Maltreatment

1. Maltreatment Recognizing and Reporting Child Maltreatment and Understanding the Child Protection System

2. History of Child Abuse • Story of Mary Ellen • 1874 • New York City • First documented case of legal intervention • Set precedent 74

3. Learning Objectives • Raise awareness of child maltreatment • Identify the different types of maltreatment • Navigate the child abuse reporting process

4. Child Maltreatment A report of child abuse is made every ten seconds U.S. state and local child protective services (CPS) investigated 3.2 million reports of children being abused or neglected. CPS classified 794,000 (10 per 1,000) of these children as victims 59% neglect 11% physical abuse 8% sexual abuse 4% emotional abuse

5. Child Maltreatment In 2007, 1,760 children died from abuse and neglect 76% or more 0-3 year-olds 13% 4-7 year-olds 5% 8-11 year-olds 5% 12-15 year-olds 2% 16-17 year-olds

6. Child Risk Factors Developmental delays Chronic illness Physical disabilities Parent/Caregiver Risk Factors Young maternal age Lack of parental knowledge Personality that angers or frustrates easily Lack of emotional support Childhood history of abuse or neglect Substance misuse Domestic Violence Mental illness Limited parental cognitive ability Risk Factors

7. Child Maltreatment Physical abuse Sexual abuse Neglect Emotional abuse

8. Signs of Physical Abuse May Include: • Any unexplained injury to the child • Changing or contradictory explanations for the injury • Injuries inconsistent with the developmental level of the child • Delay in seeking medical treatment

9. Shaken Baby Syndrome • Violent shaking of the child with or without impact which causes brain injury • Crying is the #1 reason why caretakers become frustrated and shake a child • On average infants cry 2-3hrs a day • Crying peeks between 6 weeks – 4 months • Childs risks is highest during this time

10. 8 week old boy • History: Saturday father was in the living room with child, rushed into the kitchen with child who was blue, the child was stiff then went limp. • 911 called EMS gives parents option to monitor child at home or go to ER for possible post seizure. Family elected to stay at home (Mom is RN). • Monday (three days later) child taken to pediatrician to evaluate persistent vomiting & irritability post “seizure”. Child discharged home to follow up with specialist • Friday (five days later) admitted to SJCH- for Gastrointestinal evaluation for work up and evaluation post seizure.

11. 8 week old boy continued… • Hospital workup revealed subdural hematoma which lead medical team to contact DCF and evaluated for possible non-accidental trauma (NAT). • After complete NAT workup a diagnosis of abusive head trauma or Shaken Baby Syndrome was made along with reflux. • DCF placed child into foster care.

12. Common Bruising

13. Location, Location, Location • Non-inflicted • Commonly found on exposed areas of the body such as: • Forehead, shins, elbows, knees • Inflicted • Often located in protected areas such as: • Genitals, ears, neck, back, abdomen, buttocks

14. Bruise with recognizable shape

15. Bruise with recognizable shape

16. Bruise with recognizable shape

17. Remember… • Always consider • The location of the bruise • The pattern • How extensive the bruising is • The age and developmental ability of the child

18. Burns: immersion, patterned and accidental

19. Neglect Defined The failure of the caregiver to provide needed food, clothing, shelter, medical care, or supervision such that the child’s health, safety, and well-being are threatened with harm. Does poverty = Neglect Poverty is when the caregiver does not have the resources to provide the basic needs. Neglect is when the caregiver has the resources, but choosesnot to provide the basic needs.

20. Neglect Often occurs in the form of: • Physical neglect • Medical neglect • Lack of Supervision • Emotional neglect

21. Physical Neglect

22. 11yr old girl Physical Neglect • History:Mother brought child into ER for possible new onset diabetes. • Medical staff noticed child was grossly unkempt, clothing was stained and dirty, she smelled of urine, hair matted, teeth rotting and noted layered dirt on soles of her feet • Parent interview by ER staff regarding neglect concerns mother states • “I have 9 children and live with a friend, my daughter doesn’t like to wear shoes, and she doesn’t want to shower” • DCF notified – physical neglect

23. 8yr old boyMedical Neglect • History: Child sustained a significant heel laceration after riding his bike with no shoes. • 5 days post injury mother brings child to ED for infection of laceration. • ER treatment – wound debridement, sent home with antibiotic prescription and DCF notification – medical neglect. • Patient returned to ER 3 days later “foot getting worse” infection has reemerged mom state “I have no car so I can’t get the medication” • Child admitted to hospital for IV antibiotics intervention and physical therapy. DCF notified again

24. Lack of Supervision • Drowning • Poisoning • Home fires

25. 10yr boy Lack of supervision History: 10yr old child and family was involved in motor vehicle crash (Car vs. tree). • 10yr old unrestrained back seat passenger complaining of abdominal pain and significant laceration to face. Vertical deep laceration extending length of nose (4 inch) exposed cartilage.

26. Lack of supervision cont… • Child was asked to explain what happened he stated: “my step-mom and her friend picked me and my brother up from school and let her friend drive the car home, she was teaching her how to drive we were going really fast and she couldn’t find the brake” • friend was an unlicensed teenage driver. • Due to severity of injury & circumstances surrounding crash DCF called for concerns of child endangerment and neglect

27. Emotional Neglect • Witness to domestic violence • Refusal/delay in mental health services • Inadequate/inconsistent nurturing or affection • Isolation

28. Sexual Abuse • About 1 out of 5 girls and 1 out of 10 boys will be sexually abused during their childhood. • Among high school students, 11% of girls and 4% of boys report having been forced to have sexual intercourse at some point in their lives. • Abuse typically occurs within a long-term, ongoing relationship between the offender and victim; escalates over time; lasts an average of 4 years. American Academy of Pediatrics 2008

29. Sexual Abuse Defined Any completed or attempted sexual act, sexual contact with, or exploitation of a child by caregiver. Caregiver on the child Child on the caregiver Child on non-caregiver (coercion/force)

30. Sexual Abuse Red Flags Fear or excessive crying Vomiting Feeding problems Bowel problems Sleep disturbances Failure to thrive Fear of particular people, places or activities Regression to earlier behaviors (bed wetting or stranger anxiety) Victimization of others Excessive masturbation Nightmares or sleep disturbances Withdrawal from family or friends Eating disturbances

31. 7yr old female Suspected Sexual Abuse • History: Child taken to pediatrician by parent on Monday for vaginal discharge for one week. • Pediatrician evaluated child, obtained chlamydia/gonorrhea vaginal culture, treated child with Rocephin & Augmentin and made a diagnosis of pin worms. • Friday chlamydia/gonorrhea vaginal culture came back positive, Pediatrician instructed mom to take pt to ED • ER staff evaluated child and notified DCF and law enforcement

32. Emotional/Psychological AbuseDefined Intentional caregiver behavior that convey to a child that he/she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another's needs (APSAC 1995) Psychologically abusive behaviors: blaming, belittling, degrading, intimidating, terrorizing, isolating, restraining, confining, corrupting, exploiting, spurring

33. Emotional/Psychological AbuseExample Verbal assault Name calling of a child Cinderella Syndrome Singling out one child to punish and/or criticize Corruption Stimulating child to engage in antisocial behavior (stealing, vandalism) Exposure to Domestic Violence Emotional damage Humiliation Caregiver performs acts that result in extreme embarrassment

34. Now what…? • Once I’ve identify child maltreatment what do I do? • Am I obligated to report? • What is the process? • Will I destroy the family if I report? • Will someone investigate my concern?

35. Mary Lee’s House

36. How do you get to MLH? The phone call is the gatekeeper Why should you make that call? Who is a mandatory reporter? What is a professionally mandated reporter?

37. FOUR ways to make a report Phone 1-800-96-ABUSE (962-2873) Fax 1-800-914-0004 TDD 8-800-453-5145 Web www.state.fl.us/cf_web

38. You are the messenger The hotline staff triages the calls and makes decision to accept or not Is it really anonymous? Be prepared! The hotline will accept a call on behalf of a child who is a Florida resident OR who has been injured in the state.

39. Then What? Accepted vs. Not Accepted Number Assignment and follow up Mandatory Reporters cannot make anonymous calls! DCF is charged with the safety and security of the child. Law Enforcement is responsible for criminality.

40. Information you need Victim’s name, age, race, gender, location Signs or indications of harm Addresses to the best of your knowledge Relationship of alleged perpetrator Any potential risks to CPI

41. Helpful Information Specific, direct and consistent Details, details, details Remember you are helping to build a case. Do not be discouraged! Your information could lay the groundwork for the next call and a stronger case!

42. Accepted CallsInvestigated in 1-24 hours Safety issues Three outcomes Unfounded Not Substantiated Verified

43. Sexual Abuse Investigation Caretaker Joint investigation Forensic Interview CPT provides Exam Proceeds as abuse case would Non Caretaker Law Enforcement Interviews and Exam No DCF investigation

44. Verified Findings In Home with Services SHELTER hearing Child Removed SHELTER hearing

45. SHELTER REMOVAL Child home with judicial in home services Child home with no services

46. In Cases of Removal Shelter hearing determines placement and permanency plan. Child’s family works on plan to be reunited with child Case Manager with Hillsborough Kids (HKI) works with family and helps with alternate permanency plan.

47. Placement Options With relative or non relative caregiver Group home or residential facility Foster home With parent and Judicial in home services

48. Review and Permanency At 6 and 12 months No Compliance Compliance with plan and child returns home TPR

49. TPR Court Places Child in Permanent Home (adopt, relative, guardian) Foster Care and may receive independent living services Remain in Foster Care Adoption Hearing Closed (by Age) Closed!

50. Detective Child Protection Investigator Attorney General Children’s Legal Services State Attorney’s Office CRIMES SAFETY