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Child Abuse & Neglect for RI EMS Providers

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Child Abuse & Neglect for RI EMS Providers Rhode Island Department of Health Division of EMS Acknowledgements Child Abuse and Neglect: A Prehospital Continuing ... – PowerPoint PPT presentation

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Title: Child Abuse & Neglect for RI EMS Providers


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)

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.

4
Introduction
  • EMS providers are societys 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 childrens lives.

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.

6
Neglect Defined
  • Neglect A childs physical, mental, or emotional
    condition has been endangered because the
    caregiver has not provided for the childs basic
    needs.

7
The EMTs 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.

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

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

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

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

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

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

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)

15
Recognizing Fractures
  • Fractures discovered accidentally
  • Skeletal injury inconsistent with history
  • Multiple fractures in different stages of healing
  • Accompanied by other injuries

16
Recognizing Falls
  • Fall from standing position or low object (less
    than childs height) rarely results in serious
    injuries
  • Fall from greater than childs height usually
    required to sustain serious injury

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

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

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

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

21
Treating sexually abused patients
  • Believe what the child says
  • Use the childs own words and document statements
    in quotes
  • Never examine unwilling child
  • Do not remove childs clothing or examine
    genitals unless severe genital pain or gross
    genital bleeding
  • Refer child to specialist for examination

22
Recognizing Emotional Abuse
  • A component of all forms of child abuse
  • Attack on childs development of self and social
    competence
  • May not be done on conscious level
  • Most cases mild, but early recognition important

23
Recognizing Emotional Abuse
  • Ignoring the child
  • Rejecting the childs needs and requests
  • Isolating the child
  • Verbally assaulting the child (eg, name-calling,
    harsh threats)
  • Encouraging destructive, antisocial behavior
  • Humiliating the child

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

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.

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

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

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

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

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

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

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

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.

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

35
Legal Obligations
  • All states have a reporting statute for
    child abuse and neglect
  • Rhode Islands 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

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)

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

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.

39
Notifications
  • Who to notify
  • 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)

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

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

42
Transfer of Care
  • Hospital action does not negate EMS providers
    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

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

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

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

46
Documentation
  • Evidentiary value
  • Information most important!
  • Documentation must be clear, accurate, detailed,
    thorough
  • Diagrams very helpful
  • Preserve physical and trace evidence when possible

47
Documentation
  • In what format
  • Descriptive terms
  • Objective and specific
  • Use direct quotes wherever possible

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

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

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 childs
    injuries

51
Documenting Statements by Child
  • Record childs statement word for word in quotes
  • Include circumstances of statement (eg, who was
    present)
  • Note childs actions and demeanor (eg, crying,
    withdrawn)
  • Record any questions asked, who asked them, and
    response

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)

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

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

55
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

56
Examination
  • Written post-test (20 questions)

57
Questions?
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