Tuesday, April 26, 2011

Wrongly Accused

The abuse of children at the hands of their parents is a tragic reality that all pediatricians confront at some point in their careers. I have had to serve as an expert witness in a trial where a young girl contracted gonorrhea when her father raped her, and in a military court martial in which a 4 month old baby had her leg broken by her father, who happened to serve in one of the branches of the military. In the last two decades there has been a strong move to train pediatricians, and other professionals that deal with children, in recognizing evidence of child abuse, and to suspect the possibility of foul play in any instance where injuries or symptoms seem unexplainable.

Unfortunately, this renewed effort can lead to false accusations when the individual that raises the question of child abuse lacks the knowledge and skills necessary to confirm or dismiss the suspicion. I have seen two children in the past month, whose parents were wrongly suspected of abuse, not because of a preponderance of evidence but as a result of simple ignorance on the accuser's part.

The first child was a boy that for the last two years has been incontinent of stool. At school and at home, the child defecates in his underwear, apparently unable or unaware of the passage of stool. A teacher referred him to a school psychologist who sent the family for counseling. Despite this, the child continued having problems. The principal then got involved, accusing the family of sexually abusing the child. The child's pediatrician was apparently Missing In Action, going along with the recommendation for counseling, but not offering any additional advice. The child was finally brought to the Emergency Department when the mom was threatened by the principal that if the child was not examined immediately for sexual abuse, she would notify the police.

The child turned out to have severe constipation leading to encopresis: the spontaneous seepage of stool. This is the most common cause of incontinence of stool in children of this age, yet this child had not received the care he needed. The family spent countless hours in needless counseling and faced intense pressure from a host of professionals that failed this child.

The second child I saw was a 6 year old girl who had started with intense anal itching, that then spread to vaginal itching. She was seen by her pediatrician who immediately suspected child abuse. No further investigation into other possible causes of vaginal symptoms was sought. After one month of excruciating itching, with the family being investigated for possible abuse, the child came to the ER where she was found to have pinworms.

What is stunning in both cases is that these children had very common conditions, but immediately, almost reflexively, symptoms that involved the anus and genitals were deemed to be indicative of abuse. Thereafter, all thinking came to a halt. In my book, I discuss the case of a child whose parents were accused of abusing their child who ended up having a life-threatening disease.

Pediatricians should be ever vigilant of the possible abuse of children, but we should approach this possibility as we would any other problem in medicine; thinking of alternative explanations of the symptoms, analyzing all evidence objectively, re-thinking our initial impressions, and keeping an open mind. None of this is possible if we latch onto a judgment in a knee-jerk fashion, and if we don't have the knowledge to recognize rational explanations for the symptoms presented.

We have a duty to protect children from harm. But we also have a responsibility to exercise diligence in our practice. Otherwise, it is we physicians who end up harming the families we care for.

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