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

2. Acknowledgements
Child Abuse and Neglect: A Prehospital Continuing Education and Teaching Resource (CD-ROM produced by The Center for Pediatric Emergency Medicine of the New York University School of Medicine)
Child Abuse/Neglect for RI EMS Providers (Slide 2)

3. Introduction
Child abuse and neglect are widespread, found across all levels of socioeconomic status, all racial and ethnic (cultural) groups, and all religious affiliations.
EMS providers in a unique position to identify abuse and neglect.
Moral and legal obligation to report abuse and neglect, whether suspected or confirmed.
Child Abuse/Neglect for RI EMS Providers (Slide 3)

4. Introduction
EMS providers are society’s first line of defense against child abuse and neglect – eyes and ears of the medical community.
By recognizing and documenting child abuse or neglect, EMS providers can save children’s lives.
Child Abuse/Neglect for RI EMS Providers (Slide 4)

5. Abuse Defined
Abuse: A child has suffered physical or emotional injury inflicted by a caregiver (eg, parent, legal guardian, teacher, etc) that results in disability, disfigurement, mental distress, or risk of death.
Child Abuse/Neglect for RI EMS Providers (Slide 5)

6. Neglect Defined
Neglect: A child’s physical, mental, or emotional condition has been endangered because the caregiver has not provided for the child’s basic needs.
Child Abuse/Neglect for RI EMS Providers (Slide 6)

7. The EMT’s role Recognize signs/symptoms of abuse and neglect.
Provide medical evaluation and treatment.
Protect from further abuse.
Report all cases of suspected abuse.
Document all findings accurately, thoroughly, and legibly.
Child Abuse/Neglect for RI EMS Providers (Slide 7)

8. Recognizing Abuse/Neglect
Importance of History
Injury or illness inconsistent with history
Critical to determine whether injury or illness could have been caused unintentionally or was inflicted
Multiple visits to same household or previous visits for family violence
Child Abuse/Neglect for RI EMS Providers (Slide 8)

9. Recognizing: Right to Privacy
Children have right to refuse
Adolescents especially sensitive
Do not examine unwilling child, especially if sexual abuse is suspected
Give choices if possible
Child Abuse/Neglect for RI EMS Providers (Slide 9)

10. Recognizing: Skin Injuries
Most common and easily recognized sign of abuse
Conduct complete, thorough skin examination
Always look for cuts, scrapes, bruises, burns, bites, redness, swelling
Describe systematically and consistently when documenting
Child Abuse/Neglect for RI EMS Providers (Slide 10)

11. Recognizing: Bruises Note location(s)
Infants rarely bruise accidentally
Young, active children tend to incur bruises naturally on front of body (eg, knees, shins, elbows, forehead)
Bruises in recognizable shape of object are suspect
Multiple bruises in different stages of healing are suspect
Child Abuse/Neglect for RI EMS Providers (Slide 11)

12. Recognizing: Burns Scald burns common
Two general patterns: immersion and splash
Immersion burns characterized by clear lines of demarcation
Examples: “Donut” pattern burn on buttocks or stocking/glove pattern burns of arms or lower legs
Accidental burns more often have splash marks as child withdraws from heat source
Child Abuse/Neglect for RI EMS Providers (Slide 12)

13. Recognizing: Inflicted Contact Burn
Recognized by shape that duplicates object used to produce it (eg, cigarette, curling iron)
Tend to be in less exposed areas, deeper, larger
Child Abuse/Neglect for RI EMS Providers (Slide 13)

14. Recognizing: Bites Adult human bite marks strongly suggest abuse
In general, bite marks are multiple, random, well defined
No one tooth mark stands out (differing from animal bites)
Child Abuse/Neglect for RI EMS Providers (Slide 14)

15. Recognizing: Fractures
Fractures discovered “accidentally”
Skeletal injury inconsistent with history
Multiple fractures in different stages of healing
Accompanied by other injuries
Child Abuse/Neglect for RI EMS Providers (Slide 15)

16. Recognizing: Falls
Fall from standing position or low object (less than child’s height) rarely results in serious injuries
Fall from greater than child’s height usually required to sustain serious injury
Child Abuse/Neglect for RI EMS Providers (Slide 16)

17. Recognizing: Injuries to Face & Head
Unintentional injuries usually involve front of body
Specific injuries to side of face, cheeks, ears suspicious of abuse
Direct blow to mouth usually results in lip tear, possibly with broken jaw or teeth
Considerable force required to cause severe head trauma
Child Abuse/Neglect for RI EMS Providers (Slide 17)

18. Recognizing: Hair Loss
Can be manifestation of child abuse
May be self-inflicted to relieve stress
Can be caused by dragging child by hair, using excessive force during brushing, or certain types of hair braiding
Often blood at the surface or beneath scalp
Child Abuse/Neglect for RI EMS Providers (Slide 18)

19. Recognizing: Shaken Baby Syndrome
Most common in children less than 2 years old
May be no evidence of external trauma
Possible signs include decreased consciousness, seizures, vomiting, other signs of head injury, unusual cry
Altered mental status may be only sign
Recognizing the possibility should trigger suspicion of abuse
Child Abuse/Neglect for RI EMS Providers (Slide 19)

20. Recognizing: Sexual Abuse
Frequently thought of as occurring recently (within last 72 hours)
In these cases, signs may include pain, bleeding, or discharge from urethra, vagina, or rectum
Can also be insidious, chronic, “hidden” abuse occurring over weeks or months
In these cases, signs may include nonspecific abdominal pain, vaginal inflammation, or painful urination
Physical examination normal in most cases
Child Abuse/Neglect for RI EMS Providers (Slide 20)

21. Treating sexually abused patients
Believe what the child says
Use the child’s own words and document statements in quotes
Never examine unwilling child
Do not remove child’s clothing or examine genitals unless severe genital pain or gross genital bleeding
Refer child to specialist for examination
Child Abuse/Neglect for RI EMS Providers (Slide 21)

22. Recognizing: Emotional Abuse
A component of all forms of child abuse
Attack on child’s development of self and social competence
May not be done on conscious level
Most cases mild, but early recognition important
Child Abuse/Neglect for RI EMS Providers (Slide 22)

23. Recognizing: Emotional Abuse
Ignoring the child
Rejecting the child’s needs and requests
Isolating the child
Verbally assaulting the child (eg, name- calling, harsh threats)
Encouraging destructive, antisocial behavior
Humiliating the child
Child Abuse/Neglect for RI EMS Providers (Slide 23)

24. Recognizing: Neglect Most common form of child abuse
Likely most under- recognized and under- reported form of child abuse
Neglected children suffer greatly, often left with emotional scars
Child Abuse/Neglect for RI EMS Providers (Slide 24)

25. Recognizing: Neglect
Inadequate care, including inadequate provision of food, clothing, or shelter
Inadequate medical attention, including delay in seeking care for known illness
Example: While child is having asthma attack, mother leaves home to go shopping.
Child Abuse/Neglect for RI EMS Providers (Slide 25)

26. Recognizing: Neglect Signals to watch for: Poor personal hygiene
Unsanitary conditions
Inadequate sleeping arrangements
Lack of supervision
Evidence of substance abuse
Structural, fire, environmental hazards
Child Abuse/Neglect for RI EMS Providers (Slide 26)

27. Recognizing: Munchausen Syndrome by Proxy
Bizarre and rare form of child abuse
Illness in child is repeatedly induced by parent or other caregiver, who denies knowledge of cause
Symptoms subside when child is separated from parent or caregiver
Child should not be left alone with parent or caregiver
Child Abuse/Neglect for RI EMS Providers (Slide 27)

28. Cultural Considerations
Childrearing practices greatly influenced by culture
Examples: babies allowed to cry themselves to sleep, children sleeping in parents’ bed for several years
Practice considered abuse in one culture may be norm in another
Examples: scarification of face, physical discipline
Child Abuse/Neglect for RI EMS Providers (Slide 28)

29. Cultural Considerations
Cultural differences may affect evaluation of case
Important to be aware of other cultures in own community
Families may not realize that certain practices are considered abuse in US
Child Abuse/Neglect for RI EMS Providers (Slide 29)

30. Folk Medicine Practices
May mimic abuse
Should not be reported as abuse (usually)
Examples:
Coin rubbing – rubbing a coin along the skin may produce bruise-like rash
Cupping – applying heated cup to skin and pulling off after suction develops; causes circular bruises
Moxibustion – treatment related to acupuncture in which lighted objects placed on skin result in burns
Child Abuse/Neglect for RI EMS Providers (Slide 30)

31. Communicating with Caregivers
The primary goal is to protect the child from further injury.
Accusation and confrontation delay transportation.
Families likely to react negatively
Best to discuss in a place where assistance is immediately available
Police presence may be desirable
Child Abuse/Neglect for RI EMS Providers (Slide 31)

32. Reporting Abuse/Neglect
Reports must be made when child abuse or neglect is suspected or there is reasonable cause to believe that child abuse or neglect has occurred
Proof is NOT required
Child Abuse/Neglect for RI EMS Providers (Slide 32)

33. Reporting Abuse/Neglect
Reasonable Cause: When through training and experience, or physical evidence observed or described, the pre-hospital provider becomes aware of the possibility that neglect or non-accidental means might be the cause of an injury.
Child Abuse/Neglect for RI EMS Providers (Slide 33)

34. Reporting Abuse/Neglect
The reasons for reporting are:
to determine whether or not an investigation will ensue
to determine whether or not abuse or neglect occurred
to determine what happened and who is responsible
to safeguard the child from future injury
Child Abuse/Neglect for RI EMS Providers (Slide 34)

35. Legal Obligations
All states have a reporting statute for child abuse and neglect
Rhode Island’s requirements established by RIGL Chapter 40-11: Abused and Neglected Children
Lead agency is the RI Department of Children, Youth, and Families
Any person with reasonable cause to know or suspect child abuse/neglect must report such to DCYF within 24 hours
Child Abuse/Neglect for RI EMS Providers (Slide 35)

36. Legal Obligations
Immediate notification to DCYF required for parents of an infant who have requested:
deprivation of nutrition necessary to sustain life
deprivation of medical or surgical interventions necessary to remedy or ameliorate a life-threatening condition (may not apply to terminally ill children if treatment would be ineffective)
Child Abuse/Neglect for RI EMS Providers (Slide 36)

37. Legal Obligations
Any person with reasonable cause to know or suspect a child has died as a result of abuse or neglect must immediately notify DCYF
Child Abuse/Neglect for RI EMS Providers (Slide 37)

38. Legal Obligations
Rhode Island law makes person making such a report in good faith is immune from civil or criminal liability
Failure to report or actions to prevent someone else from reporting is a misdemeanor with a fine of up to $500 or imprisonment of up to 1 year. Such individuals are also civilly liable for damages caused by their failure to report.
Child Abuse/Neglect for RI EMS Providers (Slide 38)

39. Notifications Who to notify When: as soon as possible
Always DCYF via 24-hour hotline at 800-RI-CHILD
Local law enforcement
Hospital staff (when transporting patient)
When: as soon as possible
Immediately in some cases, 24 hours in other cases)
Child Abuse/Neglect for RI EMS Providers (Slide 39)

40. What Information to Convey
Name, address, age, sex, ethnicity of child
Names and addresses of parents or caregivers suspected of abuse/neglect
Your name and contact info
Why abuse or neglect is suspected
Nature and extent of injuries, prior injuries
Other children at risk
All actions taken
Examples: “Child transported to hospital”, “Child placed in protective custody”
Child Abuse/Neglect for RI EMS Providers (Slide 40)

41. Transfer of Care
EMS providers should indicate suspicion of abuse or neglect to emergency department personnel
Hospital personnel will examine child, meet with parent or caregiver, request social work evaluation (if available), and often make independent evaluation of need to report
Child Abuse/Neglect for RI EMS Providers (Slide 41)

42. Transfer of Care
Hospital action does not negate EMS provider’s assessment and does not relieve EMS provider of reporting responsibility.
Child protection services may:
Request child remain in emergency department until they can interview child and parents or caregivers
Release child from emergency department to go home with parents or caregivers
Child Abuse/Neglect for RI EMS Providers (Slide 42)

43. Additional Actions
Document that call or written report was made to DCYF
Also provide all information to the health care provider (eg, hospital staff) who receives child
May be appropriate to also report case to police
Child Abuse/Neglect for RI EMS Providers (Slide 43)

44. Tools for EMTs Protective custody by law enforcement
Interview techniques
Ask open-ended questions only (eg, “What happened?”, “How did you get hurt?”)
Allow child to explain in own words
Avoid leading or suggestive questions such as “Did Daddy hit you?”
Do not force child to make statement
CISD for emotional consequences to EMS personnel handling abuse
Child Abuse/Neglect for RI EMS Providers (Slide 44)

45. Documentation Purpose of documentation
Protects the patient and other children
Aids in detection of abuse and prevent future episodes
Supports accurately recalling observations and actions taken
Protects EMS providers from legal liability
Child Abuse/Neglect for RI EMS Providers (Slide 45)

46. Documentation Evidentiary value Information – most important!
Documentation must be clear, accurate, detailed, thorough
Diagrams very helpful
Preserve physical and trace evidence when possible
Child Abuse/Neglect for RI EMS Providers (Slide 46)

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

48. Documentation Basic information to include
Name, address, age, sex, ethnicity of child
Names and addresses of parents or caregivers legally responsible for child who are accused of abuse or neglect
Your name and contact info
Nature and extent of injuries, prior injuries, other children at risk
Why abuse or neglect is suspected
All actions taken
Child Abuse/Neglect for RI EMS Providers (Slide 48)

49. Documenting the Scene Describe scene rather than interpret it
Avoid words that imply opinion or judgment
Example: “garbage on floor, spoiled food on counter” is more useful than “dirty apartment”
Document who is present, their condition, and any actions they have taken
Example: “parent slurring words, smells of alcohol” is more useful than “parent drunk”
Child Abuse/Neglect for RI EMS Providers (Slide 49)

50. Documenting History/Presentation
Document all versions of history as given by child, caregiver, other witnesses (use direct quotes)
Note if history is inconsistent with child’s injuries
Child Abuse/Neglect for RI EMS Providers (Slide 50)

51. Documenting Statements by Child
Record child’s statement word for word in quotes
Include circumstances of statement (eg, who was present)
Note child’s actions and demeanor (eg, crying, withdrawn)
Record any questions asked, who asked them, and response
Child Abuse/Neglect for RI EMS Providers (Slide 51)

52. Documenting Statements by Others
Identify person making statement and record statements word for word in quotes
Include circumstances of statement (eg, whether statement was made in response to a question, who else was present, how the person acted)
Child Abuse/Neglect for RI EMS Providers (Slide 52)

53. Documenting Additional Victims
Same principles of documentation apply
Document any statements made by or about other child suspected to be victim of abuse or neglect
Document any actions taken regarding this child
Child Abuse/Neglect for RI EMS Providers (Slide 53)

54. Confidentiality
Under RI law, all records concerning reports of child abuse and neglect, including reports to DCYF, are confidential
Under RI law, communications are not privileged between husband and wife and any professional person and his/her patient or client when related to known or suspected child abuse or neglect
Child Abuse/Neglect for RI EMS Providers (Slide 54)

55. Additional Help
Rhode Island DCYF RI-CHILD ( ) nationwide, 24 hours
Childhelp USA® National Child Abuse Hotline: A-CHILD®
RI Department of Health, Division of EMS, at
Child Abuse/Neglect for RI EMS Providers (Slide 55)

56. Examination Written post-test (20 questions)
Child Abuse/Neglect for RI EMS Providers (Slide 56)

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