HealthStream Regulatory Script

Transcription

1 HealthStream Regulatory Script [Identifying and Assessing Victims of Child Abuse and Neglect] Version: [May 2005] Lesson 1: Introduction Lesson 2: Definitions and Consequences Lesson 3: Identifying Victims Lesson 4: Assessment and Referral Lesson 5: Reporting Requirements

2 Lesson 1: Introduction 1001 Introduction Welcome to the introductory lesson on identifying and assessing victims of child abuse and neglect. IMAGE: 1001.JPG Child maltreatment is a significant problem in the United States. For example, in 2002: Child Protective Services had 2.6 million reports of suspected abuse. These reports involved a total of 4.5 million children. Nearly one million of the reported children were found to be victims of abuse. 1,400 children died as a result of child abuse or neglect. Most of these children were under the age of four. Source: National Clearinghouse on Child Abuse and Neglect Information, Child Maltreatment 2002: Summary of Key Findings. As your partner, HealthStream strives to provide its customers with excellence in regulatory learning solutions. As new guidelines are continually issued by regulatory agencies, we work to update courses, as needed, in a timely manner. Since responsibility for complying with new guidelines remains with your organization, HealthStream encourages you to routinely check all relevant regulatory agencies directly for the latest updates for clinical/organizational guidelines. Point 1 of 5 2

3 1002 Introduction: JCAHO Standard PC.3.10 The 2004 JCAHO Comprehensive Accreditation Manual for Hospitals (CAMH) includes a standard for victims of abuse or neglect(standard PC.3.10). IMAGE: 1002.GIF The rationale for the standard explains the importance of identifying victims. See the text image to the right for the major points of this rationale. Point 2 of 5

4 1003 Course Rationale This course focuses on child abuse and neglect. IMAGE: 1003.JPG You will learn how to identify, assess, refer, and report victims. This will help you: Improve public health and your facility s quality of patient care. Comply with JCAHO Standard PC Note: For more details about JCAHO Standard PC.3.10, and an overview of all types of abuse and neglect, see the course: Identifying and Assessing Victims of Abuse and Neglect. Point 3 of 5

5 1004 Course Goals After completing this course, you should be able to: NO IMAGE Recognize forms of child maltreatment. List the effects of child abuse and neglect. Recognize methods for identifying victims. List steps in the process of assessing a victim. Recognize the importance of laws about reporting child abuse. Point 4 of 5

6 1005 Course Outline This introductory lesson provides you with the course rationale, goals, and outline. FLASH ANIMATION: 1005.SWF/FLA Lesson 2 presents background information on child abuse and neglect. This will help you understand what abuse and neglect mean. You also will learn about the harmful effects of abuse and neglect. Lesson 3 provides information on identifying victims of child abuse and neglect. Lesson 4 presents information on assessing and referring victims. Finally, lesson 5 talks about reporting child maltreatment. Point 5 of 5

7 Lesson 2: Definitions and Consequences 2001 Introduction Welcome to the lesson on definitions and consequences. FLASH ANIMATION: 2001.SWF/FLA This lesson will give you a better understanding of what child maltreatment is, and how it affects its victims. Point 1 of 15

8 2002 Objectives After completing this lesson, you should be able to: NO IMAGE List important features and examples of physical abuse, sexual abuse, emotional abuse, and neglect. List important effects of child maltreatment. Point 2 of 15

9 2003 Forms of Child Maltreatment Child maltreatment may be: IMAGE: 2003.JPG Physical abuse Sexual abuse Emotional abuse Neglect Let s take a closer look at each. Point 3 of 15

10 2004 Child Maltreatment: Physical Abuse Physical abuse: Tends to be the most visible form of child abuse Occurs when a caretaker injures a child on purpose IMAGE: 2004.GIF Examples of physical abuse include: Severe and unreasonable physical punishment Punching Beating Kicking Biting Burning Shaking Throwing If this form of abuse is not stopped promptly, it is likely that: The abuse will become more and more severe. The abuser will find it harder and harder to stop abusing the child. Point 4 of 15

11 2005 Child Maltreatment: Sexual Abuse Sexual abuse happens when a caretaker involves a child in any sexual activity. IMAGE: 2005.GIF Sexually abusive acts include: Fondling a child s genitals Oral, anal, or vaginal sex with a child Exposing genitalia in front of a child Child prostitution Child pornography Forcing or persuading a child to perform sexual acts with other children Point 5 of 15

12 2006 Child Maltreatment: Emotional Abuse In 2002, 7% of abused children were emotionally abused. This type of abuse happens when a caretaker treats a child in any of the following ways on a regular basis: Rejecting Degrading Terrorizing Ignoring Isolating Corrupting Click on each type of emotional abuse for examples. CLICK TO REVEAL Rejecting behaviors may include: Avoiding a child Telling a child that he or she is useless or inferior Treating a child s thoughts, feelings, or needs as if they are not important Degrading behaviors may include: Insulting or ridiculing a child Calling a child names Teasing a child about a disability Publicly humiliating a child Terrorizing behaviors may include: Threatening a child with severe punishment Placing a child in a dangerous environment Punishing a child for not meeting unrealistic goals or expectations Causing a child to feel intense fear in any other way Ignoring behaviors may include: Not responding to a child Refusing to interact with a child Isolating behaviors can include: Physically confining a child Limiting a child s contact with others Preventing a child from having normal friendships Corrupting Corruption teaches a child to behave in antisocial or abnormal ways. Point 6 of 15

13 2007 Child Maltreatment: Neglect Child neglect occurs when a caretaker does not meet a child s basic needs. IMAGE: 2007.GIF These needs may be physical, developmental, or psychological. For example, all children need: Food Clothing Shelter Emotional support Love and nurturing Education Safety Medical and dental care Point 7 of 15

14 2008 Consequences of Child Abuse/Neglect Child abuse has far-reaching effects. IMAGE: 2008.GIF These effects include: Physical health consequences for the child Psychological consequences for the child Behavioral consequences for the child Costs to society Let s take a closer look at each. Point 8 of 15

15 2009 Consequences: Physical The immediate physical health effects of abuse range from minor to severe. Examples of minor injuries include cuts and bruises. Examples of severe effects include broken bones, massive bleeding, and even death. The long-term physical effects of abuse can include: Damage to the nervous system caused by shaken baby syndrome Problems with brain development caused by long-term abuse Long-term physical health problems Click on each effect to learn more. CLICK TO REVEAL Damage to the nervous system caused by shaken baby syndrome Long-term effects of shaken baby syndrome can include: Blindness Learning disabilities Mental retardation Cerebral palsy Paralysis Problems with brain development caused by long-term abuse Child abuse and neglect can cause certain areas of the brain to form incorrectly. This can cause: Problems with physical development Problems with mental development Problems with emotional development Long-term abuse also can cause a stress response. This stress can cause certain areas of the brain to become abnormally sensitive to input from the outside world. This can lead to: Hyperactivity, including attention deficit/hyperactivity disorder (ADHD) Sleep disorders Anxiety Post-traumatic stress disorder (PTSD) Behavioral problems Learning and memory problems Long-term physical health problems Victims of childhood abuse or neglect may be at high risk for health problems as adults. These health problems can include: Sexually transmitted diseases Heart disease Cancer Lung disease Bone fractures Liver disease Point 9 of 15

16 2010 Consequences: Psychological The immediate psychological effects of child abuse or neglect include: Isolation Fear Inability to trust IMAGE: 2010.GIF These problems can lead to lifelong troubles. Victims of childhood abuse often have psychological problems later in life. These problems can include: Depression Anxiety Eating disorders Suicide attempts Source: U.S. Department of Health and Human Services, Administration for Children & Families, Long-Term Consequences of Child Abuse and Neglect. Point 10 of 15

17 2011 Consequences: Behavioral Victims of childhood abuse or neglect are at high risk for behavioral problems during their teenage years. These problems can include Crime Teen pregnancy Poor grades in school Drug use IMAGE: 2011.GIF Victims of childhood abuse or neglect also are at high risk for: Crime as adults Cigarette use Alcohol abuse Other drug abuse Finally, victims of childhood abuse or neglect are more likely to become abusive parents. Point 11 of 15

18 2012 Consequences: Societal Child abuse and neglect have costs for all of us. IMAGE: 2012.GIF Direct costs come from: Investigating abuse Treating abused children and their families Indirect costs come from the effects discussed earlier in the lesson. For example, society pays a price for victims of childhood abuse or neglect who: Need a lot of healthcare. Need special education. Have mental illnesses. Abuse drugs or alcohol. Go on to abuse their own children. Are unemployed or underemployed. Commit crimes. Point 12 of 15

19 2013 Review The most common form of child maltreatment is: a. Neglect b. Sexual abuse c. Physical abuse d. Emotional abuse MULTIPLE CHOICE INTERACTION Correct answer: A Feedback for A: Correct. According to 2002 statistics, 60% of cases of child maltreatment involved neglect. Twenty percent of cases involved physical abuse, 10% involved sexual abuse, and 7% involved emotional abuse. Feedback for B: Incorrect. The correct answer is A. According to 2002 statistics, 60% of cases of child maltreatment involved neglect. Twenty percent of cases involved physical abuse, 10% involved sexual abuse, and 7% involved emotional abuse. Feedback for C: Incorrect. The correct answer is A. According to 2002 statistics, 60% of cases of child maltreatment involved neglect. Twenty percent of cases involved physical abuse, 10% involved sexual abuse, and 7% involved emotional abuse. Feedback for D: Incorrect. The correct answer is A. According to 2002 statistics, 60% of cases of child maltreatment involved neglect. Twenty percent of cases involved physical abuse, 10% involved sexual abuse, and 7% involved emotional abuse. Point 13 of 15

20 2014 Review Survivors of childhood abuse or neglect are at high risk for: a. Substance abuse and crime b. Heart disease, cancer, and lung disease c. Depression, anxiety, and eating disorders d. All of these e. None of these MULTIPLE CHOICE INTERACTION Correct answer: D Feedback for A: Not quite. The correct answer is D. Survivors of childhood abuse or neglect are at high risk for all of these problems. Feedback for B: Not quite. The correct answer is D. Survivors of childhood abuse or neglect are at high risk for all of these problems. Feedback for C: Not quite. The correct answer is D. Survivors of childhood abuse or neglect are at high risk for all of these problems. Feedback for D: Correct. Survivors of childhood abuse or neglect are at high risk for all of these problems. Feedback for E: Incorrect. The correct answer is D. Survivors of childhood abuse or neglect are at high risk for all of these problems. Point 14 of 15

21 2015 Summary You have completed the lesson on definitions and effects. NO IMAGE Remember: Physical abuse happens when a caretaker injures a child on purpose. Sexual abuse happens when a caretaker involves a child in any sexual activity. Emotional abuse happens when a caretaker rejects, degrades, terrorizes, ignores, isolates, or corrupts a child on a regular basis. Child neglect happens when a caretaker does not meet a child s basic needs. Child abuse and neglect have both immediate and longterm consequences for the child. These include harm to the child s physical, psychological, and behavioral health. Abuse and neglect also have costs to society. Point 15 of 15

22 Lesson 3: Identifying Victims 3001 Introduction Welcome to the lesson on identifying victims of child abuse/neglect. FLASH ANIMATION: 3001.SWF/FLA Point 1 of 19

23 3002 Objectives After completing this lesson, you should be able to: NO IMAGE List risk factors for child abuse and neglect. Recognize signs and symptoms of child abuse and neglect. Point 2 of 19

24 3003 Challenges to Identifying Victims Identifying victims of child abuse and neglect can be difficult for healthcare providers. There are two main reasons for this: IMAGE: 3003.GIF 1. Children usually do not tell anyone about the abuse or neglect. They often think that: The abuse is their own fault. Adults will not believe them if they tell about the abuse. 2. Because they see the child every day, the child s parents should notice signs and symptoms of abuse. However, parents usually do not give healthcare providers good information about signs and symptoms. There are two reasons for this: In most cases of child abuse, a parent is the abuser. When parents are not the abusers, they may ignore signs and symptoms. This is because they do not want to think that their child may be a victim. Point 3 of 19

25 3004 Overcoming Challenges and Identifying Victims In short, victims and their parents rarely give healthcare providers useful information. IMAGE: 3004.GIF In this case, how can healthcare providers identify victims? Healthcare staff must be alert to the possibility of abuse. They must be aware of: Risk factors for child maltreatment Signs of abuse and neglect Let s take a closer look at each. Point 4 of 19

26 3005 Risk Factors There are three types of risk factors for child abuse and neglect: Child-related factors Family-related factors Social and environmental factors IMAGE: 3005.GIF We will review each type of factor on the following screens. Keep in mind: Many factors may put a child at risk. Some of these factors may not be listed in this lesson. The factors listed show a strong correlation with child abuse. Correlation means that child abuse is most often seen when at least one of these factors is present. Correlation does not mean that any of these factors causes child abuse. Any child may be abused or neglected. Risk factors do not have to be present. Point 5 of 19

27 3006 Risk Factors: Child-Related A child is more likely to be a victim if he or she: IMAGE: 3006.GIF Came from an unwanted pregnancy Had problems at birth (for example, premature birth or low birth weight) Has physical, mental, or emotional problems Has behavioral problems or problems with attention span Has antisocial friends Has suffered trauma [glossary] Is slow to warm up to other people Is aggressive Is between the ages of zero and three years Is a girl Important note: A child with risk factors should never be blamed for abuse. Child abuse is NEVER the child s fault. Point 6 of 19

28 3007 Risk Factors: Family-Related A child is at increased risk for abuse or neglect if a parent: IMAGE: 3007.GIF Is a single parent Is a teenager Is unemployed or homeless Does not have enough social support Has many children living in the household Has been separated or divorced, especially if the divorce was difficult Was abused as a child Abuses alcohol or other drugs Abuses an intimate partner Tends to act impulsively Does not trust others Feels insecure, especially in the relationship with his or her own parents Has depression, anxiety, stress, or other mental health problems Is easily frustrated Has an external locus of control [glossary] Has poor parenting or communication skills Does not interact effectively with the child Has negative attitudes about the child s behavior Has unrealistic expectations for the child s development Point 7 of 19

29 3008 Risk Factors: Social and Environmental Social and environmental factors that can put a child at risk for abuse include: IMAGE: 3008.GIF Poverty Stressful life events (for example, money problems or a death in the family) Not having medical care, health insurance, childcare, or social services Racism or other discrimination Poor schools Community violence or other crime Point 8 of 19

30 3009 Signs of Abuse Let s now consider signs and symptoms of abuse and neglect. NO IMAGE These include: Physical abuse: physical signs Sexual abuse: physical signs, behavioral signs Emotional abuse: behavioral signs Neglect: historical and physical signs, behavioral signs We will review these signs and symptoms on the following pages. Keep in mind: The signs listed do not prove abuse. When you suspect abuse, you must think about how all of the evidence fits together. Use your best clinical judgment to make a diagnosis. An abused child may not have physical signs or symptoms. This is often the case for sexual and emotional abuse. Be sure to look for behavioral signs and symptoms. Point 9 of 19

31 3010 Physical Abuse: Physical Signs (1) Click on each of the following to learn more about specific types of injuries that may be signs of physical abuse: Bruises and welts Burns Cuts and scrapes Broken bones Abdominal injuries Brain injuries CLICK TO REVEAL Bruises and welts may be a sign of abuse if they form patterns. These patterns often look like the item that was used: Hand Teeth Belt buckle Electrical cord Burns may be a sign of abuse. Look for: Cigar or cigarette burns. This type of burn is highly suspicious on the soles of the feet, palms of the hands, back, or buttocks. Immersion burns. On the feet and legs, these burns look like stockings. On the hands and arms, they look like gloves. On the genitals, they are donut-shaped. Patterned burns. These burns look like an iron, burner, grill, or other appliance that was used to cause the burn. Cuts and scrapes can be signs of abuse. Look for: Rope burns on the wrists, ankles, neck, or torso Cuts or scrapes on the palate, mouth, gum, lips, eyes, or ears Cuts or scrapes on the external genitalia Abuse can cause broken bones. Look for fractures in the: Skull Ribs Long bones Growth plates of the long bones Abdominal injuries can be a sign of abuse. Look for: Bruising of the abdominal wall Bruising of the small intestine Intestinal perforation [glossary] Liver or spleen rupture Blood vessel rupture Injury to the kidneys or bladder Injury to the pancreas Brain injuries may be a sign of abuse. Look for: Bleeding on the surface of the brain (often due to violent shaking or blunt trauma) Brain damage due to swelling of the brain Bleeding in the retina of the eye Point 10 of 19

32 3011 Physical Abuse: Physical Signs (2) Remember: The physical injuries listed on the previous screen do not prove abuse. IMAGE: 3011.GIF Many childhood injuries are accidents. Accidents can happen when active children explore and play. How can you tell the difference between accidental injuries and abuse? The following types of injuries are probably not accidental. They are more likely to be a sign of abuse: Injuries on both sides of the body (bilateral) Injuries on many areas of the body at one time Injuries in different stages of healing Injuries in a late stage of healing (showing that the parent did not take the child for medical care immediately) Injuries that do not match the parent s explanation A pattern of frequent, unexplained injuries Point 11 of 19

33 3012 Signs of Sexual Abuse Physical signs of sexual abuse may include: Cuts or scrapes on the genitalia or inner thighs Pain or bleeding in the rectum or genitalia Change in the size or shape of the hymen Abnormally relaxed or tensed muscles of the anus and rectum Pregnancy Sexually transmitted diseases (STDs) IMAGE: 3012.GIF STDs are very suspicious in children before puberty, if the STD did not come from the mother at or around the time of birth. See the table at the right for more information. Important notes: Sexually abused children often have no physical signs. This does not mean the child has not been abused. If you suspect sexual abuse, do not routinely screen for STDs. Screen only after considering the child s symptoms and history, the epidemiology [glossary] of STD s in the area, and any state-specific policies or requirements. Point 12 of 19

34 3013 Behavioral Signs of Sexual Abuse A child with sexual behavior that is unusually mature or advanced for his or her age may be a victim of abuse. IMAGE: 3013.GIF Other behavioral signs of sexual abuse tend to be nonspecific. This means that they may be signs of abuse, but also might be caused by other problems These signs include: Non-sexual behavior that is mature for the child s age Behavior that is immature for the child s age, such as bedwetting Compulsive behavior Poor peer relationships Poor grades in school Hyperactivity Withdrawal Low self-esteem Shame or guilt Distorted body image Eating disorders Fears, especially of adults Attempts to run away from home Suicide attempts Behavior that invites a sexual response Having many sexual partners Sexual abuse of a sibling, friend, or young child Pregnancy Point 13 of 19

35 3014 Behavioral Signs of Emotional Abuse Behavioral indicators of emotional abuse may include: IMAGE: 3014.GIF Depression Withdrawal Low self-esteem Severe anxiety Fearfulness Failure to thrive (in infants) Aggressive behavior Emotional instability Sleep disturbances Age-inappropriate behavior Overly passive or compliant behavior Suicide attempts Extreme dependence Underachievement Inability to trust Stealing or other forms of acting out Point 14 of 19

36 3015 Historical and Physical Signs of Neglect Historical signs of neglect can include: Lack of immunizations and other well-child medical care Lack of medical care for chronic illness Lack of eyeglasses, hearing aides, or other necessary health aides IMAGE: 3015.GIF Physical signs of neglect can include: Poor nutrition Poor hygiene Developmental delays Untreated medical conditions Tooth decay Point 15 of 19

37 3016 Behavioral Signs of Neglect Behavioral signs of neglect can include: IMAGE: 3016.GIF Depression Anxiety Bedwetting Sleep problems Excessive masturbation Lack of cuddliness Avoiding eye contact Preferring inanimate objects to people Discipline problems Aggressive behavior Role reversal (the child takes care of the parent) Too much responsibility at home Point 16 of 19

38 3017 Review Poverty and community violence child abuse and neglect. a. Cause b. Are unrelated to c. Are not risk factors for d. Show a correlation with MULTIPLE CHOICE INTERACTION Correct answer: D Feedback for A: Incorrect. Poverty and community violence are not known to cause child abuse and neglect. However, they are risk factors. The best answer is D. Poverty and community violence show a positive correlation with child abuse and neglect. Feedback for B: Incorrect. Poverty and community violence are not known to cause child abuse and neglect. However, they are risk factors. The best answer is D. Poverty and community violence show a positive correlation with child abuse and neglect. Feedback for C: Incorrect. Poverty and community violence are not known to cause child abuse and neglect. However, they are risk factors. The best answer is D. Poverty and community violence show a positive correlation with child abuse and neglect. Feedback for D: Correct. Poverty and community violence are not known to cause child abuse and neglect. However, they are risk factors. The best answer is D. Poverty and community violence show a positive correlation with child abuse and neglect. Point 17 of 19

39 3018 Review FLASH INTERACTION: 3018.SWF/FLA Children often have accidents. How can you tell the difference between an accidental injury and abuse? Type your thoughts in the box below. Then click Submit to compare your answer to ours. Did you recall some or all of the following? The following types of injuries are probably not accidental. They are more likely to be a sign of abuse: Injuries on both sides of the body (bilateral) Injuries on many areas of the body at one time Injuries in different stages of healing Injuries in a late stage of healing (showing that the parent did not take the child for medical care immediately) Injuries that do not match the parent s explanation - A pattern of frequent, unexplained injuries Point 18 of 19

40 3019 Summary You have completed the lesson on identifying victims of child maltreatment. NO IMAGE Remember: Certain factors increase the risk of child abuse and neglect. Victims of abuse and neglect often have signs and symptoms. Knowing the risk factors, signs, and symptoms can help you identify victims. Point 19 of 19

41 Lesson 4: Assessment and Referral 4001 Introduction Welcome to the lesson on assessment and referral. FLASH ANIMATION: 4001.SWF/FLA Point 1 of 21

42 4002 Objectives After completing this lesson, you should be able to: NO IMAGE Identify the components of a child abuse assessment. Specify when and how the physical health component of a child abuse assessment should be performed. List guidelines for interviewing suspected victims and their caretakers. Recognize procedures for collecting and documenting evidence of child abuse or neglect. Point 2 of 21

43 4003 Components of the Assessment A child abuse or neglect assessment has two basic parts: IMAGE: 4003.GIF A physical health check of the suspected victim Interviews with the suspected victim and his or her caretakers Let s take a closer look at each part. Point 3 of 21

44 4004 Components: Physical Health Assessment The first part of a child abuse assessment is a full physical health check. IMAGE: 4004.GIF This health check should include: Taking a full medical history Performing a full pediatric physical exam Assessing the child s developmental status Ordering any necessary lab tests The goals of the health check are to: Look carefully at any current injuries. Find signs of any previous injuries. Look for any other physical problems that need medical care. Record evidence of abuse or neglect (as discussed in greater detail later in the lesson). Point 4 of 21

45 4005 Physical Health Assessment: When When should the physical health check be performed? IMAGE: 4005.GIF In cases of sexual abuse, it may be necessary to collect forensic evidence. If so, the physical health check should be performed right away. In most cases of child abuse and neglect, however, forensic evidence is not an issue. In these cases, the full physical health check may be scheduled for a follow-up visit. If the child seems unusually upset, check with a mental health professional before conducting the physical exam. Point 5 of 21

46 4006 Physical Health Assessment: How When physically examining a suspected victim of abuse: IMAGE: 4006.GIF Explain each step of what you are doing. Ask for the child s permission before each step. Never use restraint or force. Go slowly. Make sure the child feels okay with the pace of the examination. Be gentle and sensitive. Point 6 of 21

47 4007 Physical Health Assessment: Suspected Sexual Abuse (1) When physically examining a suspected victim of sexual abuse: IMAGE: 4007.GIF Make sure another adult is present. This adult should not be the suspected abuser. This adult should be someone the child trusts. Examine the child s genitals as part of a full physical exam. Do not examine the genitals as an isolated procedure. Consider screening for STDs. The decision to screen should be based on the child s symptoms and history, the epidemiology of STDs in the area, and any legal requirements in your state. Point 7 of 21

48 4008 Physical Health Assessment: Suspected Sexual Abuse (2) Examining a victim of sexual abuse can be upsetting. IMAGE: 4008.GIF Do not start a sexual abuse assessment unless you are prepared to: Accept that sexual abuse of children does happen. Take everything the child says seriously. Respond sensitively to everything the child says. Collect forensic evidence. Stop the exam to get help from an expert, if needed. Point 8 of 21

49 4009 Components: Interviewing the Child and the Caretakers The second part of the child abuse assessment is the interview process. IMAGE: 4009.GIF If at all possible, there should be two separate interviews: The child should be interviewed in private, without the caretakers. The caretakers should be interviewed in private, without the child. Point 9 of 21

50 4010 Interviewing: Before the Interview Before interviewing the child or caretakers, it is a good idea to get some background information from a reliable source. Useful background information includes: Specific details of the abuse A complete social history Click on each item for details. CLICK TO REVEAL Specific details of the abuse Ask your source exactly what happened to cause the child s injuries. Ask about: The date, time, and place of the abusive incident The sequence of events Any witnesses How long the caretakers waited before getting medical care for the child A complete social history Ask your source: Where the child lives How long he or she has lived there Who lives with the child What types of support systems the family has Who takes care of the child (parent, babysitter, nanny, daycare center) Point 10 of 21

51 4011 Interviewing: The Child When interviewing the child: DO Meet in private, without the caretaker. Sit near the child, at the child s eye level. Establish trust. Explain the reason for the interview in words the child can understand. Ask the child to explain any of his or her words or terms that are unclear to you. Then use the child s words and terms whenever possible. Use aids such as anatomic dolls only if you are trained in their use. Encourage the child to ask questions. Answer all questions sensitively and truthfully. Let the child know that you understand how difficult the situation is. Make sure the child knows that he or she is not at fault in any way. Do NOT Offer answers or rewards. Press for answers. Criticize or correct the child s choice of words. Say anything that might cause the child to feel guilt or blame. Leave the child alone. Act shocked or horrified at what the child tells you. Point 11 of 21

52 4012 Interviewing: The Caretakers When interviewing the caretaker(s) of a suspected victim of child abuse: DO Stay objective. Explain the reason for the interview. Explain that the law requires you to report suspected abuse. Describe what will be done to protect the child. Answer any questions that do not compromise the child s safety or the evidence in the case. Do NOT Judge or blame before knowing all the facts. Try to prove that the child has been abused or neglected. Act angry, horrified, or disapproving. Talk about the explanation the parents have given for the child s injuries (this could help the parents change an unlikely explanation). Point 12 of 21

53 4013 Documentation and Collection of Evidence Careful documentation of the child abuse assessment is critical. IMAGE: 4013.JPG Documentation can provide evidence for: Legal action to protect the child Legal action to prosecute the abuser In some cases, the medical record may provide the only hard evidence of abuse. Point 13 of 21

54 4014 Documentation: Written Record The following should be documented in the medical record: IMAGE: 4014.GIF Results of the pediatric health check, including the patient s medical and social history Results of pertinent lab tests or other diagnostic tests Any statements made by the victim and caretaker(s), including any taped interviews Observed appearance and behavior of the victim Name of the abuser and his or her relationship to the victim (if known) Date, time, location, and description of the abusive event(s) (if known) Detailed description of injuries (see text image to the right) Any other information or physical evidence relevant to the patient s injuries Point 14 of 21

55 4015 Documentation: Photographs Photographs should not replace a full written description of injuries. However, photos can provide valuable additional evidence. IMAGE: 4015.JPG When taking photographs of injuries: Photograph injuries before treating them, if possible. Use color film and a color standard. Photograph bite marks in both black-and-white and color, if possible. Hold up a coin, ruler, or other object to show the size of the injury. Include the victim s face in at least one picture. Take at least two pictures of every major injury. Carefully label all photographs. Point 15 of 21

56 4016 Documentation: Forensic Evidence Each state has an established set of procedures for collecting forensic evidence of sexual assault. This set of procedures is called a rape kit. IMAGE: 4016.GIF Evidence collected during a rape kit exam is used to: Establish the time and place of the assault. Establish the identity of the attacker. The rape kit exam is only useful within 72 hours of an assault. Therefore, rape kits are not generally used in cases of child sexual abuse. This is because: The child is often a victim of ongoing, undisclosed abuse. The victim is unlikely to see a healthcare provider within 72 hours of any given abusive incident. If the child is seen immediately after a sexual assault, however, forensic evidence can be important. In this case, be sure to follow the rape kit protocol when collecting evidence. This helps ensure that the evidence can be used in a court of law. Point 16 of 21

57 4017 Forensic Evidence: Typical Protocol A typical rape kit protocol has the following steps: The patient takes off his or her clothes on a clean cloth or sheet.* The patient places each item of clothing in a separate paper bag.* The patient places the cloth or sheet in another paper bag.* The patient puts on a gown and lies on the exam table. The clinician uses a Wood s light to look for dried semen on the patient. The clinician records the location(s) of semen. The clinician performs a full physical exam. During the exam, samples of semen, blood, hair, and saliva may be taken. The patient gives a urine specimen. IMAGE: 4017.JPG * During these steps, a healthcare worker can help the patient, if necessary. The worker must wear clean gloves. Important notes: The steps described in this typical protocol may not be used in your state. Other procedures may apply. Check with your supervisor or a legal expert. Throughout the rape kit exam, be careful to follow chain-ofevidence [glossary] protocols. Point 17 of 21

58 4018 Referrals All facilities should be prepared to refer victims of abuse to outside sources of support. IMAGE: 4018.JPG Some facilities may not have staff who are trained and qualified to assess suspected victims of abuse. These facilities also must be prepared to refer victims for assessment. For a list of agencies and resources on child abuse and neglect, see: childabuse.pdf [link to childabuse.pdf] childsexabuse.pdf [link to childsexabuse.pdf] Point 18 of 21

59 4019 Review A full child abuse assessment should be performed as soon as a suspected victim is identified. a. True b. False TRUE / FALSE INTERACTION Correct answer: B Feedback for A: Incorrect. In most cases, the assessment should be scheduled for a follow-up visit. Assess a suspected victim right away only when there is forensic evidence to collect. Feedback for B: Correct. In most cases, the assessment should be scheduled for a follow-up visit. Assess a suspected victim right away only when there is forensic evidence to collect. Point 19 of 21

60 4020 Review When photographing injuries as evidence of suspected abuse: a. Use black-and-white film only. b. Hold up a common object to show the size of the injury. c. Protect the victim s confidentiality by not including his or her face in any of the photographs. d. All of these are correct. e. None of these is correct. MULTIPLE CHOICE INTERACTION Correct answer: B Feedback for A: Incorrect. Black-and-white film should be used for bite marks. For all other injuries, color film should be used. The correct answer is B. Feedback for B: Correct. Feedback for C: Incorrect. The victim s face should be included in at least one photograph, to establish his or her identity. The correct answer is B. Feedback for D: Incorrect. Black-and-white film should be used for bite marks. For all other injuries, color film should be used. The victim s face should be included in at least one photograph, to establish his or her identity. The correct answer is B. Feedback for D: Incorrect. The correct answer is B. Point 20 of 21

61 4021 Summary You have completed the lesson on assessment and referral. NO IMAGE Remember: The child abuse assessment has two basic parts: the physical health check and the interview. Know the guidelines for each of these procedures. Carefully document all evidence during the child abuse assessment. Documentation of the abuse assessment should include a written record. Photographs of injuries can provide valuable additional evidence. Forensic evidence may be important in some cases of sexual abuse. If so, collect all evidence according to your state s rape kit protocol. Point 21 of 21

62 Lesson 5: Reporting Requirements 5001 Introduction Welcome to the lesson on reporting requirements. FLASH ANIMATION: 5001.SWF/FLA Point 1 of 10

63 5002 Objectives After completing this lesson, you should be able to: NO IMAGE Recognize the importance of learning the reporting requirements in your state. Recognize typical reporting requirements and procedures. List potential consequences of failing to report when required to do so by law. Point 2 of 10

64 5003 Variation in Reporting Requirements Healthcare providers are mandatory reporters of child abuse and neglect in all states. IMAGE: 5003.GIF This means that all states have laws that require healthcare providers to report suspected child abuse and neglect. However, state laws differ in their: Definitions of child abuse and neglect Reporting procedures Learn the laws in your state, including: What you are required to report How to report Point 3 of 10

65 5004 Typical Reporting Requirements In most states, clinical healthcare professionals must report suspected abuse or neglect in two different types of situations. IMAGE: 5004.GIF These are: 1. A healthcare provider notices certain signs and symptoms in a pediatric patient under his or her direct care. The provider suspects abuse or neglect. This provider must make a report to Child Protective Services (CPS). 2. An adult who is legally responsible for the care of a child suspects abuse or neglect. The adult talks to a healthcare provider. This provider must make a report to CPS. Non-clinical staff who have contact with pediatric patients also must report suspected abuse. These staff members should report their suspicions to a supervisor. The supervisor decides whether or not the suspicion is substantial enough to report to CPS. Point 4 of 10

66 5005 Typical Reporting Procedures Remember: Reporting procedures differ from state to state. IMAGE: 5005.GIF In general, when a report is required: 1. The mandatory reporter must contact CPS immediately by phone. 2. The mandatory reporter must file a written report within a certain amount of time. Point 5 of 10

67 5006 Immunity from Liability Mandatory reporting laws protect mandatory reporters from legal liability. NO IMAGE To ensure legal protection, the report must be made in good faith. Point 6 of 10

68 5007 Mandatory Reporting vs. Patient Confidentiality IMAGE: 5007.JPG When a healthcare provider reports suspected abuse or neglect, he or she may need to share confidential patient information. Because of the circumstances, this is not considered a violation of patient-provider privilege. Providers must report suspected abuse or neglect. Patient confidentiality is not a legal excuse for not reporting. Point 7 of 10

69 5008 Penalties for Not Reporting Most states have criminal penalties for not reporting suspected abuse or neglect. IMAGE: 5008.JPG The crime is a misdemeanor in most states. Penalties may include: Fines Jail time Providers who do not report also risk civil liability. At some later time, the patient or the patient s family could sue the provider for not reporting. Point 8 of 10

70 5009 Review All 50 of the United States require healthcare workers to report suspected child abuse or neglect. a. True b. False TRUE / FALSE INTERACTION Correct answer: A Feedback for A: Correct. This statement is true. Feedback for B: Incorrect. This statement is true. Point 9 of 10

71 5010 Summary You have completed the lesson on reporting requirements. NO IMAGE Remember: Healthcare providers in all 50 states are required by law to report suspected child abuse and neglect. Reporting requirements and procedures differ from state to state. Learn the laws in your state. Point 10 of 10

72 Course Glossary # Term Definition chain-of-evidence protocols external locus of control maltreatment neurological trauma intestinal perforation pancreatic injury bilateral injuries epidemiology procedures (including documentation and testimony) that ensure that evidence is not altered or tampered with in any way after being obtained; also referred to as chain-of-custody protocols belief that one s own behavior doesn't matter much and that what happens in life is generally outside of one s control cruel or inhumane treatment of or relating to the nervous system physical injury caused by external violence; severe emotional or psychological shock or distress a hole in the wall of the large or small intestine damage to the pancreas injuries on both sides of the body study of the incidence, distribution, and control of disease in a population

73 [Identifying and Assessing Victims of Child Abuse and Neglect] Pre-Assessment 1. Failing to provide for a child s safety in a developmentally appropriate way is an example of: a. Neglect b. Sexual abuse c. Physical abuse d. Emotional abuse Correct Answer: A Answer Rationale: This is an example of neglect: failing to meet any of the basic needs of a child. 2. Victims of childhood abuse or neglect are at increased risk for poor grades in school. a. True b. False Correct Answer: A Answer Rationale: Victims of childhood abuse or neglect are at increased risk for a number of problems during the teenage years. These problems include poor grades in school. 3. The direct costs of child abuse and neglect are about annually. The indirect costs are about per year. a. $2.4 million, $6.9 million b. $24 million, $69 million c. $24 billion, $69 billion d. $24 trillion, $69 trillion Correct Answer: C Answer Rationale: According to Prevent Child Abuse America, the direct costs of child abuse and neglect are $24 billion annually. The indirect costs are $69 billion annually. 4. Which of the following children is at increased risk for abuse or neglect? a. An intelligent eight-year-old b. A physically healthy ten-year-old c. A friendly, affectionate, outgoing six-year-old d. A seven-year-old with attention deficit/hyperactivity disorder

74 Correct Answer: D Answer Rationale: Attention deficits and other behavioral problems are risk factors for abuse and neglect. 5. Bleeding on the surface of the brain could be a sign of abusive shaking (for example, in shaken baby syndrome). a. True b. False c. Correct Answer: True Answer Rationale: This statement is true. 6. Anorexia is always a sign of childhood sexual abuse. a. True b. False Correct Answer: False Answer Rationale: Eating disorders can be a sign of childhood sexual abuse. However, eating disorders also can occur for other reasons. 7. You are interviewing a suspected victim of abuse. The child describes an incident of severe physical abuse by his mother. Which of the following responses is (are) appropriate? a. What a horrible thing your mother did to you! I can t believe a mother would do that! b. Your mother was probably just frustrated with you. Sometimes parents get frustrated when their children are difficult or disobedient. c. I believe what you are telling me. I m sure that must have been very hard for you. I want you to know that you are not to blame for what happened. d. Any of these would be an appropriate response. e. None of these is an appropriate response. Correct Answer: C Answer Rationale: When interviewing a suspected victim of child abuse, do validate the child s experience, and do make sure the child knows that he or she is not at fault. Do not act shocked or horrified, and do not say anything that might suggest guilt or blame. 8. A rape kit exam should be part of the assessment of most victims of child sexual abuse. a. True b. False Correct Answer: B Answer Rationale: The rape kit exam is only useful within 72 hours of an assault. Therefore, rape kits are generally not used in cases of child sexual abuse. In these cases, there is usually ongoing abuse. The child is unlikely to see a healthcare provider within 72 hours of any given abusive incident.

75 9. Which of the following describe(s) a case in which the healthcare worker is required to make a report of suspected child abuse? a. A pediatric patient comes in for her annual checkup. Based on physical findings, the pediatrician strongly suspects that the child may be a victim of abuse. b. The receptionist at a pediatric clinic notices a mother and son in the clinic waiting room. Based on what she sees, the receptionist suspects that the child may be a victim of abuse. c. A mother brings her daughter in for a checkup. During the checkup, the mother asks to speak to a nurse privately. The mother tells the nurse that she has noticed recent changes in her daughter s behavior. She thinks her new husband may be sexually abusing her daughter. However, she is afraid to confront her husband or ask her daughter. d. All of these healthcare workers are required to report. e. None of these healthcare workers is required to report. Correct Answer: All of these healthcare workers are required to report. Answer Rationale: Healthcare workers must report personal suspicions of child abuse or neglect. They also must report if a responsible adult talks to them about suspicions of abuse or neglect. 10. Physical signs are seen in most cases of sexual abuse. a. True b. False Correct Answer: B Answer Rationale: Physical signs are frequently not seen in sexually abused children. This does not mean the child has not been abused. 11. A child comes to the emergency room with severe physical injuries. His mother explains that he fell out of his tree house. After examining the child, you might question the mother s story and suspect abuse if: a. The child s injuries are bilateral. b. The child s injuries are in a late stage of healing. c. X-rays reveal a very recent fracture in the collarbone, as well as a number of other healed and partially healed fractures. d. Any of these might make you suspect abuse. e. None of these is suspicious. Correct answer: D Rationale: Many physical injuries in children are the accidental result of normal childhood activity. However, abuse is more likely if injuries are 1) bilateral, 2) at a late stage of healing (showing that the caretaker did not seek immediate medical care for the child), or 3) in different stages of healing. Abuse is also more likely if injuries are 4) on multiple body sites, 5) not adequately explained, or 6) suspiciously frequent. 12. Corporal punishment can be a form of physical abuse. a. True b. False

76 Correct answer: A Rationale: Corporal punishment is abusive if it is unreasonable or too severe. 13. Emotional abuse: a. Can harm a child psychologically, but not physically b. Is more common than sexual abuse of children (according to 2002 statistics) c. Is less common than physical abuse of children (according to 2002 statistics) d. All of these answers e. None of these answers Correct answer: C Rationale: According to 2002 statistics, 60% of cases of child abuse or neglect involved neglect. Twenty percent of cases involved physical abuse, 10% involved sexual abuse, and 7% involved emotional abuse. Thus, emotional abuse is least common. This form of abuse can have severe psychological and physical consequences. For example, infants who experience emotional abuse may fail to thrive. 14. Be especially alert for signs and symptoms of abuse if a child s parent: a. Is divorced and unemployed b. Interacts well with the child c. Has a strong social support network d. Knows the timeline for physical, mental, and emotional development in children e. None of these Correct answer: A Rationale: Divorce and unemployment increase the risk that a parent will abuse or neglect a child. 15. You have started the physical health component of a child abuse assessment. True or False: You should use restraint or force as necessary to ensure full examination and documentation of all injuries. a. True b. False Correct answer: B Rationale: Never use restraint or force during a child abuse assessment. Be gentle and sensitive. Also be sure to ask the child for permission before each step in the exam. This gives the child a sense of safety and control.

77 Final Exam Question Title: Question 1 Question: Physical abuse of a child: Answer 1: Tends to become more and more severe over time Answer 2: Should not be confused with severe corporal punishment Answer 3: Is defined as accidental injury to a child Answer 4: Is seen in 50% of cases of child maltreatment (according to 2002 statistics) Correct Answer: Tends to become more and more severe over time Answer Rationale: Physical abuse must be stopped promptly. Otherwise, the injuries to the child tend to become more and more severe over time. Question Title: Question 2 Question: Which of the following is (are) sexually abusive? Answer 1: Fondling a child s genitals Answer 2: Producing child pornography Answer 3: Sexual intercourse with a child Answer 4: All of these Answer 5: None of these Correct Answer: All of these Answer Rationale: All of these are sexually abusive. Question Title: Question 3 Question: Threatening to kill a child in his or her sleep is an example of: Answer 1: Neglect Answer 2: Sexual abuse Answer 3: Physical abuse Answer 4: Emotional abuse