Child Abuse

Slide 1: Child Abuse: An EMS Nightmare By Robert S. Cole Paramedic, CCEMT-P

Slide 2: "There is no more fundamental test of a society than how it treats its children." By: --Ronald Reagan

Slide 3: Revision Info • Last Revised 12-08-04 • For Info contact Steve Cole at: –colemedic@hotmail.com

Slide 4: Objectives • Recognize 4 major categories of Child Abuse • Understand reporting requirements of abuse. • Understand common presentations of abuse • Understand common misidentified abuse.

Slide 5: Types of Child Abuse • Neglect - failure to meet basic needs • Physical - intentional infliction of physical injury • Sexual - sexual contact or exploitation • Emotional - behaviors resulting in humiliation, rejection, fear, isolation, etc.

Slide 6: Centuries of Child Maltreatment • 1874 - 1st Legal Case • 1900 - Juvenile Justice System • 1962 - “Battered Child Syndrome • 1963 - 1st Reporting Laws • 1974 - US Child Abuse and Prevention Act (CAPTA) • 1980’s - Sexual Abuse Laws

Slide 8: Mary Ellen 1 year later • Mary Ellen's story ended well. • She was taken to an upstate New York farm to be raised with other children in a safe and happy home. • She later married and had two children and adopted a third little girl. • Two of the children became schoolteachers • Mary Ellen lived to be 92.

Slide 9: Statistics* United States – 2000* • 2.8 million children reported abused/neglected • 63% Neglect, 19% Physical, 10% Sexual Idaho – 2002** • 8613 children reported abused/neglected • 50% Neglect, 25% Physical, 7% Sexual *Child Maltreatment 2000: US. National Clearinghouse on Child Abuse and Neglect ** Idaho Dept. of H&W Facts, Figures, Trends 2002-2003

Slide 10: Child Maltreatment “…the physical or mental injury, sexual abuse or exploitation, negligence or maltreatment of a child under the age of 18…by persons responsible for the child’s welfare.”* *US Child Abuse Prevention and Treatment Act

Slide 11: More Facts • The National Committee for Prevention of Child Abuse estimated 3,126,000 reported child abuse victims in 1996, as compared to 1,919,000 in 1985. This does not include cases of abuse that were not reported. (Wang & Daro, 1997). • In 1996, an estimated 1,046 children died from abuse and neglect. In other words, almost three children died daily in the U.S. as a result of maltreatment. This signifies a 20% increase from 1985. (IBID.). • Most sexual abuse offenders are not strangers, but persons that the abused child knows and trusts. (PACER Center Inc., 1990.)

Slide 12: More Facts • Today, children are eight to ten times more likely to be abused in the foster care system than in their own homes (Toth, 1997; Spencer & Knudsen, 1992; Pryor, 1991; American Civil Liberties Union, 1994; Bolton, et al., 1981) • Remember , Mary Ellen was in FOSTER CARE!

Slide 13: The National Center on Child Abuse and Neglect estimates: • * For children 1-6 months of age, abuse is the second leading cause of death behind Sudden Infant Death Syndrome (SIDS). • For children 1-5 years of age, abuse is second only to accidents as the cause of death.

Slide 14: Childhood Mortality • Homicide is the only leading cause of childhood death that has increased in the past 30 years. • It accounts for 5% of all deaths in children,but only 1% of deaths in adults

Slide 15: Domestic Violence and Child Maltreatment (Oregon State University, July 2000 Study): • DV occurred in 38% of confirmed cases of child maltreatment • DV proceeded child maltreatment in 78% • Children under age 5 are disproportionately present in homes with DV (Fantuzzo & Mohr, 1999)

Slide 16: Victims of Maltreatment Child abuse and neglect affects all children of all ages. 1999 - 2,974,000 children referred in the US.* • 62% Female • 14%/1000 were age 0-3 yrs. • 25%/1000 were African/American (*Child Maltreatment 1999: US. National Clearinghouse on Child Abuse and Neglect)

Slide 17: Contributing Factors - Victim • Less than 5 years of age • Prematurity/multiple births • Chronic health problems • Developmentally delayed • ADD/ADHD • Child Irritability

Slide 18: Perpetrator “Someone who maltreats 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)

Slide 20: Contributing Factors - Perpetrator • Substance abuse • Poverty/Unemployment • Poor coping/parenting skills • Immaturity • Poor Education • History of abuse/domestic violence • Behavioral /Psych/Depression • Social Isolation

Slide 21: Determining Maltreatment • Is the history consistent with the injury pattern? • Is the history vague or changing? • Is the history consistent with child’s developmental level?

Slide 22: Suspicious Signs • unexplained • destructive injuries; behavior; • poor hygiene; • sleep or speech • inadequate disorders; nutrition; • difficulty walking • failure to thrive; or sitting; • lack of supervision • pain or bleeding in or abandonment; the genital area; • and venereal disease.

Slide 23: Physical Maltreatment “Any act committed by an adult or person in authority over a child that results in intentional physical injury to the child”

Slide 24: Common Types of injuries (not all inclusive) • welts; • broken bones; • internal injuries; • burns; • cigarette burns; • bites; • immersion burns; • strangulation; • and/ or dry burns

Slide 25: Bruising/Contusions “Any bruise may be intentional” “Common” bruising “Suspicious” bruising • Occurs on extensor skin • Occurs on fatty areas or surfaces areas covered by clothing, • Occurs over bony, non- diapers fatty areas • Pattern marks • Usually isolated and • Multiple bruises in poorly defined various stages of healing

Slide 26: Multiple bruises at different stages of healing, dating of bruises by appearance (estimates): Age of bruise Appearance < 6 hrs Red, swollen, tender 6-12 hours Blue Swollen , Tender 4-10 days Yellow to green 10-14 days brown 2-4 weeks clearing Health condition, medication therapy, and other variables come into play.

Slide 32: Bite Marks

Slide 36: Other Bazaar Marks Bizarre marks: a.Blunt instruments b.Tattoos c.Fork mark punctures d.Circumferential marks (wrists, ankles) binding e.Gag marks

Slide 37: Burns “Any burn may be intentional” “Common” burns “Suspicious” burns • Splatter/splash pattern • Immersion/dunking • Burns consistent with patterns history and child’s • Contact pattern developmental level • Bilateral burns • Cigarette burn

Slide 38: Courtesy of David Effron, M.D.

Slide 41: Skeletal Injuries “Any fracture may be intentional” “Common” fractures “Suspicious” fractures • Clavicle • Long bones • Wrist • Metaphyseal fractures • Forearm • Ribs • Lower leg

Slide 42: ABD Injuries • Abd injuries prone to cause shock and mortality. – Compression of viscus against vertebral column – Pummeling blows by blunt objects, may see abodominal bruises in periumbilical region, or over liver or spleen. – Rarely discolored – Injured sites: – Ruptured liver or spleen – Intestinal perforation – Intramural hematoma of duodenum (most common) – Ruptured great vessel (rare) – Pancreatic injury (pseudocyst, traumatic pancreatitis) – Kidney injury (rare)

Slide 43: Head Trauma “Any head injury may be intentional” “Common” head injury “Suspicious” head trauma • Simple skull fracture • Simple skull fracture in infant • Complex skull fracture • Subdural/Epidural hematoma • Sudden CNS involvement

Slide 44: Shaken Baby Syndrome “Caused by VIGOROUS shaking of infant or small child” • Tearing/shredding of small cerebral blood vessels and neurons • Sudden or rapid CNS involvement • Retinal hemorrhage

Slide 45: Munchausen Syndrome by Proxy • Manufacturing illness or disease by fabricating symptoms • Intentionally harming a child in order to produce injury or symptoms of illness Consider all sources for the illness or injury. Nothing is too far-fetched.

Slide 46: Sexual Maltreatment “Any sexual contact or exposure to sexual stimuli to a child, rendered by an adult or older person.” Encompasses a broad spectrum of acts

Slide 47: Sexual Maltreatment • obscene language; • pornography; • exposure; • fondling; • molesting; • oral sex; • intercourse; and • sodomy

Slide 48: Conditions That Mimic Maltreatment • Cultural Practices • Elbow Subluxation – Nursemaids elbow • Congenital Conditions – Mongolian spots

Slide 49: Cultural Practices • There are some cultural customs used as home remedies to cure or relieve the symptoms of some ailments such as: • Backache • Itchy skin • Flu Symptoms • These practices are primarily seen in Southeast Asian cultures, but some are also used by Russian immigrants and Mexican-American families. • These practices are usually performed by a trained practitioner. • From culture to culture, these remedies have different names and the process differs slightly.

Slide 50: Coining

Slide 51: Coining

Slide 52: Cupping

Slide 53: Two Cultural Practices Which Should be Reported • Stick Burns and Moxibustion • Hair Pulling

Slide 54: Stick Burns and Moxibustion • Primarily Asian cultures. • Used to relieve a variety of symptoms such, as fever and abdominal pain. • These are related to acupuncture, however, they cause a circular, cigarette-tip size burn. • Should be reported. • A stick, similar to an incense stick is lit, and placed on the palms of the hands, soles of the feet and genital area. • In some cultures, a hollow bamboo stick stuffed with cotton is lit and then extinguished. • Moxa herbs or yarn are rolled into a pea-sized ball and placed on the skin. The ball is then lit and allowed to burn to the point of pain.

Slide 55: Stick Burns and Moxibustion

Slide 56: Hair Pulling • This home remedy is to relieve headache pain. The hair is pulled, and if too much force is used, the hair may be pulled out of the scalp

Slide 57: Elbow Subluxation • In children under about 4 years old, • When the arm is straightened and pulled, the elbow joint is loose enough to separate for a moment while a bit of ligament slips between the bones before they snap back together. Ouch! • It is especially common if kids are yanking their arms against the pull. • The injury also happens sometimes with falls. • The main symptom is refusal to use the affected arm. • Kids will usually hold the arm close to the body, with the elbow bent. The hand is usually turned down or toward the body. • Kids may scream if you attempt to turn the hand or move the elbow, but there is unlikely to be swelling

Slide 58: Mongolian Spots • Mongolian spots are basically birth marks commonly seen in those of African American and Asian descent. • Mongolian spots are present at birth, and most of them fade (at least somewhat) by age two. Most have completely disappeared by age five. • If Mongolian spots remain at puberty (uncommon), they are likely to be permanent. • Tend to have a poorly defined border and an irregular shape. • Tend not to be tender. • Will not have a halo. • Will not be swollen.

Slide 59: Mongolian Spots

Slide 60: Mongolian Spots

Slide 61: Medical Exam • Majority of cases - no physical evidence • Evidence can be collected up to 72 hrs. • Colposcopy - visual exam of genitals • No speculums for females prior to menarche

Slide 62: Neglect “Failure to provide the basic necessities of life” • Food • Clothing • Shelter • Safe Environment • Medical/Dental Care

Slide 64: Emotional/Psychological Maltreatment “Patterns of behavior by a person over a child resulting in • Verbal assaults degradation, • Threats humiliation, rejection • Blaming or terror to that • Name-calling child.”

Slide 65: Ritual Abuse “A bizarre form of child maltreatment in which the child may be forced to witness or participate in various acts of sexual and/or physical violence” • Rare • Community hysteria • McMartin case

Slide 66: Child Maltreatment is a Crime • Reporting • Collection/preservation of evidence • Documentation

Slide 68: Reporting Child Maltreatment Idaho Code 16-1619 “Any physician, resident…intern, nurse, coroner, school teacher, day care personnel, social worker, or other person having reason to believe that a child under the age of eighteen (18) years has been abused, abandoned or neglected…shall report report or cause to be reported within twenty-four (24) hours…to the proper law enforcement agency or the department…”

Slide 69: Immunity Idaho Code 16-1620 “Any person who has reason to believe that a child has been abused, abandoned or neglected and…makes a report of abuse, abandonment or neglect as required in section 16- 1619…shall have immunity…in any judicial proceeding resulting from such report. Any person who reports in bad faith or with malice shall not be protected by this section.”

Slide 70: Taking the report DO’s DONT’S Do use the child's own Do not make promises you vocabulary. cannot keep, especially that you will not tell anyone. Do listen carefully to what the Do not ask direct questions of the child is saying. child - this might compromise the investigation. Do tell the child the abuse was Do not investigate or push the not her/his fault and that s/he is child into giving details of the not bad or to blame. abuse. Your job is to listen to what the child wants to tell you. Do be supportive. Remember Do not discuss what the child told why the child came to you. S/he you with anyone who is not needs your help, support, and directly involved in helping the guidance. Let the child know that child. telling was the right thing to do.

Slide 71: Taking the report (cont) DO’s DONT’S Do know your limits and what Do not notify the parents or your role is; this is not a situation anyone (outside of health care you can or should handle by and law enforcement) involved in yourself. the case when a report is made. The CPS worker will notify them. Do tell the truth and be specific; Do not have an out-of-control let the child know you will be reaction. Anger and disbelief can making a report to get him/her cause the child to take back their help. disclosure. Do immediately make a report to Do not delay in making the report. CPS without further questioning You could be the last hope for this the child or contacting the family. child. Do Document thoroughly, Don’t document opinions or objectively speculations Document your reporting of the suspected abuse.

Slide 72: Who Reports • Physician, Resident, Intern • Nurse • Coroner • School Teacher • Day Care Personnel • Social Worker • Other person having reason to believe...

Slide 73: What to Report Suspicion that a child under age 18 has been: • Abused • Neglected • Abandoned

Slide 74: Report To: Report within 24 hours Law Enforcement Agency • Police Department • Sheriff Department • Military Police • School Resource Officer Department of Health and Welfare • Division of Children and Family Services

Slide 75: Idaho Lines • During business hours, call the Idaho CareLine: –1-800-926-2588 –(TDD 208-332-7205) • 24 Hours: number listed below for your nearest town. –Ada County, Elmore County, 1-800-600- 6474 – Canyon County, Owyhee County: 454-0421

Slide 76: Washington, Utah, Oregon, & Montana • Montana - 800-332-6100 –406-444-5900 (out of state) • Washington – –800-562-5624 (nationwide) • Utah – –800-678-9399 (nationwide) • Oregon – –800-854-3508 ext.2402 –(in state, during business hours) : 503-378-5414 –(TTY, hearing impaired) 503-378-6704 (nationwide, during business hours)

Slide 77: Please visit the National Clearinghouse on Child Abuse and Neglect Information web site to learn more about mandated reporters state by state. http:// www.calib.com/nccanch/statutes/index.cfm#rep

Slide 78: Prevention Primary Prevention - directed at general public/families at risk • School based programs • Parenting classes • Healthy Families Program • Screening Secondary Prevention - after abuse has occurred • Reporting • Counseling

Slide 79: Cycle of Abuse “The cycle of violence and abuse continues from generation to generation until the cycle is broken.” We can break the cycle

Slide 80: Questions???

Slide 81: Special Thanks to: Marti Monk RN. CEN. Clinic Coordinator St. Luke’s CARES Program

Slide 82: www.adaparamedics.org 208-287-2972