Abuse and Neglect Across Populations

1. Abuse and Neglect Across Populations Presence Regional EMS April 2014 Continuing Education

2. Objectives • Describe the risk factors for abuse and neglect in the pediatric, adult and geriatric populations. • Recognize features in the history and physical assessment that suggest maltreatment of children, adults and seniors. • Discuss the various forms that abuse and neglect can take: physical, mental, financial, sexual • Describe the prehospital professionals responsibility when abuse/neglect and domestic violence are suspected.

3. Pediatric Abuse and Neglect • One out of fifty-eight children in the United States is a victim of child abuse or neglect affecting over one million children each year. • Child maltreatment is the leading cause of trauma-related death in children under four years of age accounting for 80% of all child abuse fatalities. • Unfortunately, the discovery of abuse is often made too late, with over 1700 deaths, 18,000 permanent injuries and 150,000 serious injuries occurring each year.

4. Case Presentation You respond to a call for a toddler who “won’t stop crying.” You arrive at a messy apartment and find a 3-year-old boy curled on the couch, clutching a stuffed rabbit and looking apprehensive. The mother tells you the child has been crying “all day,” and she doesn’t know why. Her husband volunteers that Alex was rough-housing with their dog the previous day and may have injured himself when he fell off the sofa.

5. General Assessment: PAT Appearance Starts to cry and says, “No, no, no! I’ll be good,” when his father approaches him. Work of Breathing Normal What do you think is going on? Circulation to Skin Normal

6. General Impression and Management Priorities • General impression: • The child is not sick. • The social interactions do not “feel right.” • On further questioning, the father is not sure when the child and dog were playing and how the child actually fell. He now states he may have tripped while running through the apartment. No immediate medical treatment is needed. • Further assessment of the scene and child is the priority.

7. Initial Assessment: ABCDE • Airway—patent • Breathing—RR 28; breath sounds clear • Circulation—HR 100; capillary refill 2 seconds • Disability—AVPU — A • Exposure—multiple brown, yellow, and purple bruises on buttocks, trunk, and legs; child is guarding his left arm, which is tender to palpation and appears swollen and slightly deformed near the wrist. What are you thinking at this point?

8. Bruises on young children from accidental falls are commonly found on the front of legs and arms but rarely on the buttocks and posterior thighs unless it is from abuse. • Although the color of bruises cannot be used to determine accurately the time of injury multiple bruises of different colors suggest repeated injury over a period of time • In this situation the child is stable and the scene may be unsafe.

9. Management Priorities • Numerous bruises, possible fracture • BLS and ALS management: • Speak to toddler in a calm voice; get down to his level and use his name. • Immobilize left arm (splint or sling). Do you want to stay or go?

10. Transport Decisions: Stay or Go? • The child does not need immediate medical treatment but is at risk for further injury. • Communicate the need for transport to the parents/caregiver. • Avoid confrontation with caregivers. • Be nonjudgmental and do not make accusations. • Consider law enforcement assistance. • Transport to ensure patient safety. • Consider the safety of the mother and other children in the home.

11. Historical “Red Flags” for Abuse • History that is inconsistent with injuries • History that changes over time • History that does not fit child’s developmental stage • Delay in seeking care • Inappropriate child–caregiver interaction • Caregiver aloof, unconcerned or inappropriate • Child does not seek parent for consolation and protection

12. Risk Factors for Abuse • Younger children, less than 4 years of age • Drug or alcohol use in home • A history of domestic violence • A family history of maltreatment

13. Spectrum of Child Maltreatment Children may present with: • Physical abuse • Emotional abuse • Sexual abuse • Neglect (physical or emotional)

14. Spectrum of Child Maltreatment Physical Abuse: • When a person intentionally inflicts or allows to be inflicted injury to a child under 18 years of age or to a mentally disabled child under 21 years of age that results in the risk of death, disfigurement or distress. • Any act of discipline that leaves a lasting physical mark on the child is considered excessive force and constitutes child maltreatment.

15. Injury Patterns That Signify Abuse • Stocking/glove burn • “Donut–shaped” burn • Results from “dipping” of body part in scalding water

16. Play Injuries Versus Abuse Injuries • Any bruise with an identifiable pattern • Multiple fractures • Facial bruising

17. Spectrum of Child Maltreatment Emotional Abuse: • Ongoing and consistent pattern of behavior that interferes with the normal psychological and social development of a child. Sexual Abuse: • An older child or adult engages in sexual activities with a dependent child for the older persons own sexual excitement or for the enjoyment of other people as in the case of child pornography.

18. Spectrum of Child Maltreatment Neglect: • When a child’s physical, mental or emotional condition is endangered by failure to supply basic necessities' such as food, clothing, shelter, healthcare and protection from harm.

19. Spectrum of Child Maltreatment • Child maltreatment occurs in all ethnic and socioeconomic groups. • Preconceptions about the type of adult who could hurt a child could lead you to miss intentional injuries.

20. Case Progression • En route: The child is transported to the emergency department with the mother in the ambulance. • In ED: An X-ray shows a forearm fracture and several other healing extremity fractures. • The mother discloses ongoing physical abuse of the child and herself by her husband. • Photos are taken of the injuries. • Law enforcement and CPS are notified.

21. Case Summary • Diagnosis: Nonaccidental trauma • Outcome: The father is arrested; the child is placed in a safe home environment by CPS.

22. Case Presentation You respond to a call at midnight for a choking infant. You are met at the door by a 7-year-old girl, who leads you into a living room where her 4-month-old sister, wearing only a wet diaper, lies on the floor beside a 2-year-old brother, also wearing only a diaper. An open bottle of alcohol is nearby. The girl says the baby choked when she was feeding her water, and she called 9-1-1.

23. General Assessment: PAT Appearance Awake and crying Work of Breathing Noisy breathing, no nasal flaring, no retractions What is your general impression? Circulation to Skin Pink

24. General Impression and Management Priorities • This baby is stable. • The noisy breathing without nasal flaring or retractions could be due to positioning or nasal congestion. • Choking or gastroesophageal reflux can lead to signs of respiratory distress with feeding.

25. Initial Assessment: ABCDEs • Airway—patent • Breathing—RR 36; SpO2 99%; transmitted upper airway sounds; no wheezing or stridor • Circulation—HR 136; strong pulses; capillary refill 2 seconds • Disability—alert, stops crying when held for examination • Exposure—no bruising or signs of injury What is your overall assessment? What do you want to do?

26. Management Priorities • BLS/ALS: • Suction nose; give supplemental O2 as needed. • Scene size-up: • Evaluate child’s environment for: • Potential hazards • Toxins or drugs • Room temperature • Unsafe or unsanitary conditions • Presence of food, formula

27. Transport Decisions: Stay or Go? • Stay or go? • Because the infant is stable, you can assess the situation further. • The girl says her mother went out several hours ago. She doesn’t know how or where to reach her. She says she often has to take care of the younger children because her mother leaves them alone. • The girl has not seen her father in a long time. • Should you transport the children to the hospital?

28. “Red Flags” for Maltreatment • Poor home conditions • Underage caregiver • Low-income, single-parent family • Drug, alcohol abuse by caregiver • Lack of formula, milk, food • Malnourished, growth failure • Lack of appropriate medical care

29. EMS Responsibilities in Suspected Abuse • Medical/legal responsibilities: • Recognize suspicious circumstances. • Ensure the safety of the child and yourself. • Assess the child and the history. • Communicate with the family/caregivers in a nonjudgmental manner. • Document findings. • Note other children living at the scene. • Report suspicion of maltreatment or neglect to ED personnel.

30. Mandated Reporters Illinois State Law mandates that workers in certain professions must make reports if they have reasonable cause to suspect abuse or neglect of children. A majority of reports are initiated by calls from mandated reporters. • Illinois Compiled Statutes: 325 ILCS 5/) Abused and Neglected Child Reporting Act. • Child Abuse Hotline (800) 25-ABUSE (1-800-252-2873)

31. Case Progression • After suctioning, the infant’s breathing normalizes. • In the ED: • Chest X-ray is negative for aspiration. • CPS is called. • Mother comes to the ED at 2 am, obviously intoxicated. • The children are discharged with an aunt, pending CPS investigation.

32. Case Summary • Diagnosis: child neglect • Outcome: • This is the third referral to CPS for this family. • Mother is mandated to inpatient alcohol treatment. • Aunt receives temporary custody of the children.

33. Summary • Be suspicious of maltreatment whenever: • An inconsistent history is offered by the caregiver • There is a delay in seeking care • There are multiple injuries of multiple ages • There is an inappropriate child–caregiver interaction • There is an inappropriate response to the child by the caregiver • Physical findings are not explained by history or are inconsistent with developmental abilities of the child

34. Elder Abuse and Neglect • The extent of elder abuse is not known for several reasons: • It has been largely hidden from society. • Definitions of abuse and neglect among the geriatric population vary. • Victims are often hesitant to report the problem. • Elder abuse occurs most often in women older than 75 years. • People with dementia are at greater risk of elder abuse than those without. • The vast majority of abusers are family members

35. Case Presentation • You are dispatched to the home of a 74 year old patient. Upon arrival you are greeted by the patient’s son who states that the patient is out of control due to dementia and has become violent. • He states he had to throw the patient to the ground to keep her under control. • He informs you he has full power of attorney and wants the patient taken to a psychiatric facility.

36. General Impression • You find the patient seated in a chair. • She appears calm but tearful. • She is alert and oriented x 4 and states she has no complaints. • She tells you her son is trying to take her finances and her home. • She states her son threw her to the ground and she fears for her safety.

37. General Impression • You observe the patient is well nourished with appropriate hygiene and the home is well kept. • You see a large roll of duct tape lying on the table. The patient states her son threatened to tie her up if she did not sign her social security check.

38. Initial Assessment • Airway: patent • Breathing: 20 breaths/min • Circulation: Pulse is 96 and irreg; BP is 150/100 • Disability: alert and aware of surroundings • Exposure: Red contusions on the forearms and left cheek What are you thinking at this point?

39. Management Priorities • The patient does not need immediate medical treatment but is at risk for physical, psychological and financial abuse. • Transport the patient for her own safety.

40. Risk Factors for Abuse • Older people at risk for abuse: • Women • Over 75 years • Live with or dependent on the abuser • Chronic physical or mental impairment • Socially isolated • Problematic behavior from the older person

41. Red Flags • Inadequate care • Poor environment • Patient fearful or hostile toward caregiver • Patient reluctant when questioned • Patient appears depressed • Conflicting accounts • Caregiver answers for patient • Lack of caregiver concern

42. Spectrum of Elder Abuse • Physical abuse • Psychological abuse • Financial abuse • Neglect • Isolation • Lack of medical care, medications and food • Unhealthy environment

43. Profile of Abuser • Live with victim • Drug or alcohol users • Most over age 50 • Dependent for financial support • Poor impulse control • History of domestic violence

44. Mandated Reporter • Illinois State Law (320 ILCS 20/) Adult Protective Services Act requires certain professionals to make reports of suspected abuse of adults with disabilities and seniors who are unable, due to dysfunction, to report for themselves. • Mandatory reporting requirements only apply when the reporter believes that the person is not capable of reporting the abuse themselves. • To report suspected abuse, exploitation or neglect of a senior or an adult with disabilities, call the statewide, 24-hour Adult Protective Services Hotline: 1-866-800-1409

45. Domestic Violence • One in four women experience domestic violence in their lifetime. • Men may also be victims of domestic violence. • Sixty percent of domestic violence incidents happen at home. • Domestic violence is most likely to occur between 6:00 PM and 6:00 AM. • Most domestic violence incidents are never reported.

46. Case Presentation • You are called for a 22-year-old woman with a bloody nose. Dispatchers state the 911 caller was a friend of the patient. The caller stated there had been a domestic dispute. Law enforcement is also enroute. • Upon your arrival you find the patient with her friend. She makes no eye contact with EMS. • Law enforcement are on the scene and speaking to a male subject.

47. General Impression • The patient is crying and shaky. • Bright red blood from both nares • Will not make eye contact

48. Initial Assessment • Airway: patent • Breathing: 24 breaths/min • Circulation: pulse is 110 and BP is 110/70; slightly pale and sweaty • Disability: Flat affect • Exposure: Circumferential bruises of wrists, multi-colored bruising over lower back, swelling to the bridge of her nose with bright red bleeding from both nares

49. Management Priorities • After careful assessment of the situation, you recommend transport to ED. • The patient refuses treatment. Does this patient meet criteria for refusal of transport? What can you do?

50. Information for Victims of Domestic Abuse • According to the IDPH Rules and Regulations Section 515.330 EMS System Program Plan, the EMS System Manual must contain a policy for “Offering immediate and adequate information regarding services available to victims of abuse, for any person suspected to be a victim of domestic abuse” • EMS agencies should have information on services available for victims of domestic abuse. • PREMSS agencies should contact the PREMSS office for available printed information.