Child abuse and neglect

The goals of the National Child Protection Education Project included the following: • assess current understanding of the recognition, reporting, and prevention of child abuse and negle

Medicine

Readers are encouraged to duplicate and use all or part of the information contained in this publication for educational purposes only In accordance with accepted publishing standards, permission must be obtained from the Center for Pediatric Emergency Medicine for information reproduced in another publication

Illustrations created by Virginia Ferrante, MA All drawings and text may be reproduced, as they appear, for not-for-profit use to educate medical personnel

Cite as: David Markenson, Michael G Tunik, Marsha Treiber, Arthur Cooper, Andrew

Skomorowsky, George L Foltin Child Abuse and Neglect: A Prehospital Continuing Education

and Teaching Resource New York, NY: Center for Pediatric Emergency Medicine, 2003

The mission of the Center for Pediatric Emergency Medicine (CPEM) is to improve emergency medical services for children in the United States through education, research, advocacy, and systems development Established in 1985 at New York University School of Medicine and Bellevue Hospital Center in New York City, CPEM is funded primarily by the US Department of Health and Human Services/Health Resources and Services Administration through its Maternal and Child Health Bureau, EMSC Program

The recommendations in this publication are not intended to

indicate an exclusive course of treatment or to serve as a

standard of medical care Individual circumstances may require

variations on these recommendations CPEM disclaims any

liability or responsibility for the consequences of any action

taken in reliance on the statements or opinions contained herein

27 th Street & First Avenue New York, New York 10016 212/562-4470 212/562-7753 fax www.cpem.org

This manual was supported by project grant 4 H34 MC 00077 from the Emergency Medical Services for Children Program as provided by Section 1910 of the US Public Health Service Act Emergency Medical Services for Children is administered by Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, US Department of Health and Human Services in cooperation with the National Highway Traffic Safety Administration.

Editors:

David S Markenson, MD, FAAP, EMT-P

Mailman School of Public Health, Columbia University

Michael G Tunik, MD, FAAP

New York University School of Medicine

Marsha Treiber, MPS

New York University School of Medicine

Arthur Cooper, MD, FAAP, FACS

Columbia University College of Physicians and Surgeons

Andrew Skomorowsky, MFA, NREMT-P

New York University School of Medicine

George L Foltin, MD, FAAP, FACEP

New York University School of Medicine

Executive Editor:Susan E Aiello, DVM, ELS

Contributors:

Raphael M Barishansky, MPH, Hudson Valley Regional EMS Council

Kathleen Brown, MD, Emergency Department of Children’s National Medical Center

Linda Cahill, MD, Child Protection Center of Montefiore Medical Center

Karen M Caravaglia, MS, EMT-P, National Center for Disaster Preparedness,

Columbia University Mailman School of Public Health

Lynn Babcock Cimpello, MD, Departments of Emergency Medicine and Pediatrics

University of Rochester School of Medicine and Dentistry

Susan McDaniel Hohenhaus, RN, BS, EMSC at Duke University Health System

Lori Legano, MD, Child Protection and Development Center of Bellevue Hospital

Hedda Matza-Haughton, MSW, CSW, “For the Health of It” Consultation Services

Margaret McHugh, MD, MPH, Child Protection and Development Center of Bellevue Hospital

Jeffrey Meade, NREMT-P, CIC, Emergency Life Support Programs of

Phelps Memorial Hospital Center

LaVoyce Reid, MSW, LCSW, National Association of Social Workers

Laura L Rogers, JD, American Prosecutors Research Institute’s

National Center for Prosecution of Child Abuse

Medical Illustrator: Virginia Ferrante, MA

Executive Producer - CD-ROM: Mark Marshall

Programming/Mastering/Package Design: Maximum Interactive

www.maximuminteractive.com

CHILD ABUSE AND NEGLECT

TABLE OF CONTENTS

Foreword……… i

Introduction Chapter Objectives 1

Background 1

Risk Factors 1

Child Risk Factors 2

Parental Risk Factors 2

Societal Risk Factors 2

Cycle of Abuse… 2

Role of Pre-Hospital Medical Providers 3

Reporting Requirements 3

Handout 4

Definitions Chapter Objectives 5

Abuse and Neglect Defined 5

The Child Abuse Prevention and Treatment Act 5

Mandated Reporters 6

The Abused Child, Abusive Actions, and the Abuser 6

Child Maltreatment 7

Types of Child Abuse 7

Physical Abuse 7

Sexual Abuse 7

Emotional Abuse 7

Neglect 7

Case Scenario 8

Handout 9

Recognition Chapter Objectives 10

Importance of the History 10

Recognizing the Mechanism and Patterns of Injury 11

Early Childhood Development 11

Right to Privacy 12

Physical Abuse 12

Skin Injuries 12

Bruises 12

Burns 13

Adult Human Bites 13

Fractures 13

Hair Loss 14

Shaken Baby Syndrome 14

Sexual Abuse 15

Emotional Abuse 15

Neglect 16

Munchausen Syndrome by Proxy 16

Sudden Infant Death Syndrome 17

Cultural Considerations 18

Case Scenarios 19

Handout 20

High-Risk Families and Situations Chapter Objectives 22

Differentiating High-Risk Families and Situations 22

Role of Prehospital Medical Providers 23

Surveying the Scene 23

Challenges and Strengths of EMS Providers 24

Intervention 24

Case Scenario 25

Handout 26

Reporting Chapter Objectives 27

State Law 27

Consequences of Failing to Report 28

Form of Report 28

Content of Report 29

Communicating with Caregivers 29

Transfer of Care 30

National Child Abuse Hotline and State Reporting Numbers 30

Case Scenario 32

Handout 33

Documentation Chapter Objectives 36

Evidence 36

Importance of Documentation 37

Proper Documentation 37

General Principles 37

Documenting the Scene 38

Documenting the History 38

Child Protection Services

Chapter Objectives 43

Function of CPS 43

Process of the CPS Agency 43

Sample Case Flow 44

Further Role of EMS Providers 44

Handout 45

Medicolegal Issues Chapter Objectives 46

Introduction and Overview 46

Hearsay Exceptions 47

Excited Utterance 47

State of Mind 47

Statement Made for Medical Diagnosis 47

Present Sense Impression 48

Catch-all Exception 48

Totality of the Circumstances 48

Report Writing and Evidence Collection 49

Verbatim Statements 49

Demeanor and Emotions 49

Timing 49

Evidence Collection 49

Mandatory Reporting 51

Hearsay and EMS Providers (Expanded Explanatory Text) 52

Handout 63

Illustrations Figure 1 – Accidental Bruising 66

Figure 2 – Inflicted Burns and Pinch and Slap Marks 67

Figure 3 – Inflicted Burns 68

Figure 4 – Accidental Splash Burns 69

Figure 5 – Cord and Belt Marks and Inflicted Burns 70

Figure 6 – Coining and Cupping 71

Images Image A – Slap Mark, Face 72

Image B – Grab Marks, Arm 73

Image C – Accidental Bruising, Shins 74

Image D – Immersion Burns, Hands 75

Image E – Immersion Burns, Feet 76

Image F – Immersion Burns, Buttocks 77

Image G – Hot Liquid Burn, Face and Chest 78

Image J – Looped Cord Marks 81 Image K – Strangulation Marks 82

CHILD ABUSE AND NEGLECT

FOREWORD

What do emergency medical services (EMS) providers know about child abuse and neglect? This question was the focal point of a three-year grant project undertaken by the Center for Pediatric Emergency Medicine (CPEM) and funded by the EMS for Children (EMSC)

Program of the federal Health Resources Services Administration (HRSA)/Maternal and Child Health Bureau (MCHB)

The goals of the National Child Protection Education Project included the following:

• assess current understanding of the recognition, reporting, and prevention of child abuse and neglect; treatment of its victims; and the attitudes toward this distressing problem among the nation’s prehospital medical providers

• analyze the results

• bring EMS, EMSC, and child protection advocates together to evaluate results

• utilize the findings to develop this educational program

Three million cases of child abuse are reported in the US annually, making this a significant public health care concern EMS providers are in a unique position, often being the only individuals who have access to a patient’s home They can be the “eyes and ears” of the medical community Their ability to assess and deal sensitively with this issue can have a positive impact on the morbidity and mortality of children While there is a vast amount of information on managing child maltreatment for many levels of health care providers, there has been little information regarding the role of EMS providers Furthermore, there has been

no information on the knowledge, attitude, and state of readiness of EMS providers to deal with child maltreatment The result was a lack of uniform national resource material

addressing the educational needs, attitudes, and role of EMS and other prehospital providers

in child protection CPEM has addressed this gap

First, a national coalition of experts in EMS, EMSC, and child protection was formed This group, along with input of the National EMSC Data Analysis Research Center, created,

piloted, and refined a survey questionnaire in collaboration with the National Registry of EMTs and 15 State EMS Directors In concert with this survey, courses and curricula

currently in existence on child abuse and neglect were identified Although there were many

courses and curricula for other professionals, such as police, social workers, and nurses,

virtually nothing existed specifically for the prehospital provider In addition, information concerning statewide regulations on child abuse in all 50 states was compiled

Second, EMS providers throughout the nation, at the EMT-Basic, EMT-Intermediate, and

EMT-Paramedic levels, were assessed regarding their knowledge of the following:

• the definitions of child abuse and neglect

• possible signs and symptoms of child abuse or neglect

• treatment and transportation strategies

• proper documentation and reporting

• child abuse and neglect laws, regulations, and agency policies in their area of

operation

A key aspect of the project was to evaluate and consider the self-efficacy and attitudes of

prehospital providers toward recognition and management of child abuse and neglect

Following these efforts, a Blue Ribbon panel of national experts in EMSC and child

protection met in October of 2001 to review the results of these surveys and to make

recommendations on content for the EMS child protection resource (Proceedings can be

found on the CPEM website, www.cpem.org, under “Resources.”)

The final result, Child Abuse and Neglect: A Continuing Education and Teaching Resource

for the Prehospital Provider, was created specifically for instructors of EMS prehospital

providers A review board of national experts in EMS, EMSC, and child protection reviewed

draft sections of this educational resource, and national and regional workshops were held to

gather the input of the EMS instructors themselves

CPEM is gratified by the continuing confidence shown in us by the federal government in the

funding of our efforts to improve EMSC around the country We are thankful for the

enormous amount of enthusiasm generated by this exciting project We are grateful for the

wonderful letters of support from EMS, pediatric and child protection organizations, and

especially the State EMS Directors who have consistently supported our efforts

ACKNOWLEDGMENTS

We would like to acknowledge those individuals whose contribution to the development of

this resource was invaluable We thank Dr David Heppel, Dan Kavanaugh, MSW, Cindy

Doyle, RN, and Mickey Reynolds of the HRSA/MCHB EMSC Program, for their direction

and assistance with this project; thanks also to that agency as a whole for providing financial

support We express our appreciation to Lenora Olson, MA and Lawrence Cook, MStat, from

the National Data Analysis Research Center (NEDARC), and to William R Brown, Jr.,

NREMT-P, and Philip Dickison, NREMT-P, of the National Registry of EMTs (NREMT) for

assistance in the design and distribution of the assessment questionnaire, and in the

subsequent data collection, management, and analysis of the results

The authors would especially like to thank Hedda Matza-Haughton, MSW, CSW, for her

professional and enthusiastic management of the project in the establishment of the advisory

board and expert review panel, in the development of the assessment questionnaire and its

distribution, and in the coordination of the Blue Ribbon panel consensus meeting Sarah

Gagnon, EMT, also provided capable and efficient administrative assistance during the

developmental stages of the project

We would like to thank Jane Ball, RN, MPH, DrPH, Ken Allen, Yvonnada Cousins, and the

staff of the EMSC National Resource Center, who helped to coordinate the consensus

meeting, as well as those who attended and provided invaluable input

This program was piloted, with the skilled assistance of Karen Caravaglia, MSOL, EMT-P, at

the New York State Vital Signs Conference (coordinated by Donna Gerard), the Alaska State

EMS Conference (coordinated by Doreen Risley), and at a special workshop hosted by

Oklahoma City EMSC at the University of Oklahoma (coordinated by Paul Marmen) We are

extremely grateful for their gracious hospitality and for the individuals in the workshops who

provided essential feedback about our program

We would like to thank Dr Margaret McHugh and Dr Lori Legano of the Child Protection

and Development Center of Bellevue Hospital, whose consistent support and expertise greatly

strengthened this resource

Many national organizations provided representation on our advisory board, including the

following: American Academy of Pediatrics (AAP), American Academy of Child and

Adolescent Psychiatry, American College of Emergency Physicians, Ambulatory Pediatric

Association, American Psychological Association, Child Welfare Institute, Emergency Nurses

Association, International Association of Chiefs of Police, International Association of Fire

Chiefs, International Society for the Prevention of Child Abuse and Neglect, National

Alliance of Children’s Trust and Prevention Funds, National Association of Emergency

Medical Services Educators, National Association of Emergency Medical Services

Physicians, National Association of Emergency Medical Technicians, National Association of

Pediatric Nurse Practitioners, National Association of School Nurses, National Association of

Social Workers, National Association of State Emergency Medical Services Directors,

National Children’s Alliance, National Center for Prosecution of Child Abuse, National

Council of State Emergency Medical Services Training Coordinators, National EMSC Data

Analysis Resource Center, National Registry of Emergency Medical Technicians, and Prevent

Child Abuse America Their participation and continued support are deeply appreciated

We would like to thank the AAP for their gracious permission to use the color images

included on the CD version of this resource from their publication The Visual Diagnosis of

Child Physical Abuse, 1994

We are grateful to Senator Daniel K Inouye of Hawaii; to his dedicated administrative

assistant, Dr Patrick DeLeon; and to Senator Orrin G Hatch of Utah for creating the EMSC

National Funding Initiative; and to those individuals who work diligently to upgrade

emergency medical services for children in the United States

Finally, we are extremely grateful to the numerous paramedic instructors, medical experts,

and educational consultants who carefully critiqued the information to ensure that this

resource would be both relevant and appropriate Many more dedicated professionals than we

could possibly name gave generously of their own time and expertise Their enthusiastic

participation has been a motivating force behind this project, and they received no

compensation beyond the knowledge that they were helping to create a greatly needed

resource We hope the final product lives up to their efforts, hopes, and expectations

George L Foltin, MD, FAAP, FACEP

Director

Center for Pediatric Emergency Medicine

www.cpem.org

CHILD ABUSE AND NEGLECT

INTRODUCTION

CHAPTER OBJECTIVES

• Create awareness of prevalence of child abuse and neglect

• Identify various risk factors for child abuse and neglect

• Emphasize unique role and contributions of prehospital medical providers in

recognizing and reporting child abuse and neglect

• Introduce legal aspects of reporting child abuse and neglect

BACKGROUND

Child abuse and neglect is found across all levels of socioeconomic status, all racial and

ethnic (cultural) groups, and all religious affiliations Abuse and neglect is widespread

and found in every type of household All EMS providers will likely see cases of child

abuse or neglect at some time

Child abuse is far more prevalent in the United States than many people think The

combined incidence of abuse and neglect is estimated to be about 3 million cases per

year, or about 12 cases for every thousand children (US Department of Health and Human

Services Child Maltreatment 1996: reports from the States to the National Child Abuse and Neglect Data

System, Washington DC: U.S Government Printing Office, 1998) Several thousand children die

each year from acts of child abuse Many cases are never reported, so the actual figures

are certainly much higher In addition, many more children who are assumed to have

died of illness or accidental injury may have suffered abuse as a contributing factor

K EY P OINT : Child abuse and neglect is found across all levels of socioeconomic status,

all racial and ethnic (cultural) groups, and all religious affiliations

K EY P OINT : All EMS providers will likely see cases of child abuse or neglect at some

time

Dr C Henry Kempe is considered to be the “father” of the study of child abuse and

neglect Although it’s tempting to believe that parents who abuse their children don’t

love them, Kempe’s work showed that this generally is not true Often, these adults treat

their children as their parents treated them; in other words, they do not know how to treat

their children appropriately or how to be effective parents Although seeing these types

of cases can generate a lot of emotion, it is important to remember that most of these

parents “love their children very much but not very well.”

RISK FACTORS AND THE CYCLE OF ABUSE

As mentioned above, child abuse or neglect is found in every type of household and is

not restricted to any economic, racial, or cultural segment of society However, there are

certain conditions that can make children more vulnerable to becoming a victim of abuse

These risk factors can result from the characteristics of the child or the parent, or from the

influences of today’s society

Child Risk Factors

Some children are unable to meet their parents’ expectations simply because of their age

(usually younger than 4 years old), or if they have congenital anomalies or a chronic

illness Even when parents’ expectations are realistic and age-appropriate, children who

for any reason experience slow development or a developmental delay may not be able to

meet these expectations Hence, the child may be perceived as “different” or “abnormal”

and possibly more vulnerable to abuse These children often require additional care,

time, and resources, which can all place additional burdens on an already stressed parent

or family

Parental Risk Factors

Parents sometimes have unrealistic expectations of their child’s development or behavior

For example, it is unrealistic for parents to expect a one-year-old child to be

toilet-trained Parents who were abused when they were children and who haven’t learned how

to deal with stress, frustration, or anger might be more likely to abuse their own children

Substance abuse is also a risk factor, as is isolation When families are isolated or isolate

themselves, they often do not develop support systems, do not know how to identify and

use social support systems, and do not trust others

Societal Risk Factors

Risk factors imposed by society include various types of violence, as well as poverty and

a lack of access to health care and other services The rate of child abuse is far higher in

homes in which there is domestic violence and the mother is also abused Exposure to

violence on television has also been related to an increased acceptance of aggressive

attitudes and behavior

The Cycle of Abuse

Family violence is associated with an increased likelihood of child abuse Children who

have been abused often learn in turn to be more aggressive toward other more vulnerable

family members In this way, abuse is perpetuated into the next generation, resulting in

the “abused-to-abuser” cycle

To prevent abuse from continuing, the cycle must be interrupted Ways to assist in doing

so include:

• obtaining greater assistance from local child protection agencies (eg, parenting

information and classes)

• providing counseling and support for all family members

• involving the child with a nonabusive adult

Having family resources available to EMS providers may help the referral system in a

community

ROLE OF PREHOSPITAL MEDICAL PROVIDERS

EMS providers are in a unique position of being able to recognize and report suspected

child abuse and neglect This important role is based on a number of factors EMS

providers are:

• often the only health care professionals who have unannounced access to a

patient’s home

• able to assess the family environment and relationships among family members

• often first on the scene of an emergency

• first to gather the history in a situation that is suspicious of abuse or neglect

Accordingly, EMS providers also have a great responsibility to recognize and report

suspected child abuse and neglect to help safeguard children To fulfill this important

role, EMS providers must be able to:

• recognize the signs and symptoms of abuse or neglect

• provide immediate medical evaluation and treatment

• protect the child from further abuse

• document all findings accurately, thoroughly, and legibly

• report all cases of suspected abuse and neglect

K EY P OINT : EMS providers are society’s first defense against child abuse and neglect

They can be the eyes and ears of the medical community

REPORTING REQUIREMENTS

States differ in their laws regarding the reporting of suspected child abuse or neglect, and

all EMS providers should become familiar with the laws in their state In most states,

EMS providers are legally required to report such suspicions to the appropriate

authorities For example, in the state of New York, all EMS providers are mandated

reporters and, therefore, are required to report information concerning suspected child

abuse provided such information was attained in the performance of their official duties

Furthermore, there are penalties associated with failing to report a case of suspected child

abuse or neglect However, in all states, the law provides for immunity from liability, as

long as the report was made in “good faith” with no malicious intent In addition to the

legal obligation to report, everyone has a moral obligation to report suspected child abuse

or neglect to prevent it from continuing (For more information on reporting, see also the

chapters on Reporting and Medicolegal Issues.)

CHILD ABUSE AND NEGLECT

INTRODUCTION

Background

Child abuse and neglect is widespread and found across all levels of socioeconomic

status, all racial and ethnic (cultural) groups, and all religious affiliations

All EMS providers will likely see cases of child abuse or neglect at some time

EMS providers are society’s first defense against child abuse and neglect They can be

the eyes and ears of the medical community

Risk Factors

Risk factors can make children more vulnerable to becoming a victim of child abuse or

neglect Risk factors can result from the characteristics of the child (eg, delayed

development, chronic illness) or of the parent (eg, unrealistic expectations, substance

abuse, isolation), or from the influence of today’s society (eg, violence, poverty)

Role of Prehospital Medical Providers

Prehospital medical providers are in a unique position to recognize and report suspected

child abuse or neglect They are:

• Often the only health care professionals permitted access to a patient’s home

• Able to assess family environment and relationships among family members

• Often first on the scene

• First to gather history

Prehospital medical providers also have a great responsibility in suspected cases of child

abuse or neglect They must be able to:

• Recognize signs and symptoms of abuse or neglect

• Provide medical evaluation and treatment

• Protect from further abuse

• Document all findings accurately, thoroughly, and legibly

• Report all cases of suspected abuse or neglect

Reporting Requirements

Reporting requirements vary by state In most states, EMS providers are mandated

reporters, ie, legally required to report suspected child abuse or neglect All states

provide mandated reporters with immunity from liability provided the report was made in

“good faith” with no malicious intent Everyone has a moral obligation to report

CHILD ABUSE AND NEGLECT

DEFINITIONS

CHAPTER OBJECTIVES

• Define child abuse and neglect

• Define mandated reporters

• Explain the legal definition of child maltreatment

• Define and explain physical abuse, sexual abuse, emotional abuse, and neglect

• Present and discuss case scenario

ABUSE AND NEGLECT DEFINED

The following are general definitions of child abuse and neglect:

In child abuse, a child has suffered physical and/or emotional injury inflicted by a

caregiver (eg, parent, legal guardian, teacher, etc) that results in disability, disfigurement,

mental distress, or risk of death

In child neglect, a child’s physical, mental, and/or emotional condition has been

endangered because the caregiver has not provided for the child’s basic needs

However, states vary in their definition of child abuse and neglect and in their efforts to

regulate protective services for children For example, some states emphasize the

presence of serious physical injury to substantiate a finding of physical abuse or neglect,

while other states emphasize simply the presence of an imminent threat of injury When

in doubt, prehospital medical providers should always err on the side of caution and

either consult with child protection services or make a referral

The Child Abuse Prevention and Treatment Act

A widely accepted definition of child abuse and neglect is provided by the federal Child

Abuse Prevention and Treatment Act (PL 93-247) enacted in 1974, as amended by the

Child Abuse Prevention, Adoption, and Family Services Act of 1988 and by the Keeping

Children and Families Safe Act of 2003

The Act defines child abuse and neglect as:

“the physical or mental injury, sexual abuse or exploitation, negligent treatment,

or maltreatment of a child under the age of 18, or except in the case of sexual

abuse, the age specified by the child protection law of the State by a person

(including any employee of a residential facility or any staff person providing

out-of-home care) who is responsible for the child's welfare under circumstances

which indicate that the child’s health or welfare is harmed or threatened

thereby ”

The Act defines sexual abuse as:

“the use, persuasion, or coercion of any child to engage in any sexually explicit

conduct (or any simulation of such conduct) for the purpose of producing any

visual depiction of such conduct, or rape, molestation, prostitution, or incest with

children ”

Amendments to the Child Abuse Prevention and Treatment Act also include as child

abuse the withholding of medically indicated treatment for an infant’s life-threatening

condition(s)

MANDATED REPORTERS

Mandated reporters are professionals designated by state law because they are

specifically equipped to recognize child maltreatment, abuse, or neglect In addition, by

virtue of their position and role in society, they are opportune personnel to recognize

child maltreatment, abuse, or neglect Mandated reporters are legally required to report

suspected child abuse or neglect when presented with reasonable cause Examples of

individuals who are mandated reporters in all or most states include EMS providers,

physicians, nurses, teachers, police, lawyers, counselors, and others (For more

information on reporting, see also the chapters on Reporting and Medicolegal Issues.)

K EY P OINT : Mandated reporters are legally required to report suspected child abuse or

neglect when presented with reasonable cause EMS providers are

mandated reporters in most states

THE ABUSED CHILD, ABUSIVE ACTIONS, AND THE ABUSER

An abused child is a child less than 18 years old whose parent or other person legally

responsible for his or her care, inflicts, or allows to be inflicted on the child, serious

physical injury, a substantial risk of physical injury, or a sexual offense against the child

Abusive actions against a child include serious physical injury that is not explained by the

history and cannot have been caused accidentally, any act of a sexual nature on or with a

child, or chronic attitude or acts that interfere with the healthy psychological or social

development of a child

Close to 90% of the perpetrators of child maltreatment are the parents, a parent’s

paramour, or other relatives The rest are persons in other caretaking roles (eg, foster

parents, facility staff, child care providers)

CHILD MALTREATMENT

A maltreated child is a child less than 18 years old whose physical, mental, and/or

emotional condition has been impaired or is in danger of becoming impaired as a result of

the failure of his or her parent or other person legally responsible for his or her care to

exercise a minimal degree of care This includes the following:

• failure to supply the child with adequate food, clothing, shelter, education, or

medical or surgical care, although financially able to do so or offered financial or

other reasonable means to do so

• failure to provide the child with proper supervision or guardianship

• unreasonably inflicting, or allowing to be inflicted, harm or substantial risk

thereof, including the infliction of excessive corporal punishment

• using a drug or drugs

• using alcoholic beverages to the extent that he or she loses self control of his or

her actions

• any other acts of a similarly serious nature requiring the aid of the family court

TYPES OF CHILD ABUSE

The four types of child abuse are physical abuse, sexual abuse, emotional abuse, and

neglect, with the latter being the most common

Physical Abuse

In physical abuse, a nonaccidental physical injury that results in distress, disfigurement,

or death is inflicted on a child Examples of physical abuse include punching, beating,

kicking, biting, burning, and shaking The use of physical discipline is also included if it

leaves a lasting physical mark

Sexual Abuse

Sexual abuse consists of using, persuading, or coercing a child to engage in any sexually

explicit conduct Examples include fondling, intercourse (including incest), rape,

molestation, sodomy, and exhibitionism Forcing a child to view pornography is also

considered sexual abuse

Emotional Abuse

In emotional abuse, the parent or caregiver exhibits persistent behavior that interferes

with the normal development of a child Emotional abuse is present in all other forms of

child abuse, but it can also be seen by itself

Neglect

Neglect is the most common form of abuse It is failure to act on behalf of a child and

includes the following:

• Failure to provide for the child’s physical, mental, or emotional needs

• Failure to provide adequate food, clothing, shelter, education, or medical care,

including a delay in seeking care for a known illness

• Failure to meet requirements basic to a child’s physical development

• Failure to provide support or affection necessary to a child’s psychological and

social development

• Failure to provide proper supervision

• Abandonment

• Substance abuse (excessive use of drugs or alcohol) by the parent or caregiver

such that it interferes with his or her ability to supervise the child

K EY P OINT : The four types of child abuse are physical abuse, sexual abuse, emotional

abuse, and neglect Emotional abuse is present in all other forms of child abuse but can also be seen by itself Neglect is the most common form of child abuse

CASE SCENARIO

Discuss the following case scenario and whether child abuse or neglect should be

suspected

Case: On arriving at an emergency call, EMS providers find a 2-year-old girl sitting on

the couch in the living room with her mother and aunt The child has her feet up and a

bag of ice on her lower left leg The mother says that the girl fell off a chair in the living

room while trying to reach a jar on a high shelf On examining the child, there is a

greenish yellow bruise surrounding her upper right arm and a long, rectangular, reddish

purple bruise across the child’s back The mother offers no explanation for these bruises

The ankle under the ice bag is swollen, bruised, and tender The aunt says the child fell

off the parents’ bed and hurt her leg When the EMS providers ask the girl how she hurt

her leg, the girl becomes upset and starts to cry No shelves are seen in the living room,

and the floor is carpeted

CHILD ABUSE AND NEGLECT

DEFINITIONS

General Definitions

In child 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 In child neglect, a child’s physical, mental, or emotional

condition has been endangered because the caregiver has not provided for the child’s

basic needs

Note: States vary in their definition of child abuse and neglect and in their efforts to

regulate protective services for children When in doubt, prehospital medical providers

should always err on the side of caution

K EY P OINT : Mandated reporters are legally required to report suspected child abuse or

neglect when presented with reasonable cause EMS providers are

mandated reporters in most states

Types of Abuse

In physical abuse, an inflicted physical injury results in distress, disfigurement, or death

of a child (eg, punching, beating, kicking, biting, burning, shaking)

Sexual abuse consists of using, persuading, or coercing a child to engage in any sexually

explicit conduct (eg, fondling, intercourse, rape, molestation, sodomy, exhibitionism)

In emotional abuse, the parent or caregiver exhibits persistent behavior that interferes

with the normal development of a child Emotional abuse is present in all other forms of

child abuse, but it can also occur by itself

Neglect is the most common form of abuse It is failure to act on behalf of a child and

includes the following:

• Failure to provide for the child’s physical, mental, or emotional needs

• Failure to provide adequate food, clothing, shelter, education, or medical care,

including a delay in seeking care for a known illness (eg, a baby’s diaper changed

so infrequently that a severe, red, scaly diaper rash develops)

• Failure to meet requirements basic to a child’s physical development

• Failure to provide support or affection necessary to a child’s psychological and

social development

• Failure to provide proper supervision

• Abandonment

• Substance abuse (excessive use of drugs or alcohol) by the parent or caregiver

such that it interferes with his or her ability to supervise the child

K EY P OINT : The four types of child abuse are physical abuse, sexual abuse, emotional

abuse, and neglect Emotional abuse is present in all other forms of child abuse but can also be seen by itself Neglect is the most common form of child abuse

CHILD ABUSE AND NEGLECT

RECOGNITION

CHAPTER OBJECTIVES

• Emphasize the importance of the history in relation to the extent of injury in

recognizing the possibility of child abuse

• Recognize patterns of injury in child abuse to differentiate between unintentional

and inflicted injuries

• Develop familiarity with normal childhood developmental abilities

• Review typical injuries commonly seen in physical abuse of children, including

skin injuries, fractures, falls, injuries to the face and head, hair loss, and shaken

baby syndrome

• Review typical presentation of cases of sexual abuse in children and how to

appropriately manage such cases

• Review characteristics of emotional abuse in children

• Review specific indicators of neglect

• Create awareness of cultural differences and the impact they have on evaluation

of suspected child abuse

• Explain recognition and management of cases of sudden infant death syndrome

• Present and discuss case scenarios

IMPORTANCE OF THE HISTORY

To recognize abuse, abuse must be considered a possibility Errors in recognizing child

abuse can have devastating consequences; the child, and possibly other children in the

household, may suffer needlessly

Determining whether an injury or illness could have been caused unintentionally or was

inflicted is critical In general, people want and tend to believe what they are told

Therefore, considering whether the injury or illness is consistent with the history given by

the parent or caregiver and by the child is extremely important For example, if a parent

says a child fell off the couch and struck her head on the floor, but the floor is carpeted

and the child is limp and unresponsive, the extent of injury is inconsistent with the

history Likewise, when the parent or caregiver says “I don’t know what happened,” or

“It was an accident,” or the explanation given is vague, further investigation is warranted

Other historical factors that might indicate the presence of abuse include multiple visits to

the same household, inadequately explained incidents, or previous visits to the household

for family violence Noting this information may indicate a more in-depth evaluation,

especially when multiple health care providers are involved

RECOGNIZING THE MECHANISM AND PATTERNS OF INJURY

One of the most important areas of expertise for the EMS provider is the interpretation of

mechanism of injury This must be considered in view of the history, again noting

whether or not the injuries are consistent with the history

Early Childhood Development

When trying to identify the mechanism of an injury in a child, it is important to consider

the child’s developmental age For an injury to occur unintentionally, the child must be

developmentally mature enough to have caused the specific injury, ie, the child must

have specific motor skills For example, an explanation of a 6-week-old infant crawling

into a hazardous area raises suspicion because such a young child is not physically or

developmentally able to crawl Likewise, if the explanation is that a sibling caused the

injury, whether the sibling is developmentally capable of doing so must be considered

The following table provides some general guidelines for developmental abilities in early

childhood

Birth–1 month Normally alert, looking around

Focuses on faces or objects, but does not follow movement Extremities flexed at elbows and knees

2–3 months Follows movement of objects or faces

Begins to smile Extremities flexed at elbows and knees 4–6 months Begins to eat baby food with assistance

Reaches for objects

Rolls over May grab at objects or push away hand(s) of others Extremity flexion decreases

6–8 months Can sit up

Becomes fearful of strangers Begins imitating word sounds (eg, ma ma ma, da da da)

12-18 months Learns to walk

Can climb stairs one step at a time (18 months) Begins to use single words

2 years Actively explores environment

Does not like to sit still (understatement)

3 years and older Develops language and some reasoning abilities

Note: Children who are frightened or in pain may act younger than their age

RIGHT TO PRIVACY

Children have the right to privacy and can refuse to have their privacy invaded

Adolescents are often especially sensitive about privacy issues An unwilling child

should never be examined, especially if the child is suspected to be a victim of sexual

abuse In these cases, the EMS provider could be perceived as part of the assault

Certainly, there are times when a child needs care and doesn’t like it Explanations can

sometimes help, but the child should be given choices when possible

CAUTION: Some of the images in the slide presentation associated with this chapter are of a graphic and disturbing

nature These images are not meant to shock or upset, but rather to inform and instruct Knowing in advance various

presentations of child abuse can better prepare the prehospital provider for exposure to actual instances of child abuse

and neglect

Many people react emotionally to images of injured children; these responses are normal and vary from individual to

individual Instructors are urged to use discretion in presenting these slides.

PHYSICAL ABUSE

Skin Injuries

Skin injuries are the most common and easily recognized sign of physical abuse The

skin examination should be complete and thorough; it should always include looking for

cuts, scrapes, bruises (ecchymosis), burns, bites, redness, and swelling See Images A

and B If these injuries are not present, this should also be documented For example,

“5-year-old girl with red, swollen right cheek No tears, abrasions, or bruising seen.”

Diagramming the information on the ambulance call report is very important

Skin injuries should be described in a consistent manner If injuries are described

systematically and completely, an injury that might otherwise be missed is more likely to

be identified For example, a child being treated for an apparent unintentional burn may

have other, less obvious injuries The most readily visible injury may not be the only

one

Bruises: Documenting the appearance and location of a bruise is important, as is how

the child and parent or caregiver states that it was incurred The key to assessing bruising

is noting whether it is in an area where the child is unlikely to have sustained it

accidentally Infants rarely bruise accidentally because they are not yet standing or

walking Toddlers and other young, active children tend to incur bruises naturally on the

front of their bodies (eg, knees, shins, elbows, forearms, forehead) as they explore the

world and hit various objects Bruises that take the recognizable shape of an object are

suspect See Figure 1 and Image C for examples of accidental bruising

Multiple bruises in various locations and that are different colors, generally indicating

different stages of healing, are suspect In these cases, parents may say that the child

“bruises easily.” In general, the specific aging of bruises should be left to a clinician

specifically trained in child abuse

Some common conditions can be confused with abuse For example, mongolian spots,

which may appear to be bruises on the buttocks, are often found in dark-skinned children

Burns: Scald burns are one of the more common inflicted burns in child abuse The two

general patterns of scald burns are immersion and splash Immersion burns are

characterized by clear lines of demarcation with no or few splash marks The

“donut-pattern” burn on the buttocks or stocking pattern burns of the lower legs are typical In

accidental burns, splash marks are common due to the child rapidly withdrawing from the

source of the heat See Figures 2, 3, 4, and 5 and Images D, E, F, and G for examples of

immersion burns and splash burns

Another type of burn seen in child abuse is an inflicted contact burn This type of burn is

recognized by having a shape that duplicates the object used to produce it (eg, a cigarette,

a curling iron) In contrast, when a child accidentally touches a hot object and reflexively

withdraws, the shape of the burn tends to be irregular Such unintentional burns are

commonly found on the hands or face Intentional burns tend to be in less exposed areas

and are deeper and larger See Figures 2 and 5 for examples of inflicted contact burns

Adult Human Bites: Adult human bite marks strongly suggest abuse Generally, in

human bite marks, no one tooth mark stands out, differing from an animal bite Marks

from the canine teeth are more easily recognizable when the bite is inflicted by an adult

as opposed to by another child

Bite marks on infants tend to be found on the genitals and buttocks, and are usually

inflicted as punishment Older children tend to have bite marks that are associated with

assault or sexual abuse In general, there are multiple, random bite marks that have a

well-defined appearance and may be associated with a sucking mark

K EY P OINT : Skin injuries are the most common and easily recognized sign of physical

abuse The skin should be examined completely and thoroughly, looking for cuts, scrapes, bruises, burns, bites, redness, and swelling

Fractures

Fractures are suspicious of abuse in the following situations:

• The skeletal injury is inconsistent with the history

• Unsuspected fractures are discovered in the course of the examination

• Fractures are multiple, symmetrical, or in different stages of healing

• Skeletal trauma is accompanied by other injuries (eg, burns) to other parts of the

body

Falls

Children who fall from a standing position or from a fairly low object less than the

child’s height (eg, a couch) rarely have serious injuries Even falling down stairs usually

results only in bruises over different body sites, although sometimes a skull fracture may

be sustained In general, it takes a fall from approximately greater than the child’s height

to sustain serious injury

Injuries to the Face and Head

Unintentional injuries to the face or head usually involve the front of the body Injuries

to the side of the face (temple area), cheeks, or ears are suspicious of abuse A direct

blow to the mouth usually results in a ragged or linear tear of the lip(s), possibly

accompanied by a broken jaw or teeth

Infants may sustain injuries during feeding by having a spoon or other object forced into

their mouth A torn frenulum (the band of tissue connecting the tongue to the floor of the

mouth) may indicate forcing a nipple from a bottle or pacifier into the child’s mouth

Considerable force is required to cause severe head trauma High velocity impact injuries

or falls from extreme heights or onto extremely hard surfaces can result in serious injury,

and these events rarely occur without a consistent history

Hair Loss

Hair loss, either inflicted by another person or self-inflicted, can be a manifestation of

child abuse A child may pull out his or her own hair to relieve excessive stress

Dragging a child by pulling on his or her hair can cause traumatic loss of hair Trauma to

the hair and scalp can also be caused by use of excessive force during hair brushing and

certain types of hair braiding In hair loss due to abuse, there is often blood beneath or at

the surface of the scalp

Shaken Baby Syndrome

Shaken baby syndrome is most common in infants and children less than two years old

A baby who is shaken violently can have severe head injuries Shaking can damage

nerve tissue deep within the brain and tear the veins between the brain and the skull

lining, causing hemorrhages and cerebral swelling The child may also have fractures of

the long bones However, there may be no external evidence of trauma Signs to look for

include decreased consciousness, seizures, vomiting, or other signs or symptoms of head

injury Altered mental status may be the only sign that injury has occurred The child

may have an unusual cry

Although a definitive diagnosis must be made by a physician, recognizing the possibility

of shaken baby syndrome should trigger a suspicion of abuse

SEXUAL ABUSE

Sexual contact or assault is frequently thought of as having occurred recently, ie, within

the past 72 hours In these cases, most often a child will complain of pain, bleeding, or

discharge from the urethra, vagina, or rectum More insidious, but also common, is the

chronic “hidden” abuse that has occurred in the preceding weeks or months These

children may exhibit symptoms of recurring nonspecific abdominal pain, vaginal

inflammation, or dysuria (difficulty or pain during urination) Regardless, in most cases

of sexual abuse, the physical examination is normal, and the diagnosis is made primarily

based on the history Unless there is severe genital pain or gross genital bleeding, a

genital examination of a child suspected to be a victim of sexual abuse should not be

performed by prehospital personnel

When a child is suspected of being a victim of sexual abuse, the following points are key

to appropriately managing the case:

• Believe what the child says

• Use the child’s own words, and document his or her statements in quotes

• Never examine an unwilling child

• Do not remove a child’s clothing for transport or before examination by an

appropriate clinician, unless it is medically necessary

• Refer the child to a physician, a Sexual Assault Nurse Examiner (SANE), or other

health professional who has been specially trained in performing these

examinations

K EY P OINT : In most cases of sexual abuse, the physical examination is normal, and the

diagnosis is made primarily based on the history Unless there is severe genital pain or gross genital bleeding, a genital examination of a child

suspected to be a victim of sexual abuse should not be performed by

prehospital personnel

EMOTIONAL ABUSE

Emotional abuse is a component of all forms of child abuse It is a concerted attack on a

child’s development of self and social competence, although parents or other caregivers

may not do so on a conscious level Most cases are mild and do not progress to the point

that child protection services are needed However, early recognition of emotional abuse

can prompt early intervention and treatment

Emotional abuse includes the following:

• Ignoring the child and failing to provide necessary stimulation and validation of

the child’s worth in a normal family routine

• Rejecting the child’s needs and requests for adult nurturance

• Isolating the child from the family and community

• Continually verbally assaulting the child with name-calling or harsh threats

• Encouraging and reinforcing destructive, antisocial behavior, thereby corrupting

the child

• Repeatedly humiliating the child

• Pressuring the child with consistent messages to “grow up” fast and perform tasks

beyond his or her developmental level

NEGLECT

Neglect is the most common form of child abuse and likely the most under recognized

and under reported form When a child exhibits an injury or illness that could have

resulted from neglect, the EMS provider should look for a mechanism to explain the

physical signs Neglected children suffer greatly and are often left with emotional scars

that may never heal

Neglect can be manifested in many ways Some specific indicators of child neglect

include the following:

• Inadequate care, including inadequate provision of food, clothing, or shelter

• Inadequate medical attention, including a delay in seeking care for a known

illness (eg, while child is having an asthma attack, the mother leaves the home to

• Evidence of substance abuse by parent or other caregiver

• Structural, fire, or other environmental hazards

MUNCHAUSEN SYNDROME BY PROXY

Munchausen syndrome by proxy is a bizarre and rare form of child abuse, and it seems

probable that most cases go unrecognized and unreported In Munchausen syndrome by

proxy, an illness in a child is repeatedly induced (or faked) by a parent or other caregiver,

who denies knowledge of the cause The parent or caregiver persistently presents the

child for treatment, often resulting in multiple medical procedures Symptoms abate

when the child is separated from the parent or caregiver

Most victims are infants or young children, although older children have also been

affected Some common presentations are bleeding, seizures, apnea, diarrhea, vomiting,

fever, and rash The mother is almost always the perpetrator, and she usually has

sophisticated medical knowledge

If Munchausen syndrome by proxy is suspected, the safety of the child is the primary

consideration These children are at high risk of serious long-term disability or death

Social services should be contacted immediately Family members should not be allowed

to give any food, drink, or medicine to the child All sources of food, syringes,

intravenous bags, etc should be considered as suspect The child should never be left

alone with the parent or caregiver

SUDDEN INFANT DEATH SYNDROME (SIDS)

In SIDS, an apparently healthy infant dies suddenly and unexpectedly, almost always

during sleep It cannot be predicted or prevented, and no cause of death can be identified

from the medical history or investigation of the environment SIDS is a diagnosis of

exclusion made by a forensic pathologist after an autopsy examination

The focus of EMS providers at the scene of a possible SIDS incident first must be to

provide appropriate emergency care of the infant If the initial examination at the scene

does not clearly indicate death, the child should be resuscitated and transported according

to local or regional protocols If there is complete certainty that the child is dead, local

laws dictate whether the child’s body should be left as is at the scene for the arrival of the

medical examiner, or transported to a hospital or morgue If the family members are

unable to accept that the child has died despite clear findings, resuscitation should be

performed

Surveying the scene and preparing detailed documentation is extremely important in

these cases, although time may be limited because of resuscitation efforts and transport

Items to include in a general assessment of the environment where the child is found

include the overall hygiene of the household, the ambient air temperature (very hot or

cold), evidence of drug or alcohol use, and risk factors associated with sleeping (eg,

defective cribs, cords, strings, dangerous toys, plastic bags)

While SIDS may be mistaken for child abuse, it is not Although some of the physical

examination findings of an apparent SIDS victim (eg, blood-tinged foam around the nose

or mouth) may be similar to those of an abused child, the characteristic signs of physical

abuse (eg, burns, bruises, or other injuries in typical patterns or locations) are not present

Apparent SIDS is rarely determined by autopsy to be child abuse Therefore, the parents

and family of a suspected SIDS victim should be treated as grieving relatives and given

as much support as possible

CULTURAL CONSIDERATIONS

Childrearing practices are greatly influenced by the culture of the society in which the

children and parents live As such, there are many variations in childrearing For

example, in some cultures, it is acceptable to let babies cry themselves to sleep (rather

than holding them) In other cultures, children sleep in the parents’ bed for several years

Cultural differences may affect the evaluation of cases of suspected child abuse in

different ways What is considered abuse in one culture may be the norm in another For

example, in cultures that practice scarification of the face as an initiation rite, marking a

child’s face gives him a place in society; other cultures, including in the United States,

view this as child abuse Another example is the use of physical punishment for

discipline In certain families, this method of discipline is passed down from generation

to generation In the United States, severe physical punishment constitutes child abuse,

and a report to child protection services may be required Families from different

cultures may not understand the reason for the report and, therefore, need to be educated

on what is (and what is not) considered acceptable in the United States

Certain folk medicine practices may mimic abuse Many such practices result in skin

lesions that may be confused with those seen in child abuse For example, some Asian

medical practices involve rubbing a coin or spoon along the skin, which may produce a

bruise-like rash (purpura or petechiae), classically in a symmetric pattern In cupping,

which is practiced in Asia, Europe, Russia, and the Middle East, a heated cup is applied

to the skin at certain points As the cup cools, suction is created between the cup and the

skin, which can cause circular skin bruises (ecchymoses) See Figure 6 and Images H

and I for examples of coining and cupping Moxibustion is a therapy related to

acupuncture Lighted objects such as incense or yarn are placed near or on the skin at

certain points, resulting in burns Child abuse reports should not be made for folk

medicine practices

Learning about other cultures, especially those present in our own communities, is

important to help us understand why children may be treated in a certain way Although

we need to protect children from harm and report suspected child abuse, we must also be

sensitive to the fact that families may not realize that what they are doing is considered

child abuse in the United States or that certain folk medicine practices may mimic child

abuse

K EY P OINT : Childrearing practices are greatly influenced by culture, resulting in many

variations in childrearing What is considered abuse in one culture may be the norm in another In addition, certain folk medicine practices may mimic signs of abuse

CASE SCENARIOS

Consider the following case scenarios and discuss whether or not they are suspicious of

abuse or neglect If so, discuss the type of abuse or neglect suspected, and the reasons for

the suspicion

Case #1: A 6-month-old baby has fallen from her crib Her father says that she fell from

her crib with the rail up On examination, she has purple, brown, and yellow bruises on

her inner thighs and buttocks

Case #2: A 13-year-old boy is wheezing and gasping for air He has a history of asthma

since birth The mother states she ran out of his asthma medication three weeks ago, and

he’s had breathing problems just like this for two days

Case #3: A 4-year-old boy is reported to have an injured leg The father says that the

boy climbed up on the father’s bicycle and rode the bike down the street, when the

bicycle fell over On physical examination, the child has a swollen and deformed thigh

Case #4: A 2-month-old infant appears to have an altered mental status and is

unresponsive Her mother says the baby was fine before she rolled off the couch onto the

rug, and now she won’t wake up after the fall

Case #5: A 2-year-old boy has scald burns with irregular borders on his face, neck, arms,

and upper chest The parents say that he reached up over his head and grabbed a cup of

hot tea that was on the edge of the kitchen table, spilling it on himself

Case #6: A 10-year-old boy has a leg injury While the 10-year-old is being treated, his

5-year-old sister is playing with her dolls She takes off the doll’s clothes, touches the

genital area, and says, “I know it hurts, but it’s okay.”

Case #7: An unresponsive 2-month-old infant has some bloody, frothy discharge from

the nose On examination, the child’s body has no marks or bruises The parents state

they found the child this way after a nap Resuscitation efforts are begun, and the infant

is transported to the hospital, where he is declared dead

Case #8: A 6-year-old girl has called 911 because her 3-year-old sister fell and her knee

is bleeding When asked where her mother is, the 6-year-old says she went to the store a

while ago and hasn’t come back

K EY

Case #1: Suspicious of abuse; note developmental age of child and unusual location of bruises

Case #2: Suspicious of neglect

Case #3: Suspicious of abuse

Case #4: Suspicious of abuse; shaken baby syndrome

Case #5: Accidental scald

Case #6: Suspicious of sexual abuse

Case #7: Sudden infant death syndrome

Case #8: Suspicious of neglect

CHILD ABUSE AND NEGLECT

RECOGNITION

Importance of the History

K EY P OINT : Always consider whether the history is consistent with the injury If the

history is not consistent with the severity of the injury, abuse must be strongly considered

Recognizing the Mechanism and Patterns of Injury

The interpretation of the mechanism of injury must be considered in view of the history,

again noting whether or not the injuries are consistent with the history

Early Childhood Development: The child’s developmental age should be considered

when trying to identify the mechanism of injury For an injury to occur unintentionally,

the child must be developmentally mature enough to perform an action that may have led

to the specific injury, eg, the child must have specific motor skills

Birth–1 month Normally alert, looking around

Focuses on faces or objects, but does not follow movement Extremities flexed at elbows and knees

2–3 months Follows movement of objects or faces

Begins to smile Extremities flexed at elbows and knees 4–6 months Begins to eat baby food with assistance

Reaches for objects 4–10 months Crawls

Rolls over May grab at objects or push away hand(s) of others Extremity flexion decreases

6–8 months Can sit up

Becomes fearful of strangers Begins imitating word sounds (eg, ma ma ma, da da da)

12-18 months Learns to walk

Can climb stairs one step at a time (18 months) Begins to use single words

2 years Actively explores environment

Does not like to sit still (understatement)

3 years and older Develops language and some reasoning abilities

Note: Children who are frightened or in pain may act younger than their age

Right to Privacy

Children have the right to privacy and can refuse to have their privacy invaded

Adolescents are often especially sensitive about privacy issues An unwilling child

Physical Abuse

K EY P OINT : Skin injuries are the most common and easily recognized sign of physical

abuse The skin should be examined completely and thoroughly, looking for cuts, scrapes, bruises, burns, bites, redness, and swelling

Other types of physical abuse include fractures, injuries to the face and head, hair loss,

and shaken baby syndrome

Sexual Abuse

Sexual abuse can have occurred recently, or more commonly, in the preceding weeks or

months

K EY P OINT : In most cases of sexual abuse, the physical examination is normal, and the

diagnosis is made primarily based on the history Unless there is severe genital pain or gross genital bleeding, a genital examination of a child

suspected to be a victim of sexual abuse should not be performed by

prehospital personnel

Emotional Abuse

Emotional abuse is a component of all forms of child abuse It is a concerted attack on a

child’s development of self and social competence, although parents or other caregivers

may not do so on a conscious level Emotional abuse includes ignoring, rejecting,

isolating, humiliating, or verbally assaulting a child

Neglect

Neglect is the most common form of child abuse and likely the most under recognized

and under reported form Some specific indicators of child neglect include inadequate

care (eg, inadequate food, clothing, or shelter), inadequate medical attention (including a

delay in seeking care for a known illness), poor personal hygiene, lack of supervision,

and evidence of substance abuse by parent or other caregiver

Sudden Infant Death Syndrome (SIDS)

In SIDS, an apparently healthy infant dies suddenly and unexpectedly, almost always

during sleep No cause of death can be identified from the medical history or

investigation of the environment Apparent SIDS is rarely determined by autopsy to be

child abuse Therefore, parents and family should be given as much support as possible

The focus of EMS providers at the scene of a possible SIDS incident must be to provide

appropriate emergency care of the infant If the initial examination at the scene does not

clearly indicate death, or the parents cannot accept that the child is dead, the child should

be resuscitated and transported according to local or regional protocols

Cultural Considerations

K EY P OINT : Childrearing practices are greatly influenced by culture, resulting in many

variations in childrearing What is considered abuse in one culture may be the norm in another In addition, certain folk medicine practices may mimic signs of abuse

CHILD ABUSE AND NEGLECT HIGH-RISK FAMILIES AND SITUATIONS

CHAPTER OBJECTIVES

• Define and differentiate high-risk families and situations from child abuse and neglect

• Explain scene survey and challenges and strengths of EMS providers

• Describe types of interventions and other available resources

• Present and discuss case scenario

DIFFERENTIATING HIGH-RISK FAMILIES AND SITUATIONS

In recent years, child protection services throughout the United States have received 3

million referrals per year for suspected cases of child abuse or neglect In more than half

of these reports, further investigation to either substantiate or rule out abuse or neglect

was warranted, and hundreds of thousands of children were found to be victims of

maltreatment—physical abuse, sexual abuse, emotional abuse, or some form of neglect

In most of these cases, circumstances led to a suspicion of abuse or neglect However, in

other cases, more subtle (and sometimes surmountable) risk factors were present that

warranted concern for the welfare or well-being of a child, but not necessarily a report to

child protection services Some factors that may be associated with an increased

likelihood of child abuse and neglect include:

• Physical discipline in the home

• Domestic violence

• Substance abuse

• Children with special health care needs

Determining how to respond or act in high-risk situations that do not necessarily meet the

criteria for making a report or referral is often a challenge Understanding the definition

of child abuse and neglect (see Definitions chapter) is essential for distinguishing it from

high-risk situations

K EY P OINT : Distinguishing child abuse and neglect from various risk factors for child

abuse and neglect is essential

The term high-risk families refers to those families in which child abuse or neglect is

known to have occurred or in which it is likely to occur often due to interpersonal,

familial, social, or economic conflicts and pressures Examples of such conflicts and

pressures may include, but certainly are not limited to, marital conflicts, loss of

employment, depression, anxiety and other mental illnesses, or preparation and planning

for major family events or social gatherings (eg, family reunions, vacations) In some

older sibling may be acting as caregiver) However, caution should be exercised to avoid

the conclusion that all families in similar circumstances are at increased risk for child

abuse or neglect Many families living in poverty have made natural adjustments or have

sought formal and informal resources to help alleviate their financial stress

Advances in medicine have reached a point where greater numbers of technologically

dependent children are being kept at home, rather than in institutions While laudable,

this places a tremendous burden on a family Other chronic illnesses such as asthma,

sickle cell anemia, developmental delays and mental retardation are also profound

stressors on a family Because of this, children with special health care needs are

particularly vulnerable to child abuse and neglect

The term high-risk situations refers to critical circumstances affecting families that

increase the potential for child abuse or neglect to occur Examples of high-risk

situations include the following:

• violence

• weapons, knives, or other sharp objects in the home

• open windows without guards

• broken or damaged steps

• excessive yelling

ROLE OF PREHOSPITAL MEDICAL PROVIDERS

The primary role of prehospital medical providers is to tend to the immediate medical

needs, safety concerns, and well-being of their identified patient(s) or others in need of

emergency medical care EMS providers should never be placed or place themselves in

situations in which this role is compromised However, EMS providers also need to be

aware of high-risk factors or situations for child abuse or neglect and to intervene

appropriately

Surveying the Scene

When EMS providers first arrive at the emergency scene, the most immediate task is

assessing the identified patient(s) and quickly surveying the scene for factors that may

have contributed to the emergency (eg, medications) When the emergency involves a

child, the survey of the immediate surroundings must also involve a quick scan for

evidence of child abuse or neglect and for related risk factors This should be done

keeping the explanation provided for the injury in mind When the nature of the injury

and the given explanation are inconsistent, child abuse or neglect should be suspected In

contrast, there may be high-risk factors or situations that warrant concern, and extra

support for the family should be sought If ignored or overlooked, these situations could

eventually evolve into one of child abuse or neglect

Surveying an emergency medical scene where children are involved should include the

following:

• Appearance of the home and immediate surroundings: Are there risk factors

visibly present outside the home? Inside the home? Is the home clean? Do

the windows have guards? How is the temperature inside the home? Is it too

warm or too cold?

• Physical appearance and demeanor of the children: Are they clean or dirty?

Do they appear timid around the adult(s) in the home? How do they interact

with each other? With the adults? Are they friendly, or perhaps overly

friendly?

• Demeanor of the adults in the home: What is their tone of voice when

speaking to the children? How adults and children act in a situation that

involves EMS providers coming to the home may indicate how they interact

and deal with crisis or other tense situations

Challenges and Strengths of EMS Providers

Because EMS providers must focus on the immediate medical and safety needs of the

patient(s), additionally surveying the scene for risk factors can be a difficult task for a

variety of reasons First, diverting attention away from the primary role of attending to

medical needs can place the patient(s) at risk of further harm or injury Second, time at

the emergency scene is limited, further restricting the time available to intervene in a

high-risk situation Under these circumstances, actual child abuse or neglect may be

missed, or mistakenly identified as a high-risk situation Third, many emergency scenes

are fraught with heightened emotions, worry, chaos, and confusion, and EMS providers

may have the added task of calming family members and others who may be present

Despite these inherent limitations, EMS providers can make an enormous difference in

addressing child abuse or neglect Indeed, they bring a number of unique strengths to

identifying and intervening in families with children at risk for abuse and neglect

One distinct advantage over most other health care professionals is that the EMS provider

has an opportunity to observe children and families in their own homes and other usual

surroundings EMS providers also have the advantage of observing family interactions

under distress—again, something other health care providers may not have an occasion to

do This provides an opportunity to make observations and to gather a wealth of

information that can provide valuable insight In some instances, this insight may allow

for a more informed assessment in differentiating abuse and neglect from a child at risk

for abuse or neglect Furthermore, EMS providers may not represent an authority figure

to many families, often being viewed more as an ally than a threat This is especially true

of families that have had prior involvement with child protection services

Intervention

There may be only a small window of opportunity to intervene in situations in which a

child is at risk for abuse or neglect However, this is the best opportunity for intervention

and possible prevention The intervention may be as simple and quick as providing a

social services brochure, or closing a window that is not covered by a guard while briefly

explaining the dangers that uncovered windows present for young children

discussing the situation with the hospital social worker may be helpful, or a referral to

child protection services may be warranted

Lastly, taking the time to learn about availability of other resources in local communities

is very helpful For example, it can be beneficial to identify and collaborate with others

involved in intervention and prevention of child abuse or neglect (eg, hospital social

workers, physicians, nurses)

K EY P OINT : Identifying high-risk families and situations, by surveying the emergency

scene for child abuse and neglect and for related risk factors, followed by taking appropriate action (eg, referral for social services support), may prevent child abuse and neglect from happening in the future

CASE SCENARIO

Consider the following case scenario and whether child abuse and neglect is suspected or

can be ruled out

Case: EMS providersrespond to a 911 call at a home, where the identified patient is a

10-year-old girl who fell down the stairs (13 steps) and injured her back and right leg

The carpet on the steps is heavily worn and ripped The house is fairly tidy, although the

furniture is also heavily worn and stained Voices of other children are heard in the

home, although you can’t determine how many or their approximate ages There do not

appear to be any other adults present The injured girl will need to be taken to the

hospital emergency room

Discussion

The following discussion points are based on no suspicion of child abuse and neglect

• Discuss the factors that make this a high-risk situation

• Discuss the relevance of identifying whether the child lives at this home or is

visiting

• If the child’s mother accompanies the ambulance or follows behind, will she bring

the children with her to the emergency room or does she plan to leave them

behind? If she plans to leave the children behind, would this be considered

neglect? What needs to be considered for the children remaining in the home? Is

there a neighbor or other family member available to assist? Are there any other

adults in the home?

• If it is possible that the rips in the carpet contributed to the fall, consider what (if

anything) can be done immediately to prevent others from falling

• Discuss what, if any, intermediate or long-range follow-up would be helpful and

who should be involved

• What other resources can be used and how? How are these resources identified?

CHILD ABUSE AND NEGLECT HIGH-RISK FAMILIES AND SITUATIONS

Differentiating High-Risk Families and Situations

In some cases of child abuse or neglect, risk factors are present that warrant concern for

the welfare of a child, but not necessarily a report to child protection services Factors

that may be associated with an increased likelihood of child abuse or neglect include:

• Physical discipline in the home

• Domestic violence

• Substance abuse

• Children with special health care needs

K EY P OINT : Distinguishing child abuse and neglect from various risk factors for child

abuse and neglect is essential

In high-risk families, child abuse or neglect is likely to occur often due to interpersonal,

familial, social, or economic conflicts and pressures (eg, marital conflicts, loss of

employment, depression, anxiety, or preparation for major family events) The term

high-risk situations refers to critical circumstances affecting families that increase the

potential for child abuse or neglect to occur (eg, violence; weapons, knives, or other

sharp objects in the home; open windows without guards; broken or damaged steps;

excessive yelling)

Role of Prehospital Medical Providers

The primary role of prehospital medical providers is to tend to immediate medical needs

However, surveying the emergency scene for evidence of abuse or neglect and for related

risk factors, keeping the history in mind, and providing support as needed for high-risk

families are important factors to consider in identifying and preventing abuse and neglect

Challenges involved in surveying the scene include: 1) diverts attention away from

attending to medical needs, 2) time limitations, 3) the need to calm family members in an

emergency scene fraught with heightened emotions and confusion Strengths include the

opportunity to observe children and families in their own homes, under distress, thereby

providing valuable insight In addition, families often view the EMS provider as an ally

rather than a threat

Intervention may be simple and quick (eg, providing a referral to social services, or

closing a window not covered by a guard), or may require longer-term actions In these

situations, learning about other resources available in the community (eg, hospital social

workers) is very helpful

K P : Identifying high-risk families and situations, by surveying the emergency

CHILD ABUSE AND NEGLECT

REPORTING

CHAPTER OBJECTIVES

• Describe the purposes and principles of reporting child abuse and neglect

• Emphasize importance for EMS providers to know the law in their state regarding

reporting child abuse and neglect, including the consequences of failing to report

• Review the form and content of the report

• Explain how to communicate with parents and caregivers

• Describe transfer of care

• Provide reporting numbers and, if available, sample forms to complete

• Present and discuss case scenario

STATE LAW

All states, the District of Columbia, and U.S territories have a reporting statute for child

abuse and neglect While each of these laws varies in some ways, all share a common

framework and are based on the federal Child Abuse Prevention and Treatment Act (see

Definitions chapter)

In general, state reporting statutes:

• define child abuse and neglect

• specify mandated reporters

• specify the form and content of the report

• specify to whom the abuse or neglect must be reported

It is vital for EMS providers to know and understand the reporting requirements in their

state Many states specifically include EMS providers (as well as many other health care

professionals) as mandated reporters in their state law Some states address the issue of

whether or not mandated reporters are required to report even when off duty, or when the

suspected victim is not the patient In some states, all citizens are mandated reporters and

must report any suspicion of child abuse or neglect

K EY P OINT : It is vital for EMS providers to know and understand the reporting

requirements in their state

The laws clearly specify that reports must be made when child abuse or neglect is

suspected or there is “reasonable cause” to believe that abuse or neglect has occurred

Proof is not required There is reasonable cause to suspect child abuse or neglect when

through training and experience, or physical evidence observed or described, render it

possible that neglect or nonaccidental means might be the cause of an injury

K EY P OINT : All states require reporting suspected child abuse or neglect, but no state

requires the reporter to have proof that the abuse or neglect actually occurred

CONSEQUENCES OF FAILING TO REPORT

Without a report, the child is at ongoing risk of abuse, and there is potential for abuse of

other children in the household The penalties for failure of a mandated reporter to report

suspected child abuse or neglect vary from state to state and may include fines, prison

sentences of up to 1 year, or both For example, in the state of New York, any person,

official or institution that is required to report a case of suspected child abuse or

maltreatment who willfully fails to do so can be found guilty of a class A misdemeanor,

and who knowingly and willfully fails to do so can be found civilly liable for the damages

proximately caused by such failure Professionals who fail to report could also be liable

for more serious charges such as criminal negligence or accessories to assault However,

mandated reporters who act in “good faith” have immunity from civil and criminal

liability in all states

FORM OF REPORT

States vary in their requirements for an oral report, a written report, or both Many states

maintain telephone hotlines solely for oral reports of suspected child abuse or neglect In

addition, the Childhelp® USA National Child Abuse Hotline is a non-profit agency that

can provide reporting numbers; hotline counselors can also provide referrals All

telephone numbers are listed at the end of this chapter

Most states (and some EMS agencies) provide specific reporting forms for written

reports If a form is not available, the information can be documented on any piece of

paper

Some EMS agencies have policies regarding whether personnel report directly to the state

or to the EMS supervisor, who then reports to the state Informing emergency

department or other hospital personnel of the situation does not necessarily fulfill the

obligation to report However, if hospital personnel are informed and they make a report,

this may fulfill the obligation of EMS providers in a state in which the law requires EMS

providers to “report or cause to be reported.”

In all cases, EMS providers should document any and all actions taken to report the case;

doing so protects the EMS provider from future actions by the EMS agency or by state

law enforcement

CONTENT OF REPORT

Regardless of the form of the report, it should contain the following information:

• Reasons why abuse or neglect is suspected

• Nature and extent of injuries, prior injuries, other children at risk

• Name, address, age, sex, and ethnicity of the child

• Names and addresses of parents or caregivers legally responsible for child who

are accused of abuse or neglect

• All actions taken (eg, child transported to hospital, child placed in protective

custody, medical examiner notified) and transfer of care

• EMS provider’s name and contact information

In addition, the fact that the call or written report was made should be documented All

information should be provided to the health care provider who receives the child It may

also be appropriate to report the case to the police (See also the chapter on

Documentation.)

Confidentiality of reports varies by state For example, in New York, all reports are

confidential; and reporter information is not subject to Freedom of Information requests

and is never released except by court order

COMMUNICATING WITH CAREGIVERS

Reports are made in terms of the possibility that the child’s injuries or condition could

have been caused by abuse or neglect, not in terms of an accusation against parents or

other caregivers A report of suspected child abuse or neglect states that a child may be

an abused or neglected child, not that the parents or caregivers are harming the child

The primary goal is to protect the child from further injury Accusation and

confrontation delay transportation

Parents and caregivers should be informed of the following reasons for reporting:

• 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

Once a report is made, child protection services and law enforcement personnel

determine whether an investigation is warranted and are responsible for any necessary

follow up

K EY P OINT : Reports are made in terms of the possibility that the child’s injuries could

have been caused by abuse or neglect, not in terms of an accusation against parents or other caregivers The primary goal is to protect the child from further injury Accusation and confrontation delays transportation

These situations need to be handled with sensitivity and respect for privacy However,

because families are likely to react negatively to the fact that a report is being made, these

issues should be discussed in a place where assistance is immediately available For

example, in the case of parents who may become angry and threaten violence, police

presence may be desirable

TRANSFER OF CARE

The report must also cover transfer of care EMS providers should indicate their

suspicion of abuse or neglect to emergency department personnel The hospital

personnel will examine the child, meet with the parents or other caregivers, request social

work evaluation (if available), and often make an independent evaluation of the need to

report However, any action taken by hospital personnel does not negate the EMS

provider’s assessment and does not relieve EMS providers of their reporting

responsibility

Once the child is in the emergency department, child protection services may request the

child remain there until they can interview the child and the parents or other caregivers

Or, child protection services may release the child from the emergency department to go

home with the parents or other caregivers

NATIONAL CHILD ABUSE HOTLINE AND STATE REPORTING NUMBERS

Suspected abuse or neglect should be reported in the state in which it occurs Federal

agencies have no authority to intervene in individual cases of child abuse or neglect

Each state has jurisdiction over these matters and has specific laws and procedures for

reporting and investigating

Many states have reporting hotlines, although some are accessible only within that state

and some do not operate on a 24-hour basis When there is no hotline in the state in

which the abuse occurred, or information on the state hotline is not known, suspected

child abuse or neglect should be reported by calling the Childhelp USA® National Child

Abuse Hotline at:

1-800-4-A-CHILD®(1-800-422-4453) 1-800-2-A-CHILD (TDD)