with the family, to talk about risk factors. And ultimately, come to a determination as to the likelihood of abuse. And families should expect an honest and objective approach throughout the entire process.
Dr. Mike Patrick: Yes. One of the things that, I think, those of us who deal with the kids who are maltreated that’s sort of frustrating are the, I guess, you’d call them false reports where you have parents who picked one against the other in custody about their own son. A child goes to visit one parent and as soon as they get home, if there’s any little bruise at all, they’re bringing the kid to the emergency room. Can you – I mean it’s a frustrating kind of thing and yet you don’t want to miss anything either. Can you speak to that?
Dr. Jonathan Thackeray: It is frustrating. It’s frustrating for all of us and I think it’s frustrating for the CPS workers who have to investigate.
Dr. Mike Patrick: And really not fair for the kids.
Dr. Jonathan Thackeray: It’s not fair for the kids. And the problem is there are children involved in custody disputes who do get hurt. And so you don’t want to automatically discount the claim of abuse, but again, it goes back to what I said.
Every investigation both medically and from a child protective services standpoint, it’s an objective and open assessment. And especially CPS workers, they’re pretty good at early on determining what is just one parent sort of trying to punish another and where are their legitimate concerns that the child might be at risk.
Dr. Mike Patrick: Who are the most likely perpetrators of child abuse? Who, I guess, you watch out for the most?
Dr. Jonathan Thackeray: So when you talk about perpetrators of child abuse, I think it counters up an image in most people’s minds and everybody has something they think of. What may surprise people is that more than 80% of children who are maltreated or abused by one or both of their parents. It’s not a stranger walking down the street who harms the child. Women comprise the largest percentage of perpetrators of neglect and men comprised as the largest percentage of perpetrators of both sexual abuse and physical abuse.
But the message I would want your listeners to walk away with is anybody can harm a child, parents, neighbors, relatives, friends, baby-sitters and strangers. And child maltreatment occurs in very race, every ethnicity, every level of socioeconomic status. And so, there is no one type. There is no mold of perpetrators of abuse. It really can and does happen in every setting you can imagine.
Dr. Mike Patrick: When you say parent, are you talking biological parent is the most common, not necessarily mom’s boyfriends, their stepfather, stepmother?
Dr. Jonathan Thackeray: No, but we do know that certain types of injury, so abuse of head injuries, for example, the most common perpetrator would be a non-related adult in the home, so mom’s boyfriend would be a…
Dr. Mike Patrick: Be a classic example of that?
Dr. Jonathan Thackeray: But that’s only for that specific type of abuse.
Dr. Mike Patrick: Sure. Baby-sitters also are really, you want to know about the people who are watching your kids during the day and make sure that it’s not an overcrowded situation again because baby-sitters can snap and when they’re feeling stressed because they have so many kids in their house.
Dr. Jonathan Thackeray: Absolutely, and daycare providers. I think a lot of families feel like their child’s in daycare and therefore, they are protected and we see children who are harmed in a daycare setting. Like you mentioned, overcrowded settings, daycare that don’t have the proper licensure, the proper education to deal with children’s behavioral issues.
And I encourage families, when they have a child in daycare, you need to stop by randomly and check out what’s going on. You need to talk to the people involved. You need to always have just a little healthy level of suspicion in the back of your mind.
Dr. Mike Patrick: And then, I guess, this kind of goes flows into the next question. How can parents protect their children from abuse? I mean, obviously, by visiting as you say and being aware but are there other ways?
Dr. Jonathan Thackeray: Yes, so again, you have to know who your children are with at all times, whether its their friends, whether its caregivers. And I encourage families, if you have a bad feeling about somebody or some place if you just don’t trust the situation, then it’s a good sign that you probably shouldn’t be leaving your child there and that’s a good rule of thumb, I think, for parents.
When we talk about parents who harm their children, it’s important for us as pediatricians to help families identify what supports they have in the community. Who can they turn to when they’re at their most stressed and at risk for harming their child, what does a parent do when their newborn baby won’t stop crying, what do they do so when a child soils themselves and they’re learning to potty-train?
Pediatricians, family practitioners, they play a huge role in helping families identify coping mechanisms ahead of time. The other thing we should be doing is we should be asking about stress in the home, whether it’s relationship stress, economic stress, job stress and sometimes just the simple act of asking can be comforting to a family. They know it’s an issue you care about and they maybe more willing to discuss it with you in the future. Even better, it results in a better outcome for the child.
Dr. Mike Patrick: Yes, it gives them reassurance that they’re not the only ones going through that particular stress or problem. Because when you’re going through it, it does seem like you’re the only one in the world who’s dealing with this but I think there is comfort in knowing that others are there with you.
Dr. Jonathan Thackeray: Absolutely, and maybe there’s resources in the community that they don’t know about that you can link them with and help them.
Dr. Mike Patrick: So I think, bottom line for parents is this is definitely something that everyone needs to be aware about to be on the lookout for if you have that gut feeling that something’s not right, don’t ignore it. And then know how to report and who to talk to.
Dr. Jonathan Thackeray: Absolutely.
Dr. Mike Patrick: So we do have some links on the website. The National Children’s Alliance has just tons of information and resources so we’ll have the link to that and we’ll also have link to resources here at Nationwide Children’s Hospital for you as well.
Well, we appreciate you stopping by. One of the things that we talk with each of our guest about is we try to encourage families to do things together, and board games are one way that you can have some fun around the table that don’t involve screens. And so just from your own past, what’s your favorite board game?
Dr. Jonathan Thackeray: I was a big fan of Trouble. I like the little pop-up above and in the middle. That’s been a favorite of my boys as well early on.
Dr. Mike Patrick: Yes, that is a fun one. So we’re tallying up a list, so at the end of the year, we’re going to have the top 5 games of our guests and Trouble has been on the list before and so we’ll put in another vote in for that.
Alright, so we want to thank Dr. Thackeray for stopping by, and of course, thanks to all of you for taking time out of your busy day to listen to PediaCast. We really appreciate it.
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