Download Case: Non-accidental Child Injury Fall 2014 Interprofessional

Case: Non-accidental Child Injury
Fall 2014 Interprofessional Education Colloquium
Lucas is a 7-year-old boy who is brought in to your emergency room for a broken arm.
The intake triage nurse takes his vital signs and notes that his mother’s chief complaint
is “he fell off the picnic table.” Lucas does not answer any questions, but he is holding
his misshapen arm in obvious pain. He is not crying, nor is he making any eye contact.
The Emergency Center (EC) resident comes in for an assessment, and Lucas still does
not talk. Mother provides the following history:
Presenting complaint: Lucas fell off a picnic table while they were playing at the park
afterschool. She brought him to his pediatrician, who sent them to the EC. He was not
ill prior to this event, and he has never broken a bone or been to the EC previously.
She notes he is in pain, but has not noted any bleeding or loss of consciousness.
Medical History: no surgeries, remote history of asthma, no history of traumatic brain
injury.
Allergies: No known drug allergies.
Psychiatric History: his pediatrician diagnosed him with ADHD (Attention Deficit
Hyperactivity Disorder) at 3-years-old because of extreme hyperactivity, impulsivity, and
dangerous behaviors (running into street, unable to follow directions). He could not
swallow pills, so he was tried on Adderall XR sprinkles with no effect as dose was
titrated from 5 mg to 20 mg/day, at which time the medication was stopped due to
picking at his finger nails. He is currently on Daytrana Patch as he still does not
swallow pills. At 6-years-old, his pediatrician added Depakene syrup for bipolar
disorder. Mother reports that at the time, and prior to starting Depakene, Lucas was full
of “rage” and would have extreme mood swings, he would not go to bed and he would
wake up during the night and not be able to go back to sleep.
Developmental history: former full term spontaneous vaginal delivery without
complications. Mother reports that Lucas has always been a “difficult” child. He was
difficult to soothe and colicky as a baby, but he met all milestones on time. His gross
motor skills were advanced, and he was fearless. He fell a lot.
Family history: mother reports nothing is known of biological father’s history, her
mother has diabetes
Social history: he lives with mother and two younger half-siblings (4 and 2-year-old
sisters). His father and mother broke up before he was born, and they were never
married. She lived with the father of his sisters from when he was one to last year. She
is currently unemployed, and they live on inconsistent child support and WIC, TANF,
and SNAP benefits. The children have Medicaid insurance. Lucas is in 1st grade and
is struggling with reading and handwriting.
Updated: Nov. 3, 2014
Physical examination: He does permit the doctor to do a limited physical exam, but he
is in obvious pain. The doctor orders an x-ray of his arm (see films). The doctor returns
and explains the findings to mother, and that they need to set the arm and repeat the xray. The team sends mother to the waiting room while they set the arm. Lucas is given
(ketamine), and he does not flinch when the nurse starts his IV. The doctor sets and
wraps Lucas’ arm, and then repeats the x-ray to confirm it is set. While Lucas is
sedated, he notes an odd pattern of bruises on Lucas’ torso and back that were not
noticeable when he was guarding against exam. Radiology notes the evidence of old,
healed fractures on Lucas’ proximal humorous.
The resident returns to the room to discuss the findings of the healed fracture on x-ray
and bruises. Mother reports that she has already explained that Lucas is very accident
prone, and he has always been hyperactive. She states he has bruised easily since he
was started on Depakene. She reports there is no abuse and never has been, and she
does not know why there is a problem on the x-ray. The resident leaves the room and
pages social work to assist with a Child Protective Services (CPS) report, and asks how
they should manage the mother at this point. Lucas is still sedated from the ketamine,
and he is not ready for discharge medically.
One week later
Lucas is brought to the child abuse clinic for medical and psychiatric assessment. He
has been placed, along with his half-sisters, with their paternal aunt. The psychiatrist
interviews them together, and the aunt reports that he has been fine while in her home.
He is very quiet, but he does all of his own activities of daily living. He is eating and
sleeping well, although twice he has woken up during the night screaming but is able to
be soothed back to sleep after about 15 minutes. He does not seek out physical
comfort, and he is very self-sufficient, except for the activities where he needs help
because his arm is in the cast. He plays by himself, drawing or reading, and he does
not join the aunt’s older children when they play outside. She says she is concerned
because he doesn’t ask for his mother like the girls do. She has not enrolled him in
school, and she is not sure how to do that. She was also not given any of his
medications, so he has not taken either medicine since the hospital. She did not know
him other than occasionally seeing him at some family parties, so she does not know
anything about his prior history.
The psychiatrist interviews him, and he draws the whole time they talk. He will not draw
a picture of his family, but he will draw a picture of his dog who was left behind with his
mother. He does tell you that he has only seen his mother once since the hospital, and
that was at the CPS office for a supervised visit. When asked about the visit, he says
he is very scared that she will hurt him again. When asked how he broke his arm, he
says “my mommy hurt me.” His speech is quiet and soft, but he is intelligible. He
makes poor eye contact, and his affect is restricted. When asked his mood, he shrugs
his shoulders. When asked the worst thing about being taken out of the home, he says
he misses his dog. When asked the best thing, he says his mommy can’t hurt him.
Updated: Nov. 3, 2014
The child abuse pediatrician examines him, and documents his multiple skin marks. She
also notes that Lucas is very reserved, only talking when spoken to. Apart from his
physical injuries, his examination is normal.
QUESTIONS FOR DISCUSSION
Clinical (medical/dental/nursing):
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What risk factors for abuse does this family have?
What would have been useful to include from the initial interview?
What findings were most concerning for abuse? Address physical, psychological,
and social factors.
What are some side effects of the medications or treatments for ADHD (physical,
oral, psychosocial)?
What are some interdisciplinary approaches to managing children with ADHD? Child
abuse?
His aunt is concerned that he does not ask for his mother. What are some typical
reactions of latency-aged children who have been abused? Is this a normal
reaction? What advice or education would you give her?
What do you make of Lucas bluntly stating that he is afraid his mother will hurt him
again?
How would you address his psychiatric diagnoses and past medications?
Ethics
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What is the duty to report child abuse? When does it take effect in a given
case? Which health care professionals does it apply to?
Do you consider the mother a second patient? If so, where do you refer her or how
would you address that?
What should be done if the person first taking responsibility for the child proves
inadequate to the role?
Bioinformatics
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Do you think the clinician is using a paper or an electronic health record in recording
clinical findings?
What are issues in using a paper medical record?
How would those issues be mitigated using an EHR?
How would using an EHR improve medication reconciliation?
What are issues of interoperability with other agencies such as the health
department, child protective services?
Describe how e-prescribing the prescribing process?
Updated: Nov. 3, 2014
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How would decision support help clinicians improve patient care? Suggest a rule
that could be created to help the clinician.
What are issues of privacy and security of health information?
How would the use of an EHR improve privacy and security of health information?
What are the potential errors or risks using E HR?
Research
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What are some research questions that could help reduce/prevent child abuse?
What are some research questions (or potential interventions) that could help Lucas
recover from this abuse?
What might be some challenges to enrolling Lucas in a research study?
o which adult should provide informed consent?
How might biomedical research be used to reduce or better diagnose/identify child
abuse?
How might implementation and dissemination research be used to reduce or better
diagnose/identify child abuse?
Public Health
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Discuss some ways to address child abuse in our community.
Discuss the public health implications of child abuse.
LESSONS LEARNED
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What did you learn from working with students from a different discipline?
What areas of knowledge or skills were you surprised to know or not know how to
do? How would you set up the patient encounter differently after you know how the
case turned out?
Acknowledgement: This case was developed by Dawnelle Schatte, MD, Associate Professor,
Dept. of Psychiatry & Behavioral Sciences, University of Texas Medical School.
Updated: Nov. 3, 2014