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

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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

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)

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)

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)

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)

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)

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)

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)

Additional Help Rhode Island DCYF 1-800-RI-CHILD (800-742-4453) nationwide, 24 hours Childhelp USA® National Child Abuse Hotline: 1-800-4-A-CHILD® RI Department of Health, Division of EMS, at 401-222-2401 Child Abuse/Neglect for RI EMS Providers (Slide 55)

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

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