© 2003 The Center for Pediatric Emergency Medicine of the New York University School of Medicine Readers are encouraged to duplicate and use all or part of the information contained in this publication for educational purposes only In accordance with accepted publishing standards, permission must be obtained from the Center for Pediatric Emergency Medicine for information reproduced in another publication Illustrations created by Virginia Ferrante, MA All drawings and text may be reproduced, as they appear, for not-for-profit use to educate medical personnel Cite as: David Markenson, Michael G Tunik, Marsha Treiber, Arthur Cooper, Andrew Skomorowsky, George L Foltin Child Abuse and Neglect: A Prehospital Continuing Education and Teaching Resource New York, NY: Center for Pediatric Emergency Medicine, 2003 The mission of the Center for Pediatric Emergency Medicine (CPEM) is to improve emergency medical services for children in the United States through education, research, advocacy, and systems development Established in 1985 at New York University School of Medicine and Bellevue Hospital Center in New York City, CPEM is funded primarily by the US Department of Health and Human Services/Health Resources and Services Administration through its Maternal and Child Health Bureau, EMSC Program The recommendations in this publication are not intended to indicate an exclusive course of treatment or to serve as a standard of medical care Individual circumstances may require variations on these recommendations CPEM disclaims any liability or responsibility for the consequences of any action taken in reliance on the statements or opinions contained herein Published by Center for Pediatric Emergency Medicine Bellevue Hospital Center, Room East 27th Street & First Avenue New York, New York 10016 212/562-4470 212/562-7753 fax www.cpem.org This manual was supported by project grant H34 MC 00077 from the Emergency Medical Services for Children Program as provided by Section 1910 of the US Public Health Service Act Emergency Medical Services for Children is administered by Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, US Department of Health and Human Services in cooperation with the National Highway Traffic Safety Administration Editors: David S Markenson, MD, FAAP, EMT-P Mailman School of Public Health, Columbia University Michael G Tunik, MD, FAAP New York University School of Medicine Marsha Treiber, MPS New York University School of Medicine Arthur Cooper, MD, FAAP, FACS Columbia University College of Physicians and Surgeons Andrew Skomorowsky, MFA, NREMT-P New York University School of Medicine George L Foltin, MD, FAAP, FACEP New York University School of Medicine Executive Editor: Susan E Aiello, DVM, ELS Contributors: Raphael M Barishansky, MPH, Hudson Valley Regional EMS Council Kathleen Brown, MD, Emergency Department of Children’s National Medical Center Linda Cahill, MD, Child Protection Center of Montefiore Medical Center Karen M Caravaglia, MS, EMT-P, National Center for Disaster Preparedness, Columbia University Mailman School of Public Health Lynn Babcock Cimpello, MD, Departments of Emergency Medicine and Pediatrics University of Rochester School of Medicine and Dentistry Susan McDaniel Hohenhaus, RN, BS, EMSC at Duke University Health System Lori Legano, MD, Child Protection and Development Center of Bellevue Hospital Hedda Matza-Haughton, MSW, CSW, “For the Health of It” Consultation Services Margaret McHugh, MD, MPH, Child Protection and Development Center of Bellevue Hospital Jeffrey Meade, NREMT-P, CIC, Emergency Life Support Programs of Phelps Memorial Hospital Center LaVoyce Reid, MSW, LCSW, National Association of Social Workers Laura L Rogers, JD, American Prosecutors Research Institute’s National Center for Prosecution of Child Abuse Medical Illustrator: Virginia Ferrante, MA Executive Producer - CD-ROM: Mark Marshall Programming/Mastering/Package Design: Maximum Interactive www.maximuminteractive.com If you have any questions regarding the use or contents of this resource, please contact CPEM (click here to connect) CHILD ABUSE AND NEGLECT TABLE OF CONTENTS Foreword………………………………………………………………………………… i Introduction Chapter Objectives Background Risk Factors Child Risk Factors Parental Risk Factors Societal Risk Factors Cycle of Abuse… Role of Pre-Hospital Medical Providers Reporting Requirements Handout Definitions Chapter Objectives Abuse and Neglect Defined The Child Abuse Prevention and Treatment Act Mandated Reporters The Abused Child, Abusive Actions, and the Abuser Child Maltreatment Types of Child Abuse Physical Abuse Sexual Abuse Emotional Abuse Neglect Case Scenario Handout Recognition Chapter Objectives 10 Importance of the History 10 Recognizing the Mechanism and Patterns of Injury 11 Early Childhood Development 11 Right to Privacy 12 Physical Abuse 12 Skin Injuries 12 Bruises 12 Burns 13 Adult Human Bites 13 Fractures 13 Falls 14 Injuries to the Face and Head 14 Hair Loss 14 Shaken Baby Syndrome 14 Sexual Abuse 15 Emotional Abuse 15 Neglect 16 Munchausen Syndrome by Proxy 16 Sudden Infant Death Syndrome 17 Cultural Considerations 18 Case Scenarios 19 Handout 20 High-Risk Families and Situations Chapter Objectives 22 Differentiating High-Risk Families and Situations 22 Role of Prehospital Medical Providers 23 Surveying the Scene 23 Challenges and Strengths of EMS Providers 24 Intervention 24 Case Scenario 25 Handout 26 Reporting Chapter Objectives 27 State Law 27 Consequences of Failing to Report 28 Form of Report 28 Content of Report 29 Communicating with Caregivers 29 Transfer of Care 30 National Child Abuse Hotline and State Reporting Numbers 30 Case Scenario 32 Handout 33 Documentation Chapter Objectives 36 Evidence 36 Importance of Documentation 37 Proper Documentation 37 General Principles 37 Documenting the Scene 38 Documenting the History 38 Documenting the Reasons for Suspicion and Actions Taken 39 Victim other than the Specified Patient 40 Case Scenario 40 Handout 41 Child Protection Services Chapter Objectives 43 Function of CPS 43 Process of the CPS Agency 43 Sample Case Flow 44 Further Role of EMS Providers 44 Handout 45 Medicolegal Issues Chapter Objectives 46 Introduction and Overview 46 Hearsay Exceptions 47 Excited Utterance 47 State of Mind 47 Statement Made for Medical Diagnosis 47 Present Sense Impression 48 Catch-all Exception 48 Totality of the Circumstances 48 Report Writing and Evidence Collection 49 Verbatim Statements 49 Demeanor and Emotions 49 Timing 49 Evidence Collection 49 Mandatory Reporting 51 Hearsay and EMS Providers (Expanded Explanatory Text) 52 Handout 63 Illustrations Figure – Accidental Bruising 66 Figure – Inflicted Burns and Pinch and Slap Marks 67 Figure – Inflicted Burns 68 Figure – Accidental Splash Burns 69 Figure – Cord and Belt Marks and Inflicted Burns 70 Figure – Coining and Cupping 71 Images Image A – Slap Mark, Face 72 Image B – Grab Marks, Arm 73 Image C – Accidental Bruising, Shins 74 Image D – Immersion Burns, Hands 75 Image E – Immersion Burns, Feet 76 Image F – Immersion Burns, Buttocks 77 Image G – Hot Liquid Burn, Face and Chest 78 Image H – Coin Rubbing 79 Image I – Cupping 80 Image J – Looped Cord Marks 81 Image K – Strangulation Marks 82 i CHILD ABUSE AND NEGLECT FOREWORD What emergency medical services (EMS) providers know about child abuse and neglect? This question was the focal point of a three-year grant project undertaken by the Center for Pediatric Emergency Medicine (CPEM) and funded by the EMS for Children (EMSC) Program of the federal Health Resources Services Administration (HRSA)/Maternal and Child Health Bureau (MCHB) The goals of the National Child Protection Education Project included the following: • • • • assess current understanding of the recognition, reporting, and prevention of child abuse and neglect; treatment of its victims; and the attitudes toward this distressing problem among the nation’s prehospital medical providers analyze the results bring EMS, EMSC, and child protection advocates together to evaluate results utilize the findings to develop this educational program Three million cases of child abuse are reported in the US annually, making this a significant public health care concern EMS providers are in a unique position, often being the only individuals who have access to a patient’s home They can be the “eyes and ears” of the medical community Their ability to assess and deal sensitively with this issue can have a positive impact on the morbidity and mortality of children While there is a vast amount of information on managing child maltreatment for many levels of health care providers, there has been little information regarding the role of EMS providers Furthermore, there has been no information on the knowledge, attitude, and state of readiness of EMS providers to deal with child maltreatment The result was a lack of uniform national resource material addressing the educational needs, attitudes, and role of EMS and other prehospital providers in child protection CPEM has addressed this gap First, a national coalition of experts in EMS, EMSC, and child protection was formed This group, along with input of the National EMSC Data Analysis Research Center, created, piloted, and refined a survey questionnaire in collaboration with the National Registry of EMTs and 15 State EMS Directors In concert with this survey, courses and curricula currently in existence on child abuse and neglect were identified Although there were many courses and curricula for other professionals, such as police, social workers, and nurses, virtually nothing existed specifically for the prehospital provider In addition, information concerning statewide regulations on child abuse in all 50 states was compiled Center for Pediatric Emergency Medicine Child Abuse and Neglect ii Second, EMS providers throughout the nation, at the EMT-Basic, EMT-Intermediate, and EMT-Paramedic levels, were assessed regarding their knowledge of the following: • • • • • the definitions of child abuse and neglect possible signs and symptoms of child abuse or neglect treatment and transportation strategies proper documentation and reporting child abuse and neglect laws, regulations, and agency policies in their area of operation A key aspect of the project was to evaluate and consider the self-efficacy and attitudes of prehospital providers toward recognition and management of child abuse and neglect Following these efforts, a Blue Ribbon panel of national experts in EMSC and child protection met in October of 2001 to review the results of these surveys and to make recommendations on content for the EMS child protection resource (Proceedings can be found on the CPEM website, www.cpem.org, under “Resources.”) The final result, Child Abuse and Neglect: A Continuing Education and Teaching Resource for the Prehospital Provider, was created specifically for instructors of EMS prehospital providers A review board of national experts in EMS, EMSC, and child protection reviewed draft sections of this educational resource, and national and regional workshops were held to gather the input of the EMS instructors themselves CPEM is gratified by the continuing confidence shown in us by the federal government in the funding of our efforts to improve EMSC around the country We are thankful for the enormous amount of enthusiasm generated by this exciting project We are grateful for the wonderful letters of support from EMS, pediatric and child protection organizations, and especially the State EMS Directors who have consistently supported our efforts ACKNOWLEDGMENTS We would like to acknowledge those individuals whose contribution to the development of this resource was invaluable We thank Dr David Heppel, Dan Kavanaugh, MSW, Cindy Doyle, RN, and Mickey Reynolds of the HRSA/MCHB EMSC Program, for their direction and assistance with this project; thanks also to that agency as a whole for providing financial support We express our appreciation to Lenora Olson, MA and Lawrence Cook, MStat, from the National Data Analysis Research Center (NEDARC), and to William R Brown, Jr., NREMT-P, and Philip Dickison, NREMT-P, of the National Registry of EMTs (NREMT) for assistance in the design and distribution of the assessment questionnaire, and in the subsequent data collection, management, and analysis of the results Foreword Child Abuse and Neglect iii The authors would especially like to thank Hedda Matza-Haughton, MSW, CSW, for her professional and enthusiastic management of the project in the establishment of the advisory board and expert review panel, in the development of the assessment questionnaire and its distribution, and in the coordination of the Blue Ribbon panel consensus meeting Sarah Gagnon, EMT, also provided capable and efficient administrative assistance during the developmental stages of the project We would like to thank Jane Ball, RN, MPH, DrPH, Ken Allen, Yvonnada Cousins, and the staff of the EMSC National Resource Center, who helped to coordinate the consensus meeting, as well as those who attended and provided invaluable input This program was piloted, with the skilled assistance of Karen Caravaglia, MSOL, EMT-P, at the New York State Vital Signs Conference (coordinated by Donna Gerard), the Alaska State EMS Conference (coordinated by Doreen Risley), and at a special workshop hosted by Oklahoma City EMSC at the University of Oklahoma (coordinated by Paul Marmen) We are extremely grateful for their gracious hospitality and for the individuals in the workshops who provided essential feedback about our program We would like to thank Dr Margaret McHugh and Dr Lori Legano of the Child Protection and Development Center of Bellevue Hospital, whose consistent support and expertise greatly strengthened this resource Many national organizations provided representation on our advisory board, including the following: American Academy of Pediatrics (AAP), American Academy of Child and Adolescent Psychiatry, American College of Emergency Physicians, Ambulatory Pediatric Association, American Psychological Association, Child Welfare Institute, Emergency Nurses Association, International Association of Chiefs of Police, International Association of Fire Chiefs, International Society for the Prevention of Child Abuse and Neglect, National Alliance of Children’s Trust and Prevention Funds, National Association of Emergency Medical Services Educators, National Association of Emergency Medical Services Physicians, National Association of Emergency Medical Technicians, National Association of Pediatric Nurse Practitioners, National Association of School Nurses, National Association of Social Workers, National Association of State Emergency Medical Services Directors, National Children’s Alliance, National Center for Prosecution of Child Abuse, National Council of State Emergency Medical Services Training Coordinators, National EMSC Data Analysis Resource Center, National Registry of Emergency Medical Technicians, and Prevent Child Abuse America Their participation and continued support are deeply appreciated We would like to thank the AAP for their gracious permission to use the color images included on the CD version of this resource from their publication The Visual Diagnosis of Child Physical Abuse, 1994 We are grateful to Senator Daniel K Inouye of Hawaii; to his dedicated administrative assistant, Dr Patrick DeLeon; and to Senator Orrin G Hatch of Utah for creating the EMSC National Funding Initiative; and to those individuals who work diligently to upgrade emergency medical services for children in the United States Foreword Child Abuse and Neglect iv Finally, we are extremely grateful to the numerous paramedic instructors, medical experts, and educational consultants who carefully critiqued the information to ensure that this resource would be both relevant and appropriate Many more dedicated professionals than we could possibly name gave generously of their own time and expertise Their enthusiastic participation has been a motivating force behind this project, and they received no compensation beyond the knowledge that they were helping to create a greatly needed resource We hope the final product lives up to their efforts, hopes, and expectations George L Foltin, MD, FAAP, FACEP Director Center for Pediatric Emergency Medicine www.cpem.org Foreword Child Abuse and Neglect Back to chapter Back to the TOC Back to chapter Back to the TOC Back to chapter Back to the TOC Back to chapter Back to the TOC Image A: Slap mark, face Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to chapter Back to the TOC Image B: Grab marks, arm Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to chapter Back to the TOC Back to chapter Image C: Accidental bruising, shins Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to the TOC Image D: Immersion burns, hands Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to chapter Back to the TOC Image E: Immersion burns, feet Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to chapter Back to the TOC Image F: Immersion burns, buttocks Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to chapter Back to the TOC Image G: Hot liquid burn, face and chest Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to chapter Back to the TOC Image H: Coin rubbing Back to chapter Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to the TOC Image I: Cupping Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to chapter Back to the TOC Image J: Looped cord marks Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to the TOC Image K: Strangulation marks Reproduced, with permission, from The Visual Diagnosis of Child Physical Abuse, American Academy of Pediatrics, 1994 Back to the TOC ... physical abuse, sexual abuse, emotional abuse, and neglect • Present and discuss case scenario ABUSE AND NEGLECT DEFINED The following are general definitions of child abuse and neglect: In child abuse, ... definitions of child abuse and neglect possible signs and symptoms of child abuse or neglect treatment and transportation strategies proper documentation and reporting child abuse and neglect laws,... the living room, and the floor is carpeted Definitions Child Abuse and Neglect Back to the TOC Handout CHILD ABUSE AND NEGLECT DEFINITIONS General Definitions In child abuse, a child has suffered