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July 5, 2004

Objective Reporting
Child Abuse Is Serious … Handle It Properly
By Janet Needham, RT(R)

Children are precious gifts. Many gifts are taken for granted and, tragically, some even abused. Radiographers and their imaging colleagues have the responsibility to care for and address the issues of this abuse. Healthcare professionals observing something suggesting possible abuse during treatment are required by law to report their findings. In the case of a technologist, that means reporting suspected abuse to the appropriate person as described by your facility’s reporting procedures. Experts agree that’s the first step. If you’re unclear on your facility’s procedure, find out.

Becky Britt, MS, RT(R), presented a program on the physical and behavioral indicators of child abuse at the 2004 American Society of Radiologic Technologists (ASRT) annual meeting in June. Britt is an instructor in the radiography program at Northwestern State University, Shreveport, La. Her talk also covered the methods used to report abuse along with suggestions for handling reporting and ways to comfort the child in question.

Britt’s interest in child abuse came early in her career while working as a medical assistant and radiographer in a rural doctor’s office. A toddler was brought in with a fractured humerus, ostensibly caused by a fall. Britt’s interest was piqued by the way the state investigation focused on the parents as much as the caregiver who brought the child in for care. The family dynamics and the child’s fear spurred Britt to learn as much as possible about child abuse.

Today, Britt teaches radiography students to use their instincts and knowledge when imaging children. Paying attention to family dynamics can aid in a decision to report possible abuse. Britt says of her students, “They will be the only advocate that child has during that exam time, their voice.” A caring, sensitive, and responsive radiographer can accomplish more than one trying only to finish a task. “We are not doing a good service if we are only trying to complete an examination,” Britt says. “As humans, we need to be sensitive to children, allowing them to speak out.”

Abuse can be physical, emotional, or verbal. The avenues for reporting may be different in each facility, but the responsibility for reporting remains with the technologist who spots something suspicious. The protocol for notifying authorities should be taken seriously and followed to the letter. In the event no protocols are in position for your workplace, follow through with the patient’s physician and local authorities. Take care to report observations—not accuse—when making the report to protect against slander.

Some findings are easily mistaken for abuse and are actually congenital anomalies.

Careful observation and reporting full results in a complete clinical history are your legal duty and best protection in cases where you suspect abuse. The assessment or history form that accompanies the exam gives the technologist the chance to comprehensively document all aspects of the imaging and the patient. Some of the physical indicators to document include bruising, multiple fractures, bite marks, and burns. Britt includes her observation of parents’ and caregivers’ behavior in her assessment. Behavioral indicators to note include a lack of concern for the injury, a lack of response to the child’s pain, a distrust of healthcare professionals, and an excessive concern for very minor injuries. Strange family dynamics and the child’s fear are excellent reasons to heighten your awareness.

Handling the Exam
Examining a child when you suspect abuse is much the same as imaging any child. Attitude is of utmost importance, as is gaining the trust of all concerned, especially the small patient. The child may truly trust no one, and a friendly face at a time of unendurable fear may prove a turning point. Work to help the child feel safe and secure in your presence. Make yourself small in size by kneeling and use a gentle voice to accentuate your ability to communicate. Britt utilizes numerous ways to communicate with children. Speak on their vocabulary level, use terms they understand, and do not ask leading questions. Instead, she suggests asking open-ended questions to gather the most information possible. Always prepare children so they know what to expect during the examination. Rewards and incentives, such as stickers, candy, or stuffed animals, can help comfort children.

A radiographer also has the opportunity to see the patient’s imaging history at a glance. Some trips to an imaging facility may be as an outpatient or inpatient and others through the emergency department, but all the exams show up in the patient’s film record or film jacket. It is your responsibility to take note and relay suspicious information to a supervisor.

Expect abusers to blame injuries on many things—eg, childhood rough play, clumsiness that results in frequent falls, adventurousness, and climbing. Another excuse is a rare disease known as osteogenesis imperfecta, described by Medline Plus (www.nlm.nih.gov/medlineplus/osteogenesisimperfecta) as a genetic disorder characterized by bones that break easily, often from little or no apparent cause. The condition is caused by a genetic defect that affects the body’s production of collagen. A person with osteogeneis imperfecta has either less collagen or a poorer quality of collagen than normal—leading to brittle bones.

In an inpatient situation, the child is frequently isolated and reassessed with radiographs to determine the actual diagnosis. In the diagnosis of abuse, a babygram—a one- or two-film total body study—is sometimes used. A more comprehensive skeletal survey, including films consistent with usual trauma exams, will provide a more precise study.

Modalities other than diagnostic x-rays are often employed in the diagnosis of abuse. A CT scan of the head is good for evaluating acute hemorrhage, MRIs can verify epiphyseal separations, and sonography is used through the anterior fontanelle to assess long-term consequences of head injury but is best used with CT and/or MRI. Many traumas not associated with bone should be addressed in the same manner as accidental traumas.

Each year in the United States, 1 million children are reported as abused, according to child wellness experts at the Nemours Foundation (www.kidshealth.org). The actual count could be much higher, but many children are afraid to report their abuser—1,000 to 1,300 children die as a result of physical abuse. Survivors frequently have emotional issues that can affect all aspects of life long after physical wounds have healed.

Healthcare workers, like many professionals, are mandated to report child abuse. Other professions bound by law to report abuse include school personnel, child care providers, social workers, law enforcement officers, and mental health professionals.

State Laws
According to Ethical and Legal Issues for Imaging Professionals by Doreen Townsley-Cook and Theresa A. Young, “State public health laws require medical professionals and institutions to report a variety of medical conditions and incidents, including … abuse of children, elderly people, and people with disabilities. The justification for overriding patient confidentiality is the state’s interest in protecting public health. The statutory duty to report certain medical conditions or incidents may extend to the imaging professional. Because laws vary state to state, imaging professionals should seek legal counsel at their institutions regarding conditions or incidents that must be statutorily reported.”

Each state has its own child abuse laws and rules related to reporting child abuse. Some states mandate all citizens as reporters of child abuse. Checking for your state’s rules can be as simple as going to the Administration for Children and Families Web site (www.acf.dhhs.gov), which maintains a database of state requirements at http://nccanch.acf.hhs.gov/general/legal/statutes/sag/allsearch.cfm. If your state is not listed or the suspected abuse took place outside your state, you can use the Childhelp USA National Child Abuse Hotline at 800-4-A-CHILD (800-422-4453; Telecommunication Device for the Deaf: 800-2-A-CHILD).

But Britt reiterates that the first step is that “abuse should be reported by whatever method has been laid out by your department.” If there is no policy in place, report suspicions to a supervisor, radiologist, or attending physician. If you are alone at night in a hospital radiology department, consult with the emergency physician. The hotline number is also a course of action.

The ASRT’s Professional Performance Standards include several items relevant to reporting. The introduction states, “Professionals who use the standards must be aware of state and federal laws affecting their practice as well as institutional guidelines.” Additionally, Standard One, Quality, general criteria state, “The practitioner … Adheres to the accepted standards, policies and procedures adopted by the profession and regulated by law.” Professional Performance Standards, Standard Five, Ethics, state, “The practitioner … Acts as a patient advocate to support patients’ rights.” The Code of Ethics, number 5, states, “The radiologic technologist assesses situations, exercises care, discretion and judgment, assumes responsibility for professional decisions, and acts in the best interest of the patient.”

Your Responsibility
Collectively, these criteria indicate a duty to report suspected child abuse and to do so according to the state laws where the practitioner works, according to Lisa Taute, media relations manager for the ASRT.

Be a responsible practitioner and follow your instincts and the law. Your facility’s reporting protocols are your first step. Try to make a notification before the patient leaves the building. Make sure you understand your obligation under your state laws if your facility doesn’t have a policy—most certainly do have a policy. If not, consider engaging an employment law attorney to assist you. Be kind, compassionate, and smart in doing what’s right.

— Janet Needham, RT(R), is a veteran radiographer and freelance writer living in New Albany, Ind.

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