Physicians and medical neglect: variables that affect reporting

Revisiting medical neglect concerns in children with life-threatening complex chronic conditions

BACKGROUND/OBJECTIVES

Life-Threatening Complex Chronic Conditions (LT-CCCs) increase the complexity of medical neglect concerns. Clinicians' perspectives are central in concerns for medical neglect, yet little is currently known regarding clinicians' understanding of and approach to these situations. We explored how clinicians who care for children with LT-CCCs understand medical neglect.

METHODS

We conducted a semi-structured qualitative interview study with 20 clinicians of varying disciplines from critical, palliative, and complex care services about medical neglect in children with LT-CCCs. We used inductive thematic analysis to generate themes.

RESULTS

Three primary themes emerged: Relationship between family and medical community, family overwhelmed with medical demands, and insufficient support. Taken together these themes suggest that concerns for medical neglect are directly related to clinician perception of family inability to meet medical needs.

CONCLUSION

Clinicians report that concerns for medical neglect in children with LT-CCCs often arise from a mismatch of medical expectations and the perception of familial ability to provide said medical care. Given the complex and delicate medical and psychosocial environments of care for children with LT-CCCs, these medical neglect concerns are more accurately described as Medical Insufficiency, a new term. By reframing this entity, we can reframe the dialogue surrounding this issue, and reconsider approaches to studying, preventing, and resolving it.

Health Care Providers' Perspectives on COVID-19 and Medical Neglect in Children with Life-Threatening Complex Chronic Conditions

PURPOSE

Little is known regarding medical neglect in children with Life-Threatening Complex Chronic Conditions (LT-CCCs). We examined the impact of COVID-19 on concern for medical neglect in this population.

METHODS

Qualitative interview study of multi-disciplinary health care providers (HCPs) from critical care, palliative care, and complex care services on the topic of medical neglect in children with LT-CCCs. We used inductive thematic analysis to generate themes. Findings presented herein are derived from a sub-analysis of the larger study that focused specifically on discussion of COVID-19 by HCPs.

RESULTS

9 of the 20 HCPs interviewed mentioned COVID-19 as influencing situations of potential medical neglect. These 9 represent all disciplines and teams. Interviewees reported COVID-19 increased burden on parents and likelihood of medical neglect due to: 1) Familial distancing from medical and social support and, 2) Changes to medical care delivery that impaired the medical community's ability to engage and support families.

CONCLUSIONS

The COVID-19 pandemic has exposed the fragility of the medical and social systems that supports families of children with LT-CCCs. These findings are consistent with previous literature that suggest that the COVID-19 pandemic has increased the risk for child maltreatment. It additionally highlights the vulnerability of this patient population.

Factors related to medical neglect recurrence and foster care and adoption services

BACKGROUND

Medical neglect is defined as the failure of a caretaker to heed obvious signs of serious illness, to seek medical care in a timely fashion, or to follow instructions once medical advice is obtained. It is reportable as a form of child maltreatment.

OBJECTIVES

(1) identify factors associated with referrals after medical neglect to adoption and foster care services; (2) describe a cohort of children with first-time cases; and (3) assess whether there were factors associated with recurrence.

PARTICIPANTS AND SETTING

Data from the National Child Abuse and Neglect Data System for 36 U.S. states.

METHODS

A cohort of children was constructed with first confirmed reports of medical neglect in 2012 with matched confirmed reports during 2012-2017 to describe child, family, offender, and report factors associated with recurrence. These factors were then used in multivariate models, including logistic regression and Cox proportional hazard models, to assess their effects on recurrence and with referral to foster care and adoption services.

RESULTS

Complex family problems were associated with referral for foster care and adoption services, and 8.1% had recurrence within 5 years. Older children with medical problems, Black race, or who were reported by medical or legal personnel had increased risk for recurrence. Only referral to mental health care services was found to decrease this risk.

CONCLUSIONS

Medical neglect recurs within 5 years despite referrals to most services. Those trying to stop its recurrence should focus on mental health needs and families with children who are older, Black, or have complex medical problems.

Characteristics of Children Reported to Child Protective Services for Medical Neglect

OBJECTIVES

Medical neglect can have serious consequences. There is little evidence base to guide medical neglect management and research. Our objective was to describe a group of children reported to child protective services (CPS) for medical neglect to define this population as well as identify prevention and intervention approaches.

METHODS

This was a retrospective descriptive study of all patients at a pediatric hospital reported to CPS for medical neglect over a 6-year period. Data about health, health care, CPS involvement, and social history were obtained through medical record review.

RESULTS

Of the 154 patients reported for medical neglect, 140 (91%) had chronic illness. The most common diagnoses were type 1 diabetes, organ transplantation, and prematurity-related conditions. Most patients (83%) were black or Hispanic and 90% were publically insured. More than half of patients (54%) had >1 CPS report during the study period. Almost all patients (88%) returned to the hospital for care subsequent to the medical neglect report. Risk factors for child maltreatment, family stressors in the year preceding the report, and practical barriers to care were documented in more than two-thirds of patients.

CONCLUSIONS

Overall, children reported for medical neglect have serious chronic medical conditions. There is need and opportunity for improved interventions. Avenues for future study include interventions tailored to the underlying diagnosis, racial/ethnic disparities, effectiveness of CPS interventions, and targeted prevention for at-risk families with medically complex children.

Religion-Related Child Maltreatment: A Profile of Cases Encountered by Legal and Social Service Agencies

Religion can foster, facilitate, and be used to justify child maltreatment. Yet religion-related child abuse and neglect have received little attention from social scientists. We examined 249 cases of religion-related child maltreatment reported to social service agencies, police departments, and prosecutors' offices nationwide. We focused on cases involving maltreatment perpetrated by persons with religious authority, such as ministers and priests; the withholding of medical care for religious reasons; and abusive attempts to rid a child of supposed evil. By providing a descriptive statistical profile of the major features of these cases, we illustrate how these varieties of religion-related child maltreatment occur, who the victims and perpetrators are, and how religion-related child abuse and neglect are reported and processed by the social service and criminal justice systems. We end with a call for greater research attention to these important offenses against children.

Medical neglect

Medical neglect occurs when children are harmed or placed at significant risk of harm by gaps in their medical care. This is most likely to occur and to be recognized when families lack resources, commonly due to poverty, and when medical demands are high, such as with complex, severe, and chronic illness. A systematic evaluation of the probabilities for harm from gaps in care versus benefits from improved care will define medical neglect. A broad consideration of child, family, community, and medical system contributions to identified gaps will guide management. Special circumstances, such as lapsed immunizations, unremitting obesity, and medically motivated alterations in care, are often challenging for medical providers. Guidance for these specific situations is available from the American Academy of Pediatrics, and from the medical literature.

A standardized method of diplomatically and effectively reporting child abuse to state authorities. A controlled evaluation

Although many studies have examined issues relevant to reporting child maltreatment to state authorities, empirical evaluation of intervention programs to assist professionals in reporting child abuse is lacking. In the present study, a medical student was taught to perform a standardized behavioral method of reporting child abuse that incorporates nonperpetrating caregivers of child abuse victims in the reporting process. A controlled multiple baseline across behaviors (i.e., initiating child abuse report, responding to upset) experimental design was utilized to evaluate skills acquisition. Improvements in interpersonal skills related to reporting child abuse were demonstrated consequent to intervention. Future directions are discussed in light of these results.

"You are hereby commanded to appear": pediatrician subpoena and court appearance in child maltreatment

OBJECTIVE

To determine the frequency of court appearance by pediatricians evaluating child abuse and neglect cases and to identify case characteristics associated with actual court appearance or case adjournment.

DESIGN

Retrospective review of subpoenas received between 1995 and 1999 for child maltreatment cases personally evaluated by 2 pediatricians during the years 1995 to 1998. Information was collected regarding patient age, gender, race/ethnicity, type of suspected maltreatment, date of evaluation, date of subpoena, type of court hearing, whether the pediatrician actually testified in court, and legal outcomes. Case characteristics were compared between pediatricians and were used to predict physician appearance and case continuance or adjournment in logistic regression models.

RESULTS

Four hundred forty-five subpoenas concerning 260 patients were received. Although significant differences were noted between the pediatricians in type of abuse, no differences were found in patient age, gender, ethnicity or legal outcomes. The pediatricians received subpoenas in <15% of child maltreatment cases, and <5% of children seen resulted in the physician being required to actually appear in court. No case characteristics significantly predicted court appearance or case continuance or adjournment.

CONCLUSIONS

Although pediatricians are sometimes subpoenaed to appear in court to explain the medical evaluation and the needs of the child in cases of child abuse and neglect, most court cases were continued, adjourned, or settled before physician testimony. Most subpoenas did not result in the pediatrician going to court, and it is unclear which child factors may predict court involvement. Pediatricians can take steps to minimize (but not eliminate) the potential dissatisfaction and inconvenience associated with receiving and responding to subpoenas in child maltreatment cases.