Home Forums Discussions General Discussion When is it appropriate to notify child protection services?

I have a child in my practice who was diagnosed with Turner Syndrome at 5 yo. Her height is far below the 3rd percentile. The endocrinologist offered GH, but it was refused, and she was lost to follow-up at least for short stature treatment.

She is now 11 yo with a bone age of 8. She is seeing the endocrinologist again who has recommended GH therapy along with her Synthroid due to hypothyroidism. The father continues to refuse therapy.

Would anyone make a referral to the Department of Health and Human Services or is this a decision a family should make?

OK... you and this user board are a GREAT help and resource to the user board and for me (non-doctor just trying to help the doctor my wife works for). I feel compelled to chime in from a totally non-medical view.

1. I've been following the Penn State football child-abuse scandal. It appears that at least a few folks in power had the chance (in addition to others without power) to stop this 14 year mess. But, no one did, for fear of the reputation/legacy of Penn State football, and for others, their jobs.

2. I don't know if your situation can be considered "child abuse" or "child neglect", but if you think it even touches on this, seems like you've gotta do something. The worst thing to happen is if everyone stands aside, and something dreadful happens to this kid, which could have been prevented. I understand that this is a "family matter", but I think professionals should be able to step in at some point.

I remember when my son (about 9 years old at the time) had a strain in his neck, and I took him to the pediatrician. He examined my son rather carefully, and asked some pointed questions. Turns out, he was looking for signs of child abuse. I think if he saw anything, he would tell me, then report the incident.

As I've mentioned above, I don't know if your situation can be considered to be child abuse or neglect. I hope your community of colleagues can help with your decision.

Of course, you know all of this already. Just my 2 cents divided by a million or so...

I agree with Les. If it gives you an ache in the pit of your stomach, at least discuss it with child protection. They may not act, they may tell you it is not covered by state law, they may say it is a matter for parental discretion, or they may say "Oh, My God!!!" and step in. At least you will sleep better knowing you didn't blow it off.

Why is the father refusing GH and synthroid? Is it religious reasons, lack of money, inability to reason or a combination thereof? I know I would love to "freeze" my kids and have them this age forever, but can't he see the disservice he is doing her in the long run? If you can't reason with the father, then I agree with getting someone who can represent this girl's long term interests involved.

He doesn't seem to be nearly as involved as the mother. They just no showed to endocrinology and stopped considering it. It is so screwed up that endo here referred her to cardiology because she had never seen a cardiologist according to the mother. Diagnosis by cardiologist was normal heart. Well, no kidding. That was the same finding the cardiologist got six years ago, but the parents didn't remember and no one bothered to ask me.

The father isn't sure what GH does even though it has been explained. He is worried about side effects. They did allow the Synthroid for a TSH of 22. They have Mainecare so they would get it all paid for, and their is some type of program where if you need GH, it gets paid for. She would also qualify for Katie-Beckett.

Good discussion case. I would report if synthroid not being given. If only refusal of GH, I would look for any other signs of questionable parenting specifically any untreated dental issues or decay. If no red flags, I would probably report "softly" telling authorities I am only calling as it is my duty, but leave further checking to them. Marlon

I would not use a specialist that refers on to another specialist without a call or letter to me FIRST. This cardiology situation is exactly what primary care involvement is designed to prevent. Marlon

I agree about the synthroid - I think I would sit with them and explain the importance of GH and what you feel are the reasons for it and try to explain why it is important. I have heard parents say 'if it is just so she won't be a little shorter why would I do it?'. You need to reiterate the importance of treating the thyroid and why this is life sustaining and if they quit following up with you or don't fill it then I would report it.

It may just be that they don't understand the importance of treatment. Document the discussions and try to protect your patient - the child.

I guess this is where my non-medical, non-doctor emphasis would be...

If you have done the best that you can, and I am sure that you have, then I would send a referral to the state authorities...I would feel that it was my duty to do so. A caseworker would then be assigned..this child needs to have that as it appears the parents may have low thyroid as well leading to their own lack of brain development...seriously..I have a young patient who has low thyroid and when we checked mother she had it for at least 10 years and it went untreated..I fear it damaged her...take care....

The rule I've always been told since the beginning of medical school was that if you have to ask yourself the question then you should be picking up the phone to make the call.

I am going to chime in here Bert. I think you have a good reason to have a pit in your stomach. I think from what you tell us, it seems to be more of a lack of understanding/education issue. I would start by trying to get the family and the endocrinologist and you in the same room at the same time for a meeting and discuss and listen to what his issues are with starting GH (and making sure that he will continue synthroid). I know this seem utopic rather then realistic and maybe I have too much time on my hands because my practice isn't super busy yet and only seeing 40 patients a week. I do think that if you can get him and mom in the same room with both you and the endocrinologist and see what the issue is, it may help. I have had several cases where the patient kept not taking meds and then finally when put it to them bluntly they got it..i think talking about long term ramifications are def important.

Of course you probably already did something of the sort, but just at thought.

If they refuse the meeting and/or after the meeting they still refuse I would just call and mention it to the agency saying you aren't sure if this is somethign to report or not, but here is the deal.

In the end you are protecting your patient...and a child...if an adult doesn't want to take something to help themselves, that is fine, when they interfere with children's health, i have an issue with that.

Ketan

Bert, I agree with Ketan on that it seems like a case of lack of understanding...even though you may feel that you spent a considerable time explaining it. I'd say the first thing is to take one more try to discuss it with them.

In many states, physicians are required by law to report suspected child abuse. I don't know about Maine's laws. The key question is "Is this child abuse?" If you feel it is, I'd suggest reporting it. You may be told that this does not constitute child abuse. Ok, no foul. They won't act. If it IS, then you will have helped the child. In this particular case, I'd say make the report, or at least call the appropriate government office and ask.

Thanks everyone. Problem is you only get so much time with GH.

Any endocrinologists out there?

Absolutely they should be reported for the Synthroid, if that WERE an issue

GH is less of an issue. Yes, she will be shorter, but then she will already be short because of the Turner. She should have an option but a short delay in treatment will not be a major issue.

I think before referral I would try to get a better understanding of why the Dad is refusing GH, and possibly try to contact Mom to find out if there are objections.

While time is an issue, a delay of a few months is not critical. One of the issues appears to be understanding of the treatment and another is getting the parents on the same page.

It may take Child Services to get the parents on the same page but it might be worth trying to contact them first.

In Illinois Child Services can be a mixed bag. Some workers do an excellent job, some are terrible and cause more harm than good. I am careful to refer unless I feel that harm has either been or is acutely likely to occur. In this case I would think you have time to find out more - and if you can't then they should be referred to Protective Services.