Treatment and Follow-up : Siblings, Other Family Members, and At-Risk Contact Children
Risk Factors
Siblings who live in the same households or in shared custody arrangements with the child who was abused or suspected of being abused should be carefully examined, even if they are asymptomatic. Other at-risk children (contact children) may include close relatives, neighbors, or classmates, depending on the circumstances of the abuse. Symptomatic contacts should be evaluated as index cases, not through screening protocols.
Medical assessments can reveal concerns unrelated to the diagnosis in the index child and not visible to child protection staff. These may include:
- Growth and development concerns sometimes leading to failure to thrive
- Hidden (occult) injuries
- Non-compliance with needed medical care
Risk factors in the index child that increase concern for contacts include:
- Prior CPS involvement
- Caregiver mental illness, substance abuse, domestic violence, unemployment, or being a single parent
Medical Evaluation
Core Principles
- Identify All Contacts. Any child living with or under the care of a maltreated child (the “index child”) is considered a contact and should be evaluated.
- Recognize Risk. Contact children are at increased risk for maltreatment, especially if the index case involved multiple types of abuse or severe harm. Twins and other multiple-birth siblings are at particularly high risk.
- Use a Multidisciplinary Approach. A team approach involving child abuse pediatricians, radiologists, and CPS is essential.
- Don’t Assume Single-Type Abuse. For example, sexual abuse may co-occur with physical abuse or neglect. A comprehensive medical evaluation should address all potential concerns.
Medical Evaluation Components
- Clinical Assessment for All Contacts
- Take a detailed history and perform a thorough physical exam.
- Look for signs of abuse and neglect: Unexplained bruises (especially in non-mobile infants), poor growth, unmet medical needs, etc.
- Radiological Screening When Physical Abuse is Suspected
- <12 months
- Full skeletal survey + brain MRI (or head CT if MRI unavailable). Spinal MRI if brain imaging is abnormal.
- 12–24 months
- Full skeletal survey.
- 24–36 months
- Skeletal survey not routine; consider based on developmental status and index injuries.
- 3–5 years
- Imaging only in special cases (e.g., neurodevelopmental disorders, inability to report pain); use targeted radiographs if clinically indicated.
- >24 months (asymptomatic)
- No routine imaging unless there are clinical concerns or investigative findings.
- Follow-up
- Repeat skeletal survey in 11–14 days (up to 28 days) if initial findings are equivocal or abnormal. Repeat neuroimaging within 3 months if needed.
- Evaluation in Neglect Cases
- Focus on growth, nutrition, and unmet medical needs.
- Indicated if the index child experienced severe/fatal neglect or multiple forms of maltreatment.
- Evaluation in Child Sexual Abuse
- Like other forms of abuse, contact children generally deserve to be offered a comprehensive medical evaluation including a developmentally appropriate history and a thorough exam including growth parameters.
- Assess for signs of neglect or other maltreatment, including unmet medical needs.
- Unlike physical abuse evaluations, radiological imaging (e.g., skeletal surveys, head CTs) is not routinely indicated unless there is concern for physical injury.
- Specific risk factors include:
- The index child is prepubertal with a sexually transmitted infection (STI).
- There are reports or observations of suspicious behavior between the alleged perpetrator and the contact child.
- The index child has multiple risk factors or has experienced multiple forms of maltreatment.
- STI testing: Consider testing based on age, exam findings, disclosures, and risk of exposure (e.g., known STI in perpetrator or index child).
- Key finding from studies: Contact children diagnosed with sexual abuse are often older than those identified with physical abuse or neglect.
The above information is based on information found in Kellogg ND, Lukefahr JL, Koek W. Medical assessments for abuse and neglect in contacts of maltreated children. Journal of Paediatrics and Child Health. 2024; 60 (8) : 349-354. (DOI) .
For more information regarding medical evaluation for maltreatment, see: Lindberg DM, Shapiro RA, Laskey AL, Pallin DJ, Blood EA, Berger RP. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012; 130 (2) : 193-201. (DOI) .
Mankad K, Sidpra J, Oates AJ, Calder A, Offiah AC, Choudhary A. Sibling screening in suspected abusive head trauma: a proposed guideline. Pediatric Radiology. 2021; 51 (6) : 872-875. (DOI) .
Mankad K, Sidpra J, Mirsky DM, Oates AJ, Colleran GC, Lucato LT, Kan E, Kilborn T, Agrawal N, Teeuw AH, Kelly P, Zeitlin D, Carter J, Debelle GD, Berger RP, Christian CW, Lindberg DM, Raissaki M, Argyropoulou M, Adamsbaum C, Cain T, van Rijn RR, Silvera V. International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse. Jama Pediatrics. 2023; 177 (5) : 526-533. (DOI) .
