Look for clinical presentations, behavioral clues in possible child abuse cases

Issue: December 2001

It may be a routine eye examination for school, or a child may be in the optometrist’s chair because of lid ecchymosis or a subconjunctival hemorrhage. Whatever the reason for the child’s visit, the doctor notices a few unusual things: the child seems unusually quiet, seemingly afraid to talk, with the parents often answering for him or her. In addition, there are a few unusual marks, such as bruises littering the exposed flesh of the child’s arms. A red flag goes up, causing the doctor to suddenly wonder: could this be a case of child abuse?

Child abuse is probably not on the minds of most optometrists when they ready their exam chair for their next patient. However, in 1996, approximately 3.1 million children were reported to Child Protective Services as alleged victims of maltreatment. In fact, reports of child abuse have been on the rise, as the total number of reports nationwide has grown 45% since 1987 (National Committee for the Prevention of Child Abuse 1996 Annual Fifty State Survey). Therefore, whether a child presents with ocular symptoms that may reflect abuse or has simply come in for his or her annual eye exam, an optometrist may be more likely than he or she realizes to encounter a victim of child abuse.

“Those are just the cases that were reported,” said Pamela J. Miller, OD, FAAO, JD, in practice in Highland, Calif. “Who knows how many go unreported? Those are staggering numbers when you stop and think about it. Many of these children never even get into the eye doctor’s office.”

Clinical presentations

One of the clinical presentations consistent with child abuse that an optometrist may encounter is that of shaken baby syndrome. When the child is shaken, the head moves back and forth very quickly, often resulting in hemorrhaging, said Michael Bartiss, OD, MD, in private solo practice in Pinehurst, N.C. “You can get hemorrhages in the brain itself, as well as in the retina, either because the baby is being held by the arms and shaken or thrown onto a bed,” he told Primary Care Optometry News. “That’s the most common clinical presentation that will show up in an optometrist’s or ophthalmologist’s office.”

Shaken baby syndrome is often seen in an emergency room setting, said Dr. Miller, and may not be noted at all in the optometric office. Optometrists should look for unexplained injuries in children, she said, including the sudden onset of blurred or double vision that is not accounted for. “Be aware of such things as unexplained burns, bites, bruises, broken bones and black eyes. Fingerprint bruises are also a good indication; it’s a lot different from a single bruise from just falling down.”

Look at the child’s whole appearance for signs of “disorder,” Dr. Miller suggested. For instance, a child who often comes in with broken glasses may be a cause for concern. “You don’t want to leap to the conclusion that there’s child abuse going on; it may just be that the child doesn’t want to wear glasses,” she said. “But a lot of times, you may actually see the physical imprint of the glasses from impact on the child’s face. Is the child having dental problems? Is he or she losing teeth when it’s not normal for that age, or is there a lack of hair? If you’re looking at the visual system, you’re looking for things that are out of order.”

Sometimes just the opposite is true — burn marks or bruises may not be evident due to the fact that the child may be covered up by long sleeves and pants even on an extremely hot day, Dr. Miller said.

Signs of neglect

Often, the “abuse” presents in an entirely different way. Rather than the child showing signs of direct abuse from beatings or burns, he or she may be the victim of neglect. “It’s not always physical abuse, but rather the child being neglected, when he or she comes in and obviously hasn’t been bathed in a very long time,” Dr. Bartiss said. “The child may be wearing dirty clothes and smell bad. You wonder what kind of care the child is getting. If a family is too poor to provide basic care, we need to find out.”

In this instance, the optometrist can help the family access the services that are available to them to help improve the quality of their – and their children’s – lives. “However, we can’t jump to conclusions,” he said. “You have to find out the facts before you come to the conclusion that these are terrible parents. Sometimes they’re not; there are things beyond their control, and it’s just a very complex family dynamic. But certainly, there’s no question that if the child ends up being a victim of this, intervention is required.”

Behavioral clues

Studying the child’s, as well as the parents’, behavior also factors into the overall picture when trying to determine an abuse case. Barbara Anan Kogan, OD, said that this could manifest in several different ways. “You have to look at how the patient is breathing, if it’s labored,” she said. “See if the person is breaking out into a cold sweat or if he or she has the chills – flu-like symptoms. Also, see if speech is affected. Is the child really quiet? Is the speech slurred, or is he or she stuttering? Is the child absolutely afraid to talk, whispering instead?”

It is also important to gauge the parents’ reaction, because they often accompany the child into the exam room, Dr. Miller said. “Sometimes you will see a situation where a parent is incredibly overprotective and will not let that child out of his or her sight at all,” she said. “That’s a difficult one to determine, because if this is the first time the child has had his or her eyes examined, the child may be a little frightened. So you have to look at the age of the child. In my office, we always invite the parent to come in during the exam. I think a fair amount of experience helps, because you know what is normal and what isn’t.”

She also said to watch for parents who have inappropriate reactions – or overreactions – when a child misbehaves. “Most parents might give a time-out for a negative behavior; they don’t just strike the child,” she said.

The optometrist can offhandedly ask the parents about a child’s injury and gauge their reaction and response, said Dr. Bartiss. “You want to elicit information; you don’t want to be accusatory,” he said. “These sort of things may be happening in day care, which unfortunately has been known to happen and is not the parents’ fault at all. The best thing to say is: ‘What happened here?’ And if they don’t give you an answer, say they don’t know, say ‘Oh, that happens all the time’ or something else that just doesn’t sound right or doesn’t fit with the clinical presentation, then you need to investigate further and contact the primary care physician or social services.”

Talk to the child

Because the parents are often in the room during the child’s exam, it may be difficult to take the child aside and ask about injuries. The child’s response may also depend on the age, said Dr. Bartiss. “Sometimes, the demeanor of a child will give you some clues,” he said. “If you ask probing questions, and a child makes furtive glances over at Mom and Dad, it may raise a bit more of a suspicion.”

The practitioner must realize that going this route may ultimately backfire, said Dr. Miller, as children naturally will want to protect their parents. “We are not licensed psychologists or psychiatrists; our training simply does not include that,” she stated. “You can get yourself into very serious trouble if you try to separate the child from his or her parents and, in essence, make the child turn on the parents. You have to remember that the child goes home with them. You also have to remember that, from a psychological point of view, if a child decides to tell you something, he or she is not thinking that he or she will be safe but rather that you’re going to take the parents away.”

The practitioner, as well, does not want to alert the parents that he or she has any suspicions about the origins of the child’s injuries. “The most important thing is playing it cool, for the sakes of both the child and the parent,” said Dr. Kogan. “If you give a heads-up to the parent, he or she might leave with the child before the exam is over.”

Dr. Miller agreed. “The last thing you want to do is put the parent on alert,” she said. “It is inappropriate to ask if a parent is abusing a child. You certainly can say to the child that he or she has a lot of bruises and ask how they got there. Because there are medical problems where a child breaks bones and bruises very easily, you will have parents who have been wrongly accused.”

If the child does happen to offer any information, though, “don’t ever promise not to tell,” stressed Dr. Miller.

Contacting the pediatrician

After seeing a child who is a suspected victim of abuse, the practitioner may then want to contact the child’s pediatrician to get a second opinion on the situation, said Dr. Bartiss. “You have to take the whole picture into account,” he said. “That’s why the primary care physician, who has seen this child since he or she was an infant, is probably the best person to contact. He or she has a much better picture long-term and has seen the child on many more occasions than the eye doctor has.”

Or it may happen in reverse – the pediatrician sends a child to the eye practitioner to secure a second opinion, Dr. Bartiss added. “Sometimes I will see children who have been sent by a pediatrician, for example, who says that he or she suspects abuse and asks if I could look for any ocular problems that support that diagnosis,” he said. “Sometimes there are, and sometimes there aren’t. It happens just as often that way as the other way around.”

Follow-up visit

Having the child come back for a follow-up visit is another option for monitoring the situation, said Dr. Miller. Allowing 2 weeks to elapse before another visit may help answer any questions the practitioner has regarding the child’s condition in terms of the child’s appearance or behavior. “Now, the argument is, the child could be killed in that 2 weeks,” she said. “On the other hand, it’s an opportunity, because you now have established a rapport with that child, and it gives you the opportunity to compare what you saw the first time. On that second visit, the rapport with the child should be considerably improved.”

However, some practitioners maintain that waiting could potentially endanger the child’s life. “I would do something the first time, because you want to try to do what you can to prevent a second occurrence,” said Dr. Kogan. “You want to try to ensure that this parent doesn’t do something that will fatally injure the child – that’s the worst-case scenario.”

Privacy issues

The optometrist may take other avenues in trying to determine whether or not a child has been abused – such as contacting the school nurse, the child’s teacher, the principal or even the dentist – but you must be careful who you contact so that a family’s privacy is not compromised, doctors warn. “One of the problems is the privacy issue,” said Dr. Miller. “You have to balance the privacy – the child’s and the parents’ – vs. the need, as it were. They have an absolute right to privacy. On the other hand, if it’s suspected child abuse, that overrides the right-to-privacy issue.”

Teachers have an obligation to report suspected child abuse, said Dr. Miller, so you must be aware that by contacting them they are being placed on alert – and the parents are also possibly being alerted to what’s going on. However, the teacher sees the child every day and could probably easily document how often the child is coming in with bruises, as well as how often he or she misses school, she said.

If the optometrist chooses to contact the pediatrician, however, the conversation is usually kept between the two doctors, said Dr. Bartiss. If the pediatrician does not have any existing suspicions, conferring with the eye doctor about his or her findings will usually result in the physician following up with an appointment to see the child, he said.

“Each practitioner must be aware of the state’s regulations,” he said. “Most regulations are written to err on the side of protecting the child. They’d rather investigate and find out everything’s OK than the other way around.”

Moral, legal obligation

If the optometrist has observed some questionable features about the child’s appearance or behavior and feels strongly that abuse may be occurring, he or she should absolutely contact social services, the doctors agreed. “You’re obligated by law to report cases of suspected child abuse in most states,” said Dr. Miller. “So you have doctors who are basically untrained in recognizing abusive situations, whether child abuse or elder abuse, who are now legally obligated to report it. There is virtually no education for the optometric arena. They’re totally uneducated in this area, and yet they’re held to this standard, which is pretty amazing when you think about it.”

Optometrists should proceed cautiously when dealing with a case of suspected abuse, Dr. Miller said, for the sakes of their careers as well as the life of the family that is involved. “The optometrist is basically breaking new ground, as this is not very widely covered by the optometric press,” she said. “So you don’t want to be the test case. Basically, the law protects the doctor who reports cases of suspected abuse. The assumption is that you’re reporting that in good faith. The reality is, if you make a mistake, you have now jeopardized the quality of life for that child and the parents, because you put a cloud of suspicion upon that parent that he or she can never escape from.”

The doctor’s primary obligation is a moral one, said Dr. Bartiss, and the secondary obligation is legal. Documentation is key, he noted.

“Document, document, document,” he stressed. “Document in your chart whom you talked to and keep copies of any letters that you sent. If you contacted social services, record whom you talked to and what the plan is. Keeping things coordinated with either the family doctor or the primary care physician is critical. As a medical community, we work together for the welfare of a child; we have to make sure the left hand knows what the right hand is doing.”

If the doctor does not receive a response after a period of time, Dr. Bartiss suggested, place a follow-up call to social services regarding the first inquiry, requesting an evaluation of the child’s home environment. “I think that’s a very reasonable thing to do,” he said.

Difficult to prove negligence

Proving that the optometrist was negligent in failing to recognize child abuse would likely be a very complicated task, said Dr. Miller. “I think it would be very difficult,” she said. “That’s part of the irony of the law — you’re being held accountable for something that you received no training in. Inadvertently, you could break the law. You can certainly try to elicit information with the case history or while you’re talking with that child and with the parent. And if you suspect something, go back, revisit that issue, have the child return to the office and you may confirm some of your suspicions.”

For a doctor to be negligent, it would have to be proven that he or she knew or should have known that abuse was taking place — something that would be obvious to virtually all optometrists, she said. By and large, the courts will not punish a doctor for not reporting a case, Dr. Miller said, just as they do not punish a practitioner for reporting something that is unfounded — unless the doctor knew or should have known and was under a legal duty (or obligation) to report. She noted that there is a fine line between reporting when it’s appropriate and when it’s not.

“By the same token, if you have a doctor who is reporting a significant number of child abuse cases, particularly if they’re unfounded, there are probably problems with that doctor,” she said. “Then that might be disciplined by the state board. But that’s a whole other issue; that is a doctor who probably has some very big problems of his or her own.”

Go on experience, gut instinct

When observing a child who may have been abused, practitioners agree that one’s gut instinct counts for a lot. And more often than not, that is something that often comes with experience. “I think a lot of it is basic feeling, and a lot of it is based on your personal experience,” said Dr. Miller. “The doctor who’s only been in practice for 6 months or a year will have a much more difficult time, because you’re looking for a number of things: what you normally see and what other types of problems the patient is having. It’s very difficult for a newly licensed practitioner to develop a feel for what is normal and what is not. This is the rather nebulous area to really give specifics on.”

Conversely, what is considered to be abuse today may not have fallen under that category years ago and, therefore, may not seem strange to the older optometrist, said Dr. Kogan. “Years ago, when I was growing up, if your parents hit you, it wasn’t called child abuse,” she said. “The teachers were allowed to hit you if you didn’t behave in school. Today, things have changed, and some older doctors are not in the frame of mind to identify child abuse.”

It is important to raise awareness in the optometric community about child abuse, said Dr. Bartiss, because all doctors have a professional obligation. “I don’t think that it is the primary care ophthalmologist’s or optometrist’s job to determine whether or not the child has been abused,” he said. “What you can do is help to find cases where it has happened, get it investigated and then have an intervention. Unfortunately, it happens far more often than any of us would like to believe.”

For Your Information:

Pamela J. Miller, OD, FAAO, JD, may be contacted at 6836 Palm Ave., Highland, CA 92346-2513; (909) 862-4053; e-mail: drpam@omnivision.com.

Michael Bartiss, OD, MD, a member of the Primary Care Optometry News Editorial Board, is in private practice. He may be reached at Family Eye Care of the Carolinas, 5 Regional Circle, Ste. A, Pinehurst, NC 28374; (910) 235-3700; fax: (910) 235-4447;e-mail: kidseyes@earthlink.net.

Barbara Anan Kogan, OD, may be reached at 4501 Connecticut Ave. NW, Ste. 102, Washington, DC 20008-3711; (202) 244-1324; fax: (202) 244-1324; e-mail: bakogan@mindspring.com.