CHAPTER OBJECTIVES
• Define and differentiate high-risk families and situations from child abuse and neglect
• Explain scene survey and challenges and strengths of EMS providers
• Describe types of interventions and other available resources
• Present and discuss case scenario
DIFFERENTIATING HIGH-RISK FAMILIES AND SITUATIONS
In recent years, child protection services throughout the United States have received 3 million referrals per year for suspected cases of child abuse or neglect. In more than half of these reports, further investigation to either substantiate or rule out abuse or neglect was warranted, and hundreds of thousands of children were found to be victims of maltreatment—physical abuse, sexual abuse, emotional abuse, or some form of neglect.
In most of these cases, circumstances led to a suspicion of abuse or neglect. However, in other cases, more subtle (and sometimes surmountable) risk factors were present that warranted concern for the welfare or well-being of a child, but not necessarily a report to child protection services. Some factors that may be associated with an increased
likelihood of child abuse and neglect include:
• Physical discipline in the home
• Domestic violence
• Substance abuse
• Children with special health care needs
Determining how to respond or act in high-risk situations that do not necessarily meet the criteria for making a report or referral is often a challenge. Understanding the definition of child abuse and neglect (see Definitions chapter) is essential for distinguishing it from high-risk situations.
KEY POINT: Distinguishing child abuse and neglect from various risk factors for child abuse and neglect is essential.
The term high-risk families refers to those families in which child abuse or neglect is known to have occurred or in which it is likely to occur often due to interpersonal, familial, social, or economic conflicts and pressures. Examples of such conflicts and pressures may include, but certainly are not limited to, marital conflicts, loss of
employment, depression, anxiety and other mental illnesses, or preparation and planning
older sibling may be acting as caregiver). However, caution should be exercised to avoid the conclusion that all families in similar circumstances are at increased risk for child abuse or neglect. Many families living in poverty have made natural adjustments or have sought formal and informal resources to help alleviate their financial stress.
Advances in medicine have reached a point where greater numbers of technologically dependent children are being kept at home, rather than in institutions. While laudable, this places a tremendous burden on a family. Other chronic illnesses such as asthma, sickle cell anemia, developmental delays and mental retardation are also profound stressors on a family. Because of this, children with special health care needs are particularly vulnerable to child abuse and neglect.
The term high-risk situations refers to critical circumstances affecting families that increase the potential for child abuse or neglect to occur. Examples of high-risk situations include the following:
• violence
• weapons, knives, or other sharp objects in the home
• open windows without guards
• broken or damaged steps
• excessive yelling
ROLE OF PREHOSPITAL MEDICAL PROVIDERS
The primary role of prehospital medical providers is to tend to the immediate medical needs, safety concerns, and well-being of their identified patient(s) or others in need of emergency medical care. EMS providers should never be placed or place themselves in situations in which this role is compromised. However, EMS providers also need to be aware of high-risk factors or situations for child abuse or neglect and to intervene appropriately.
Surveying the Scene
When EMS providers first arrive at the emergency scene, the most immediate task is assessing the identified patient(s) and quickly surveying the scene for factors that may have contributed to the emergency (eg, medications). When the emergency involves a child, the survey of the immediate surroundings must also involve a quick scan for evidence of child abuse or neglect and for related risk factors. This should be done keeping the explanation provided for the injury in mind. When the nature of the injury and the given explanation are inconsistent, child abuse or neglect should be suspected. In contrast, there may be high-risk factors or situations that warrant concern, and extra support for the family should be sought. If ignored or overlooked, these situations could eventually evolve into one of child abuse or neglect.
Surveying an emergency medical scene where children are involved should include the following:
• Appearance of the home and immediate surroundings: Are there risk factors
the windows have guards? How is the temperature inside the home? Is it too warm or too cold?
• Physical appearance and demeanor of the children: Are they clean or dirty?
Do they appear timid around the adult(s) in the home? How do they interact with each other? With the adults? Are they friendly, or perhaps overly friendly?
• Demeanor of the adults in the home: What is their tone of voice when speaking to the children? How adults and children act in a situation that involves EMS providers coming to the home may indicate how they interact and deal with crisis or other tense situations.
Challenges and Strengths of EMS Providers
Because EMS providers must focus on the immediate medical and safety needs of the patient(s), additionally surveying the scene for risk factors can be a difficult task for a variety of reasons. First, diverting attention away from the primary role of attending to medical needs can place the patient(s) at risk of further harm or injury. Second, time at the emergency scene is limited, further restricting the time available to intervene in a high-risk situation. Under these circumstances, actual child abuse or neglect may be missed, or mistakenly identified as a high-risk situation. Third, many emergency scenes are fraught with heightened emotions, worry, chaos, and confusion, and EMS providers may have the added task of calming family members and others who may be present.
Despite these inherent limitations, EMS providers can make an enormous difference in addressing child abuse or neglect. Indeed, they bring a number of unique strengths to identifying and intervening in families with children at risk for abuse and neglect.
One distinct advantage over most other health care professionals is that the EMS provider has an opportunity to observe children and families in their own homes and other usual surroundings. EMS providers also have the advantage of observing family interactions under distress—again, something other health care providers may not have an occasion to do. This provides an opportunity to make observations and to gather a wealth of
information that can provide valuable insight. In some instances, this insight may allow for a more informed assessment in differentiating abuse and neglect from a child at risk for abuse or neglect. Furthermore, EMS providers may not represent an authority figure to many families, often being viewed more as an ally than a threat. This is especially true of families that have had prior involvement with child protection services.
Intervention
There may be only a small window of opportunity to intervene in situations in which a child is at risk for abuse or neglect. However, this is the best opportunity for intervention and possible prevention. The intervention may be as simple and quick as providing a social services brochure, or closing a window that is not covered by a guard while briefly
discussing the situation with the hospital social worker may be helpful, or a referral to child protection services may be warranted.
Lastly, taking the time to learn about availability of other resources in local communities is very helpful. For example, it can be beneficial to identify and collaborate with others involved in intervention and prevention of child abuse or neglect (eg, hospital social workers, physicians, nurses).
KEY POINT: Identifying high-risk families and situations, by surveying the emergency scene for child abuse and neglect and for related risk factors, followed by taking appropriate action (eg, referral for social services support), may prevent child abuse and neglect from happening in the future.
CASE SCENARIO
Consider the following case scenario and whether child abuse and neglect is suspected or can be ruled out.
Case: EMS providersrespond to a 911 call at a home, where the identified patient is a 10-year-old girl who fell down the stairs (13 steps) and injured her back and right leg.
The carpet on the steps is heavily worn and ripped. The house is fairly tidy, although the furniture is also heavily worn and stained. Voices of other children are heard in the home, although you can’t determine how many or their approximate ages. There do not appear to be any other adults present. The injured girl will need to be taken to the hospital emergency room.
Discussion
The following discussion points are based on no suspicion of child abuse and neglect.
• Discuss the factors that make this a high-risk situation.
• Discuss the relevance of identifying whether the child lives at this home or is visiting.
• If the child’s mother accompanies the ambulance or follows behind, will she bring the children with her to the emergency room or does she plan to leave them
behind? If she plans to leave the children behind, would this be considered neglect? What needs to be considered for the children remaining in the home? Is there a neighbor or other family member available to assist? Are there any other adults in the home?
• If it is possible that the rips in the carpet contributed to the fall, consider what (if anything) can be done immediately to prevent others from falling.
• Discuss what, if any, intermediate or long-range follow-up would be helpful and who should be involved.
• What other resources can be used and how? How are these resources identified?
CHILD ABUSE AND NEGLECT
HIGH-RISK FAMILIES AND SITUATIONS
Differentiating High-Risk Families and Situations
In some cases of child abuse or neglect, risk factors are present that warrant concern for the welfare of a child, but not necessarily a report to child protection services. Factors that may be associated with an increased likelihood of child abuse or neglect include:
• Physical discipline in the home
• Domestic violence
• Substance abuse
• Children with special health care needs
KEY POINT: Distinguishing child abuse and neglect from various risk factors for child abuse and neglect is essential.
In high-risk families, child abuse or neglect is likely to occur often due to interpersonal, familial, social, or economic conflicts and pressures (eg, marital conflicts, loss of employment, depression, anxiety, or preparation for major family events). The term high-risk situations refers to critical circumstances affecting families that increase the potential for child abuse or neglect to occur (eg, violence; weapons, knives, or other sharp objects in the home; open windows without guards; broken or damaged steps;
excessive yelling).
Role of Prehospital Medical Providers
The primary role of prehospital medical providers is to tend to immediate medical needs.
However, surveying the emergency scene for evidence of abuse or neglect and for related risk factors, keeping the history in mind, and providing support as needed for high-risk families are important factors to consider in identifying and preventing abuse and neglect.
Challenges involved in surveying the scene include: 1) diverts attention away from attending to medical needs, 2) time limitations, 3) the need to calm family members in an emergency scene fraught with heightened emotions and confusion. Strengths include the opportunity to observe children and families in their own homes, under distress, thereby providing valuable insight. In addition, families often view the EMS provider as an ally rather than a threat.
Intervention may be simple and quick (eg, providing a referral to social services, or closing a window not covered by a guard), or may require longer-term actions. In these situations, learning about other resources available in the community (eg, hospital social workers) is very helpful.
CHILD ABUSE AND NEGLECT