2. Company LOGO Non-Accidental Trauma

3. MEB 1. Introduction to Maltreatment 2. Types of Abuse and Neglect 3. Reporting Suspected Child Abuse 4. How the System Works Objectives

4. MEB The first child was identified as abused in 1874 It took 98 years to implement Federal Laws Most states only complied for Federal funds Child Protection Social Workers at SLCH since 1973 Missouri Child Abuse Hotline began in 1975 History

5. MEB Statistics* United States – 2000* 2.8 million children reported abused/ neglected 63% Neglect, 19% Physical, 10% Sexual *Child Maltreatment 2000: US. National Clearinghouse on Child Abuse and Neglect

6. MEB The Emergency Unit Our Emergency Unit is covered 24 hours per day, 7 days per week with a child protection trained social worker. This is important to you because you may call and speak with them by paging 314-424-6101, if you have questions or concerns.

7. MEB ___ ____________ ___

8. MEB Types of Reportable Abuse Abuse PhysicalSexual EmotionalNeglect

9. MEB Physical Abuse

10. MEB Contributing Factors - Victim Less than 5 years of age Prematurity/multiple births Chronic health problems Developmentally delayed ADD/ADHD Child Irritability

11. MEB Perpetrator Someone who malt -reats a child while in a caretaking relationship to the child 79% One or both parents 9% Other relatives 60% Female (*Child Maltreatment 1999: US. National Clearinghouse on Child Abuse and Neglect)

12. MEB

13. Contributing Factors – Perpetrator Substance abuse Poverty/Unemployment Poor coping/parenting skills Immaturity Poor Education History of abuse/dome stic violence Behavioral /Psych/ Depression Social Isolation

14. MEB Injuries in Unusual Places Abdomen Back Upper thighs Face Ears Feet Non-bony areas of the body

15. MEB Bruising to the feet

16. MEB Injuries in non ambulatory children

17. MEB Bruises to inner lip of infant

18. MEB Injuries to Neck from Finger Nails

19. MEB Buttock of 12 Day Old

20. MEB Foot of a 12 Day Old

21. MEB Lines of demarcation donut burn

22. MEB Child punished with a cigarette lighter.

23. MEB This 18-month old boy was seen in the Emergency Department with a patterned burn to his abdomen.

24. MEB Identifying Concerning Circumstances Injuries to uncommon areas of the body Patterned Injuries Injuries in non ambulatory children Children who do not appear to be comforted by caretakers presence Discrepancies in histories provided

25. MEB

26. Loop Marks From Cord.

27. MEB

29. Evidence of a recent beating of a 6-year-old boy with a belt (linear marks) and fist (round marks). Shown here is the boys back.

30. MEB Slap Marks

31. MEB Burns from a Hairdryer

32. MEB This 4-year-old boy was seen in the emergency room with the history of having fallen down the stairs. He had bruising on multiple surface areas in various stages of healing. He was developmentally delayed and considered a behavioral problem.

33. MEB Linear bruising from being beaten with a switch for disrespectful behavior to parent. Some of the marks are raised bruise-like marks and others have broken the skin. Beating occurred approximately 1 day before this picture was taken.

34. MEB Loop-shaped bruising from a looped belt used to beat the child for misbehavior.

35. MEB You are Considered a Mandated Reporter You are all considered mandated reporters and as such are required by law to report suspected abuse or neglect of a child. How do I Report Abuse? Missouri hotline number 1-800-392-3738 Il. Child Abuse Hotline 1-217-785-4020

36. MEB What Should I Look for When I Enter a Home? The biggest concern when you enter a home where a child has potentially been abused is consistency in the history, the environment and the injury.

37. MEB What is Important? Note the condition of the home, who is there when you arrive, who was reported to be there when the incident happened, exact time the incident was to have happened, and any discrepancies in the environment and the history.

38. MEB What Should I Document? Document what you saw, what was told to you and what concerned you about the situation. Your documentation as the first responder is so important to the case. You are the least threatening person they will encounter and you have the advantage of possibly seeing the home before anyone has an opportunity to manipulate anything.

39. MEB You will not likely remember what you saw or heard at That time years later, when the case goes to court, so please document well. When you document use observable facts rather than generic descriptions. By using this description it does not matter how long From now you may be asked about what you saw; you will be able to provide a vision of the home, without any judgment on your part. How Should I Document?

40. MEB Legally What Can I Report or Share? You can put any pertinent information in your report and once it becomes part of the medical record we can share it with PD when they request it for their investigation.

41. MEB Investigative Tools That Would Help You Help Us Digital Camera (Scene) Measuring Devices List of drugs found in the home Digital Portable Thermometer Video taped confession with demonstration of what they did to the child Anything you observed at the scene that you feel might be important to our assessment of the injury

42. MEB Information needed to Assess Injury Height of fall Surface landed on Furniture placement Position when found Who was present If possible the item used to inflict the injury Access to the care taker whenever possible Accurate temperature of household hot water The appliance which injured the child Exact time of symptom onset Accurate account when a confession is made The name of the person who last saw the child healthy and the time they saw the child

43. MEB What Do We Do With This Information? We compare the circumstances to the injury We rule out other possible causes for the symptoms we are seeing We compose an affidavit for court indicating that the injury is not consistent with the history We are able to address any possible causes of the injury aside from inflicted We are able to defend the diagnosis of inflicted injury vs. accidental injury

44. MEB Questioning Children Dont attempt to do a forensic interview Do document statements made to you by the child Dont question children when caretakers are present Do document statements made by caretakers to you

45. MEB Common Suspicious Stories The Dirty Dozen My child fell from… a low height. Especially from a height of less than 5 feet. My child fell and struck their (???) on the floor, furniture…or a hard object fell on them. Unexpectedly found dead. My child began choking so I struck him on the chest or back. My child suddenly turned blue, so I shook him.

46. MEB The Dirty Dozen continued My child had a first time seizure and died. Violent aggressive resuscitation efforts after child has stopped breathing. Alleged traumatic event one day or more prior to death. Caretaker dropped my child. Injury was inflicted by sibling. My child was left alone (in a dangerous situation) for just a few minutes. My child fell down the stairs.

47. MEB Sexual Abuse Concerns?

48. MEB Sexual Abuse Presentation with concerns for sexual abuse are not always an indication that the child has been abused. The preliminary screening and history must be collected but it must be done in such a way that it does not compromise the case, or leave a child at risk.

49. MEB How We Gather a History Out of the presence of verbal children victims Carefully document the history We do not assume that every child who presents, is abused; we probe with open ended questions and are aware of what is normal sexual exploration for children

50. MEB Some Common Reasons for Sexual Abuse Concerns The genitals look different Caretaker was a victim with unresolved issues Caretaker is uneducated about normal sexual exploration by children Caretaker is aware the child has been in the presence of someone with a history of sexual abuse of a child

51. MEB The Interview If you are not a trained interviewer then do not do an interview! Possibilities CAC, SLCH Being trained is now the expectation rather than the preferred standard If you cant defend your credentials in court you cannot protect the child.

52. MEB Findings The absence of disclosure does not necessarily mean no abuse occurred For some children disclosure is a process and they will need a series of opportunities to disclose For some children there is a one time disclosure and they will not speak of the incident again Often children do not feel safe disclosing if the abuser still has access to them

53. MEB Drawing Conclusions We must consider non-abusive explanations Consider confirming and contradictory evidence We will seldom be 100% sure sexual abuse occurred You are mandated to report reasonable cause to suspect abuse to Child Protective Services, you do not need proof of abuse It may be necessary to refer the child to a forensic interview specialist or therapist who can offer extended/in-depth interviews or on going therapy

54. MEB Neglect When we talk about inadequate housing food or clothing we are not referring to minor things such as a house that is not regularly cleaned. The conditions must pose a health hazard to the child.

55. MEB Photograph of home

56. MEB

58. How We Protect the Child In planning for the childs release we consider: 1.Will the caretaker protect the child? 2.Do they have the means to protect the child? 3.Do the caretakers believe the child? 4.Does the abuser have access to the child? 5.Does the child feel safe going home? 6.Is the child suicidal?

59. MEB Actions Discharge to caretaker Call emergency hotline and ask for an immediate response Take judicial custody of the child Send a letter of concern or affidavit to the Family Court outlining our concerns for the childs safety

60. MEB After the Hotline is Made The call may be coded as a hotline It may be coded as an emergency hotline It may be taken as a new born crisis assessment It may be taken as a referral

61. MEB Once the Investigation Begins Childrens Division has 30 days to complete an investigation If the report is coded as an emergency they have up to three hours to see the victim child, if not they have 24 hours If the report is for educational neglect they have 72 hours to make contact with the child

62. MEB Possible Outcomes The investigation can be found unsubstantiated Or preponderance of evidence Court adjudicated Unsubstantiated-preventative services indicated

63. MEB Hearings Protective Custody Hearing (3 days) Adjudicatory Hearing Dispositional Hearing Contested Trial Review Hearings (90 days) Permanency Hearings

64. MEB Safe Place for Newborns In the state of Missouri a parent or someone acting on behalf of a parent can bring a child, up to the age of 1 year. To a fireman or medical technician, on duty, in a paid or volunteer position, police or a hospital And they relinquish the child with the expressed intent not to return for the child No questions are asked and the child is to be evaluated at a medical facility With Childrens Division taking custody for Termination of Parental Rights

65. MEB Will I be Subpoenaed? Be aware that if you make a report of abuse and or neglect you can be subpoenaed to testify in court. It could be the Family Court, Criminal Court or Civil Court.

66. MEB If I go to Court What Should I Expect? Your part in presenting an unbiased account of the situation can be vital to the prosecution Spontaneous utterances made to you by the child should be documented in quotes and are admissible in most cases. You are not there to determine guilt or innocence If you are asked to testify look at the jury when you answer and dont argue with the cross examiner

67. MEB Child Deaths

68. MEB Important Information It is very important to get a detailed history as quickly as possible Chart who was with the child Chart the statements made by the caretakers Chart the demeanor of the care takers

69. MEB Once the family knows the child is dead or dying the history will change if the injury is non- accidental trauma The changing of the history is a prime factor in prosecuting abusers The careful questioning and charting of this information gives the prosecution the opportunity to make a case. The initial reactions and history cannot be recaptured so it is very important to collect it and chart it.

70. MEB SIDS? Often a death of an infant is attributed to SIDS and the cause may be, suffocation, re-breathing or trauma. Gather a detailed history of time preceding the death. Educate your new parents about safe sleep.

71. MEB Reasons Parents Sleep with Children Fear they will stop breathing (SIDS) To bond with them Parent too tired and it is convenient Advice from family and friends The child is ill Parent is concerned they will not hear the infant cry

72. MEB SIDS is not Preventable but the Risk can be Reduced Back to Sleep Firm mattress with no more than two finger width between the edge of the mattress and crib side Always in a crib No blankets, pillows or stuffed toys Consider using a pacifier at night or nap time

73. MEB 2007 Missouri Fatality in Reports 97 Healthy infants died suddenly as they slept At the time of death only one child was sleeping alone on its back in a crib (with no loose soft bedding or toys)

74. MEB 2008 Missouri Fatality Reports 162 Sudden and unexpected deaths 16 Ruled SIDS 87 Unintentional suffocation 31 Illness 17 Undetermined cause of death 11 Homicide

75. MEB What you can do to Help Remember Be aware Consider Abuse Document Concerns Make Hotlines Update Education

76. MEB Wrap Up The protection of children is dependent on the willingness of people to report abuse, document it go to court, and fight for the protection of the children. It is the obligation and duty of each of us to do our part and it is a legal requirement of the profession we have chosen.

77. MEB Questions

78. MEB My Contact info: Rich Dandridge Pre-Hospital Outreach Coordinator St Louis Childrens Hospital One Childrens Place, 5-S-40 St Louis, Mo. 63110 Office: 314-484-2834 Cell: 314-283-3760 Email: richard.dandridge@bjc.org SLCH: stlouischildrens.org