AndrewSirotnak, MD, FAAP, Pediatrics in Review Editorial Board
Child maltreatment is a challenging issue to address in the office or hospital setting,
and children with special health care needs and disabilities can be at higher risk
for maltreatment. Just as importantly, they also are at higher risk for injuries that
can happen during routine care, for example, because of immobility and osteopenia,
or bleeding abnormalities due to the adverse effects of chronic medications on liver
The October issue of Pediatrics in Review includes a wonderful review, “Child Abuse in Children and Youth with Special health Care Needs,” by Drs. Brodie, McColgan, Spector and Turchi. It highlights the vital role that
the primary care physician plays for special needs children and their families: Providing
a trusted medical home, ensuring access to general and subspecialty care, and advocating
for access to community-based services and, of course, financial coverage for medical
and behavioral services across the life span.
This is an important review that highlights a number of educational gaps and provides a number of resources for
the primary care provider. What stands out in this review for our readers and young
physicians and trainees? I will highlight two key points here.
For example, there are bruising patterns that may raise concerns for physical abuse.
Sentinel injury literature reminds us that bruising over soft tissue surfaces, head,
neck, face, and torso must be evaluated carefully for the possibility of inflicted
injury, which often can occur in the context of frustration during care or discipline.
A number of years ago, in collaboration with the parent of a child with autism spectrum
disorder, I helped create a community-based educational video on self-injurious behavior
(SIB). As a child abuse pediatrician, I rarely get consulted on children with disabilities
and physical abuse injuries, but from working with this parent I learned firsthand
how challenging behaviors may lead to frustration on the part of a caregiver and harm
for the child. We often forget these children may be in the care of babysitters, residential
treatment facilities, or respite placements—caregivers who may not know the child
or be able to cope with the behaviors as well as the child’s parents.
Second, making this video reminded me of the important partnership between parents
of a special needs child and their medical home pediatrician. Practical office-based
suggestions include making sure SIB is on the problem list, with examples of the specific
injury patterns; placing photos in the chart to document injury; and developing a
short explanatory letter that could be in the record as a flag or “FYI” regarding
the need to be aware of SIB as a presentation for injuries.
Advocating for health, welfare and safety for children with disabilities or special
health care needs is inherent to our makeup as pediatricians and includes ensuring
the child is safe from abuse and/or neglect. As AAP members, we have a wealth of resources
for this task. Check out the practiceresources and parentingresources from the AAP, listed at the end of the review, as well as the teaching slides that accompany this worthwhile article.