Child Abuse

1
Child Abuse Neglect for RI EMS Providers
Rhode Island Department of Health Division of EMS
2
Acknowledgements

• Child Abuse and Neglect A Prehospital Continuing
  Education and Teaching Resource (CD-ROM produced
  by The Center for Pediatric Emergency Medicine of
  the New York University School of Medicine)

3
Introduction

• Child abuse and neglect are widespread, found
  across all levels of socioeconomic status, all
  racial and ethnic (cultural) groups, and all
  religious affiliations.
• EMS providers in a unique position to identify
  abuse and neglect.
• Moral and legal obligation to report abuse and
  neglect, whether suspected or confirmed.

4
Introduction

• EMS providers are societys first line of defense
  against child abuse and neglect eyes and ears
  of the medical community.
• By recognizing and documenting child abuse or
  neglect, EMS providers can save childrens lives.

5
Abuse Defined

• Abuse A child has suffered physical or emotional
  injury inflicted by a caregiver (eg, parent,
  legal guardian, teacher, etc) that results in
  disability, disfigurement, mental distress, or
  risk of death.

6
Neglect Defined

• Neglect A childs physical, mental, or emotional
  condition has been endangered because the
  caregiver has not provided for the childs basic
  needs.

7
The EMTs role

• Recognize signs/symptoms of abuse and neglect.
• Provide medical evaluation and treatment.
• Protect from further abuse.
• Report all cases of suspected abuse.
• Document all findings accurately, thoroughly, and
  legibly.

8
Recognizing Abuse/Neglect

• Importance of History
• Injury or illness inconsistent with history
• Critical to determine whether injury or illness
  could have been caused unintentionally or was
  inflicted
• Multiple visits to same household or previous
  visits for family violence

9
Recognizing Right to Privacy

• Children have right to refuse
• Adolescents especially sensitive
• Do not examine unwilling child, especially if
  sexual abuse is suspected
• Give choices if possible

10
Recognizing Skin Injuries

• Most common and easily recognized sign of abuse
• Conduct complete, thorough skin examination
• Always look for cuts, scrapes, bruises, burns,
  bites, redness, swelling
• Describe systematically and consistently when
  documenting

11
Recognizing Bruises

• Note location(s)
• Infants rarely bruise accidentally
• Young, active children tend to incur bruises
  naturally on front of body (eg, knees, shins,
  elbows, forehead)
• Bruises in recognizable shape of object are
  suspect
• Multiple bruises in different stages of healing
  are suspect

12
Recognizing Burns

• Scald burns common
• Two general patterns immersion and splash
• Immersion burns characterized by clear lines of
  demarcation
• Examples Donut pattern burn on buttocks or
  stocking/glove pattern burns of arms or lower
  legs
• Accidental burns more often have splash marks as
  child withdraws from heat source

13
Recognizing Inflicted Contact Burn

• Recognized by shape that duplicates object used
  to produce it (eg, cigarette, curling iron)
• Tend to be in less exposed areas, deeper, larger

14
Recognizing Bites

• Adult human bite marks strongly suggest abuse
• In general, bite marks are multiple, random, well
  defined
• No one tooth mark stands out (differing from
  animal bites)

15
Recognizing Fractures

• Fractures discovered accidentally
• Skeletal injury inconsistent with history
• Multiple fractures in different stages of healing
• Accompanied by other injuries

16
Recognizing Falls

• Fall from standing position or low object (less
  than childs height) rarely results in serious
  injuries
• Fall from greater than childs height usually
  required to sustain serious injury

17
Recognizing Injuries to Face Head

• Unintentional injuries usually involve front of
  body
• Specific injuries to side of face, cheeks, ears
  suspicious of abuse
• Direct blow to mouth usually results in lip tear,
  possibly with broken jaw or teeth
• Considerable force required to cause severe head
  trauma

18
Recognizing Hair Loss

• Can be manifestation of child abuse
• May be self-inflicted to relieve stress
• Can be caused by dragging child by hair, using
  excessive force during brushing, or certain types
  of hair braiding
• Often blood at the surface or beneath scalp

19
Recognizing Shaken Baby Syndrome

• Most common in children less than 2 years old
• May be no evidence of external trauma
• Possible signs include decreased consciousness,
  seizures, vomiting, other signs of head injury,
  unusual cry
• Altered mental status may be only sign
• Recognizing the possibility should trigger
  suspicion of abuse

20
Recognizing Sexual Abuse

• Frequently thought of as occurring recently
  (within last 72 hours)
• In these cases, signs may include pain, bleeding,
  or discharge from urethra, vagina, or rectum
• Can also be insidious, chronic, hidden abuse
  occurring over weeks or months
• In these cases, signs may include nonspecific
  abdominal pain, vaginal inflammation, or painful
  urination
• Physical examination normal in most cases

21
Treating sexually abused patients

• Believe what the child says
• Use the childs own words and document statements
  in quotes
• Never examine unwilling child
• Do not remove childs clothing or examine
  genitals unless severe genital pain or gross
  genital bleeding
• Refer child to specialist for examination

22
Recognizing Emotional Abuse

• A component of all forms of child abuse
• Attack on childs development of self and social
  competence
• May not be done on conscious level
• Most cases mild, but early recognition important

23
Recognizing Emotional Abuse

• Ignoring the child
• Rejecting the childs needs and requests
• Isolating the child
• Verbally assaulting the child (eg, name-calling,
  harsh threats)
• Encouraging destructive, antisocial behavior
• Humiliating the child

24
Recognizing Neglect

• Most common form of child abuse
• Likely most under-recognized and under-reported
  form of child abuse
• Neglected children suffer greatly, often left
  with emotional scars

25
Recognizing Neglect

• Inadequate care, including inadequate provision
  of food, clothing, or shelter
• Inadequate medical attention, including delay in
  seeking care for known illness
• Example While child is having asthma attack,
  mother leaves home to go shopping.

26
Recognizing Neglect

• Signals to watch for
• Poor personal hygiene
• Unsanitary conditions
• Inadequate sleeping arrangements
• Lack of supervision
• Evidence of substance abuse
• Structural, fire, environmental hazards

27
Recognizing Munchausen Syndrome by Proxy

• Bizarre and rare form of child abuse
• Illness in child is repeatedly induced by parent
  or other caregiver, who denies knowledge of cause
• Symptoms subside when child is separated from
  parent or caregiver
• Child should not be left alone with parent or
  caregiver

28
Cultural Considerations

• Childrearing practices greatly influenced by
  culture
• Examples babies allowed to cry themselves to
  sleep, children sleeping in parents bed for
  several years
• Practice considered abuse in one culture may be
  norm in another
• Examples scarification of face, physical
  discipline

29
Cultural Considerations

• Cultural differences may affect evaluation of
  case
• Important to be aware of other cultures in own
  community
• Families may not realize that certain practices
  are considered abuse in US

30
Folk Medicine Practices

• May mimic abuse
• Should not be reported as abuse (usually)
• Examples
• Coin rubbing rubbing a coin along the skin may
  produce bruise-like rash
• Cupping applying heated cup to skin and pulling
  off after suction develops causes circular
  bruises
• Moxibustion treatment related to acupuncture in
  which lighted objects placed on skin result in
  burns

31
Communicating with Caregivers

• The primary goal is to protect the child from
  further injury.
• Accusation and confrontation delay
  transportation.
• Families likely to react negatively
• Best to discuss in a place where assistance is
  immediately available
• Police presence may be desirable

32
Reporting Abuse/Neglect

• Reports must be made when child abuse or neglect
  is suspected or there is reasonable cause to
  believe that child abuse or neglect has occurred
• Proof is NOT required

33
Reporting Abuse/Neglect

• Reasonable Cause When through training and
  experience, or physical evidence observed or
  described, the pre-hospital provider becomes
  aware of the possibility that neglect or
  non-accidental means might be the cause of an
  injury.

34
Reporting Abuse/Neglect

• The reasons for reporting are
• to determine whether or not an investigation will
  ensue
• to determine whether or not abuse or neglect
  occurred
• to determine what happened and who is responsible
• to safeguard the child from future injury

35
Legal Obligations

• All states have a reporting statute for
  child abuse and neglect
• Rhode Islands requirements established by RIGL
  Chapter 40-11 Abused and Neglected Children
• Lead agency is the RI Department of Children,
  Youth, and Families
• Any person with reasonable cause to know or
  suspect child abuse/neglect must report such to
  DCYF within 24 hours

36
Legal Obligations

• Immediate notification to DCYF required for
  parents of an infant who have requested
• deprivation of nutrition necessary to sustain
  life
• deprivation of medical or surgical interventions
  necessary to remedy or ameliorate a
  life-threatening condition (may not apply to
  terminally ill children if treatment would be
  ineffective)

37
Legal Obligations

• Any person with reasonable cause to know or
  suspect a child has died as a result of abuse or
  neglect must immediately notify DCYF

38
Legal Obligations

• Rhode Island law makes person making such a
  report in good faith is immune from civil or
  criminal liability
• Failure to report or actions to prevent someone
  else from reporting is a misdemeanor with a fine
  of up to 500 or imprisonment of up to 1 year.
  Such individuals are also civilly liable for
  damages caused by their failure to report.

39
Notifications

• Who to notify
• Always DCYF via 24-hour hotline at 800-RI-CHILD
• Local law enforcement
• Hospital staff (when transporting patient)
• When as soon as possible
• Immediately in some cases, 24 hours in other
  cases)

40
What Information to Convey

• Name, address, age, sex, ethnicity of child
• Names and addresses of parents or caregivers
  suspected of abuse/neglect
• Your name and contact info
• Why abuse or neglect is suspected
• Nature and extent of injuries, prior injuries
• Other children at risk
• All actions taken
• Examples Child transported to hospital, Child
  placed in protective custody

41
Transfer of Care

• EMS providers should indicate suspicion of abuse
  or neglect to emergency department personnel
• Hospital personnel will examine child, meet with
  parent or caregiver, request social work
  evaluation (if available), and often make
  independent evaluation of need to report

42
Transfer of Care

• Hospital action does not negate EMS providers
  assessment and does not relieve EMS provider of
  reporting responsibility.
• Child protection services may
• Request child remain in emergency department
  until they can interview child and parents or
  caregivers
• Release child from emergency department to go
  home with parents or caregivers

43
Additional Actions

• Document that call or written report was made to
  DCYF
• Also provide all information to the health care
  provider (eg, hospital staff) who receives child
• May be appropriate to also report case to police

44
Tools for EMTs

• Protective custody by law enforcement
• Interview techniques
• Ask open-ended questions only (eg, What
  happened?, How did you get hurt?)
• Allow child to explain in own words
• Avoid leading or suggestive questions such as
  Did Daddy hit you?
• Do not force child to make statement
• CISD for emotional consequences to EMS personnel
  handling abuse

45
Documentation

• Purpose of documentation
• Protects the patient and other children
• Aids in detection of abuse and prevent future
  episodes
• Supports accurately recalling observations and
  actions taken
• Protects EMS providers from legal liability

46
Documentation

• Evidentiary value
• Information most important!
• Documentation must be clear, accurate, detailed,
  thorough
• Diagrams very helpful
• Preserve physical and trace evidence when possible

47
Documentation

• In what format
• Descriptive terms
• Objective and specific
• Use direct quotes wherever possible

48
Documentation

• Basic information to include
• Name, address, age, sex, ethnicity of child
• Names and addresses of parents or caregivers
  legally responsible for child who are accused of
  abuse or neglect
• Your name and contact info
• Nature and extent of injuries, prior injuries,
  other children at risk
• Why abuse or neglect is suspected
• All actions taken

49
Documenting the Scene

• Describe scene rather than interpret it
• Avoid words that imply opinion or judgment
• Example garbage on floor, spoiled food on
  counter is more useful than dirty apartment
• Document who is present, their condition, and any
  actions they have taken
• Example parent slurring words, smells of
  alcohol is more useful than parent drunk

50
Documenting History/Presentation

• Document all versions of history as given by
  child, caregiver, other witnesses (use direct
  quotes)
• Note if history is inconsistent with childs
  injuries

51
Documenting Statements by Child

• Record childs statement word for word in quotes
• Include circumstances of statement (eg, who was
  present)
• Note childs actions and demeanor (eg, crying,
  withdrawn)
• Record any questions asked, who asked them, and
  response

52
Documenting Statements by Others

• Identify person making statement and record
  statements word for word in quotes
• Include circumstances of statement (eg, whether
  statement was made in response to a question, who
  else was present, how the person acted)

53
Documenting Additional Victims

• Same principles of documentation apply
• Document any statements made by or about other
  child suspected to be victim of abuse or neglect
• Document any actions taken regarding this child

54
Confidentiality

• Under RI law, all records concerning reports of
  child abuse and neglect, including reports to
  DCYF, are confidential
• Under RI law, communications are not privileged
  between husband and wife and any professional
  person and his/her patient or client when related
  to known or suspected child abuse or neglect

55
Additional Help

• Rhode Island DCYF 1-800-RI-CHILD (800-742-4453)
  nationwide, 24 hours
• Childhelp USA National Child Abuse Hotline
  1-800-4-A-CHILD
• RI Department of Health, Division of EMS, at
  401-222-2401

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Examination

• Written post-test (20 questions)

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Questions?