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Child Abuse & Neglect for RI EMS Providers. Rhode Island Department of Health Division of EMS. Acknowledgements.

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child abuse neglect for ri ems providers

Child Abuse & Neglect for RI EMS Providers

Rhode Island Department of Health

Division of EMS

acknowledgements
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)

Child Abuse/Neglect for RI EMS Providers (Slide 2)

introduction
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.

Child Abuse/Neglect for RI EMS Providers (Slide 3)

introduction4
Introduction
  • EMS providers are society’s 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 children’s lives.

Child Abuse/Neglect for RI EMS Providers (Slide 4)

abuse defined
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.

Child Abuse/Neglect for RI EMS Providers (Slide 5)

neglect defined
Neglect Defined
  • Neglect:A child’s physical, mental, or emotional condition has been endangered because the caregiver has not provided for the child’s basic needs.

Child Abuse/Neglect for RI EMS Providers (Slide 6)

the emt s role
The EMT’s 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.

Child Abuse/Neglect for RI EMS Providers (Slide 7)

recognizing abuse neglect
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

Child Abuse/Neglect for RI EMS Providers (Slide 8)

recognizing right to privacy
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

Child Abuse/Neglect for RI EMS Providers (Slide 9)

recognizing skin injuries
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

Child Abuse/Neglect for RI EMS Providers (Slide 10)

recognizing bruises
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

Child Abuse/Neglect for RI EMS Providers (Slide 11)

recognizing burns
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

Child Abuse/Neglect for RI EMS Providers (Slide 12)

recognizing inflicted contact burn
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

Child Abuse/Neglect for RI EMS Providers (Slide 13)

recognizing bites
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)

Child Abuse/Neglect for RI EMS Providers (Slide 14)

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

Child Abuse/Neglect for RI EMS Providers (Slide 15)

recognizing falls
Recognizing: Falls
  • Fall from standing position or low object (less than child’s height) rarely results in serious injuries
  • Fall from greater than child’s height usually required to sustain serious injury

Child Abuse/Neglect for RI EMS Providers (Slide 16)

recognizing injuries to face head
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

Child Abuse/Neglect for RI EMS Providers (Slide 17)

recognizing hair loss
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

Child Abuse/Neglect for RI EMS Providers (Slide 18)

recognizing shaken baby syndrome
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

Child Abuse/Neglect for RI EMS Providers (Slide 19)

recognizing sexual abuse
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

Child Abuse/Neglect for RI EMS Providers (Slide 20)

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

Child Abuse/Neglect for RI EMS Providers (Slide 21)

recognizing emotional abuse
Recognizing: Emotional Abuse
  • A component of all forms of child abuse
  • Attack on child’s development of self and social competence
  • May not be done on conscious level
  • Most cases mild, but early recognition important

Child Abuse/Neglect for RI EMS Providers (Slide 22)

recognizing emotional abuse23
Recognizing: Emotional Abuse
  • Ignoring the child
  • Rejecting the child’s needs and requests
  • Isolating the child
  • Verbally assaulting the child (eg, name-calling, harsh threats)
  • Encouraging destructive, antisocial behavior
  • Humiliating the child

Child Abuse/Neglect for RI EMS Providers (Slide 23)

recognizing neglect
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

Child Abuse/Neglect for RI EMS Providers (Slide 24)

recognizing neglect25
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.

Child Abuse/Neglect for RI EMS Providers (Slide 25)

recognizing neglect26
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

Child Abuse/Neglect for RI EMS Providers (Slide 26)

recognizing munchausen syndrome by proxy
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

Child Abuse/Neglect for RI EMS Providers (Slide 27)

cultural considerations
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

Child Abuse/Neglect for RI EMS Providers (Slide 28)

cultural considerations29
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

Child Abuse/Neglect for RI EMS Providers (Slide 29)

folk medicine practices
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

Child Abuse/Neglect for RI EMS Providers (Slide 30)

communicating with caregivers
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

Child Abuse/Neglect for RI EMS Providers (Slide 31)

reporting abuse neglect
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

Child Abuse/Neglect for RI EMS Providers (Slide 32)

reporting abuse neglect33
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.

Child Abuse/Neglect for RI EMS Providers (Slide 33)

reporting abuse neglect34
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

Child Abuse/Neglect for RI EMS Providers (Slide 34)

legal obligations
Legal Obligations
  • All states have a reporting statute for child abuse and neglect
  • Rhode Island’s 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

Child Abuse/Neglect for RI EMS Providers (Slide 35)

legal obligations36
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)

Child Abuse/Neglect for RI EMS Providers (Slide 36)

legal obligations37
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

Child Abuse/Neglect for RI EMS Providers (Slide 37)

legal obligations38
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.

Child Abuse/Neglect for RI EMS Providers (Slide 38)

notifications
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)

Child Abuse/Neglect for RI EMS Providers (Slide 39)

what information to convey
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”

Child Abuse/Neglect for RI EMS Providers (Slide 40)

transfer of care
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

Child Abuse/Neglect for RI EMS Providers (Slide 41)

transfer of care42
Transfer of Care
  • Hospital action does not negate EMS provider’s 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

Child Abuse/Neglect for RI EMS Providers (Slide 42)

additional actions
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

Child Abuse/Neglect for RI EMS Providers (Slide 43)

tools for emts
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

Child Abuse/Neglect for RI EMS Providers (Slide 44)

documentation
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

Child Abuse/Neglect for RI EMS Providers (Slide 45)

documentation46
Documentation
  • Evidentiary value
    • Information – most important!
    • Documentation must be clear, accurate, detailed, thorough
    • Diagrams very helpful
    • Preserve physical and trace evidence when possible

Child Abuse/Neglect for RI EMS Providers (Slide 46)

documentation47
Documentation
  • In what format
    • Descriptive terms
    • Objective and specific
    • Use direct quotes wherever possible

Child Abuse/Neglect for RI EMS Providers (Slide 47)

documentation48
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

Child Abuse/Neglect for RI EMS Providers (Slide 48)

documenting the scene
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”

Child Abuse/Neglect for RI EMS Providers (Slide 49)

documenting history presentation
Documenting History/Presentation
  • Document all versions of history as given by child, caregiver, other witnesses (use direct quotes)
  • Note if history is inconsistent with child’s injuries

Child Abuse/Neglect for RI EMS Providers (Slide 50)

documenting statements by child
Documenting Statements by Child
  • Record child’s statement word for word in quotes
  • Include circumstances of statement (eg, who was present)
  • Note child’s actions and demeanor (eg, crying, withdrawn)
  • Record any questions asked, who asked them, and response

Child Abuse/Neglect for RI EMS Providers (Slide 51)

documenting statements by others
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)

Child Abuse/Neglect for RI EMS Providers (Slide 52)

documenting additional victims
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

Child Abuse/Neglect for RI EMS Providers (Slide 53)

confidentiality
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

Child Abuse/Neglect for RI EMS Providers (Slide 54)

additional help
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

Child Abuse/Neglect for RI EMS Providers (Slide 55)

examination
Examination
  • Written post-test (20 questions)

Child Abuse/Neglect for RI EMS Providers (Slide 56)

questions
Questions?

Child Abuse/Neglect for RI EMS Providers (Slide 57)