Child Abuse & Neglect for RI EMS Providers

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

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

4. 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)

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

6. 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)

7. 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)

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

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

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

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

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

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

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

15. 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)

16. 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)

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

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

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

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

21. 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)

22. 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)

23. 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)

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

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

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

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

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

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

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

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

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

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

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

35. 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)

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

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

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

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

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

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

42. 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)

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

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

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

46. 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)

47. Documentation • In what format • Descriptive terms • Objective and specific • Use direct quotes wherever possible Child Abuse/Neglect for RI EMS Providers (Slide 47)

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

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

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 child’s injuries Child Abuse/Neglect for RI EMS Providers (Slide 50)