HealthStream Regulatory Script

HealthStream Regulatory Script Identifying and Assessing Victims of Child Abuse and Neglect Release Date: June 2009 HLC Version: 602 Lesson 1: Introduction Lesson 2: Definitions and Consequences Lesson 3: Identifying Victims Lesson 4: Assessment and Referral Lesson 5: Reporting Requirements

Lesson 1: Introduction 1001 Introduction Welcome to the introductory lesson on identifying and assessing victims of child abuse and neglect. IMAGE: 1001.JPG 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. If you have concerns about any aspect of the safety or quality of patient care in your organization, be aware that you may report these concerns directly to The Joint Commission. Point 1 of 4 2

1002 Course Rationale Child maltreatment is a serious problem in the United States: 905,000 children are abused each year. 1,530 children die. IMAGE: 1002.JPG The Joint Commission has a standard for victims of abuse or neglect (Standard PC.01.02.09). The rationale for the standard explains the important role of healthcare workers in identifying victims. This course focuses on child abuse and neglect. 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 The Joint Commission Standard. Note: For more details about The Joint Commission Standard PC.01.02.09, and an overview of all types of abuse and neglect, see the course: Identifying and Assessing Victims of Abuse and Neglect. Point 2 of 4

1003 Course Goals After completing this course, you should be able to: 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 NO IMAGE Point 3 of 4

1004 Course Outline This introductory lesson gave the course rationale and goals. 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. FLASH ANIMATION Lesson 1: Introduction Lesson 2: Definitions and Effects Prevelance Forms of child abuse How child abuse affects victims and society Lesson 3: Identifying victims Risk factors Signs and symptoms Lesson 4: Assessment and Referral Physical health assessment Interviews with child and caretakers Documentation of evidence of abuse Referral Lesson 5: Reporting Requirements What to report How to report Implications of reporting/not reporting Point 4 of 4

Lesson 2: Definitions and Consequences 2001 Introduction & Objectives Welcome to the lesson on definitions and consequences. After completing this lesson, you should be able to: List important features and examples of physical abuse, sexual abuse, emotional abuse, and neglect List important effects of child maltreatment FLASH ANIMATION Lesson 2: Definitions and Effects Prevelance Forms of child abuse How child abuse affects victims and society Point 1 of 15

2002 Child Abuse Statistics Child maltreatment [glossary] is a significant problem in the United States. IMAGE: 1001.JPG For example, in 2006: Child Protective Services had reports of suspected abuse involving a total of 3.6 million children. 905,000 of those children were found to be victims of abuse or neglect. 1,530 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 2005: Summary of Key Findings. Point 2 of 15

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

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.JPG 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

2005 Child Maltreatment: Sexual Abuse Sexual abuse happens when an adult or older child involves a child in any sexual activity. IMAGE: 2005.JPG 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

2006 Child Maltreatment: Emotional Abuse In 2006, 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

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

2008 Consequences of Child Abuse/Neglect Child abuse has far-reaching effects. IMAGE: 2008.JPG 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

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/shaken impact 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/shaken impact syndrome [glossary] Long-term neurological [glossary] effects of shaken baby syndrome can include: Blindness, hearing loss, seizures 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

2010 Consequences: Psychological The immediate psychological effects of child abuse or neglect include: Isolation Fear Inability to trust IMAGE: 2010.JPG These problems can lead to lifelong troubles. Victims of childhood abuse often have psychological problems later in life. These problems can include: Depression Anxiety Difficulty forming relationships with others 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

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.JPG 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

2012 Consequences: Societal Child abuse and neglect have costs for all of us. IMAGE: 2012.JPG 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

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 2005 statistics, 63% of cases of child maltreatment involved neglect. Seventeen percent of cases involved physical abuse, 9% involved sexual abuse, and 7% involved emotional abuse. Feedback for B: Incorrect. The correct answer is A. According to 2005 statistics, 63% of cases of child maltreatment involved neglect. Seventeen percent of cases involved physical abuse, 9% involved sexual abuse, and 7% involved emotional abuse. Feedback for C: Incorrect. The correct answer is A. According to 2005 statistics, 63% of cases of child maltreatment involved neglect. Seventeen percent of cases involved physical abuse, 9% involved sexual abuse, and 7% involved emotional abuse. Feedback for D: Incorrect. The correct answer is A. According to 2005 statistics, 63% of cases of child maltreatment involved neglect. Seventeen percent of cases involved physical abuse, 9% involved sexual abuse, and 7% involved emotional abuse. Point 13 of 15

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

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 an adult or older child 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

Lesson 3: Identifying Victims 3001 Introduction & Objectives Welcome to the lesson on identifying victims of child abuse/neglect. After completing this lesson, you should be able to: List risk factors for child abuse and neglect Recognize signs and symptoms of child abuse and neglect FLASH ANIMATION Lesson 3: Identifying victims Risk factors Signs and symptoms Point 1 of 18

3002 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: 3002.JPG 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 2 of 18

3003 Overcoming Challenges and Identifying Victims In short, victims and their parents rarely give healthcare providers useful information. IMAGE: 3003.jpg 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 3 of 18

3004 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: 3004.JPG 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 4 of 18

3005 Risk Factors: Child-Related A child is more likely to be a victim if he or she: 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 IMAGE: 3005.GIF Important note: A child with risk factors should never be blamed for abuse. Child abuse is NEVER the child s fault. Point 5 of 18

3006 Risk Factors: Family-Related A child is at increased risk for abuse or neglect if a parent: 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 IMAGE: 3006.GIF Point 6 of 18

3007 Risk Factors: Social and Environmental Social and environmental factors that can put a child at risk for abuse include: 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 IMAGE: 3007.JPG Point 7 of 18

3008 Signs of Abuse Let s now consider signs and symptoms of abuse and neglect. IMAGE: 3009.jpg 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 8 of 18

3009 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 Pancreatic injury [glossary] 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 9 of 18

3010 Physical Abuse: Physical Signs (2) Remember: The physical injuries listed on the previous screen do not prove abuse. IMAGE: 3011.JPG 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) [glossary] 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 10 of 18

3011 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) NO IMAGE STDs are very suspicious in children before puberty, if the STD did not come from the mother at or around the time of birth. 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 11 of 18

3012 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.JPG 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 12 of 18

3013 Behavioral Signs of Emotional Abuse Behavioral indicators of emotional abuse may include: 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 IMAGE: 3014.JPG Point 13 of 18

3014 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.JPG Physical signs of neglect can include: Poor nutrition Poor hygiene Developmental delays Untreated medical conditions Tooth decay Point 14 of 18

3015 Behavioral Signs of Neglect Behavioral signs of neglect can include: 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 IMAGE: 3016.JPG Point 15 of 18

3016 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 16 of 18

3017 Review FLASH INTERACTION: 3017.SWF 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 17 of 18

3018 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 18 of 18

Lesson 4: Assessment and Referral 4001 Introduction & Objectives Welcome to the lesson on assessment and referral. After completing this lesson, you should be able to: 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 FLASH ANIMATION Lesson 4: Assessment and Referral Physical health assessment Interviews with child and caretakers Documentation of evidence of abuse Referral Point 1 of 20

4002 Components of the Assessment A child abuse or neglect assessment has two basic parts: A physical health check of the suspected victim Interviews with the suspected victim and his or her caretakers IMAGE: 4002.JPG Let s take a closer look at each part. Point 2 of 20

Components: Physical Health Assessment The first part of a child abuse assessment is a full physical health check. IMAGE: 4003.JPG 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 or medical imaging 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 Rule out a medical cause for the physical exam findings (e.g. genetic bleeding disorder) Record evidence of abuse or neglect (as discussed in greater detail later in the lesson) Point 3 of 20

4004 Physical Health Assessment: When When should the physical health check be performed? IMAGE: 4004.JPG 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 4 of 20

4005 Physical Health Assessment: How When physically examining a suspected victim of abuse: 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 IMAGE: 4005.JPG Point 5 of 20

4006 Physical Health Assessment: Suspected Sexual Abuse (1) When physically examining a suspected victim of sexual abuse: 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. IMAGE: 4006.JPG Point 6 of 20

4007 Physical Health Assessment: Suspected Sexual Abuse (2) Examining a victim of sexual abuse can be upsetting. IMAGE: 4007.JPG 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 7 of 20

4008 Components: Interviewing the Child and the Caretakers The second part of the child abuse assessment is the interview process. IMAGE: 4008.JPG 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 8 of 20

4009 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 9 of 20

4010 Interviewing: The Child A child older than age 3 years may be able to tell a sensitive and skillful interviewer that a particular adult hurt him or her. 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 10 of 20

4011 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 11 of 20

4012 Documentation and Collection of Evidence Careful documentation of the child abuse assessment is critical. IMAGE: 4012.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 12 of 20

4013 Documentation: Written Record The following should be documented in the medical record: 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 IMAGE: 4013.JPG Point 13 of 20

4014 Documentation: Photographs Photographs should not replace a full written description of injuries. However, photos can provide valuable additional evidence. IMAGE: 4014.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 14 of 20

4015 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: 4015.JPG 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 15 of 20

4016 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: 4016.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 16 of 20

4017 Referrals All facilities should be prepared to refer victims of abuse to outside sources of support. IMAGE: 4017.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. Children with suspected abuse should not be discharged from the facility without consulting the appropriate child protective services agency. 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 17 of 20

4018 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 18 of 20

4019 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 19 of 20

4020 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 20 of 20

Lesson 5: Reporting Requirements 5001 Introduction & Objectives Welcome to the lesson on reporting requirements. After completing this lesson, you should be able to: 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 FLASH ANIMATION Lesson 5: Reporting Requirements What to report How to report Implications of reporting/not reporting Point 1 of 9

5002 Variation in Reporting Requirements Healthcare providers are mandatory reporters of child abuse and neglect in all states. This means that all states have laws that require healthcare providers to report suspected child abuse and neglect. IMAGE: 5002.SWF http://www.childwelfare.gov/systemwide/laws_policies/ statutes/mandaall.pdf 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 2 of 9

5003 Typical Reporting Requirements In most states, clinical healthcare professionals must report suspected abuse or neglect in two different types of situations. IMAGE: 5003.JPG 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 3 of 9

5004 Typical Reporting Procedures Remember: Reporting procedures differ from state to state. IMAGE: 5004.JPG 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 4 of 9

5005 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 5 of 9

5006 Mandatory Reporting vs. Patient Confidentiality When a healthcare provider reports suspected abuse or neglect, he or she may need to share confidential patient information. IMAGE: 5006.JPG 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 6 of 9

5007 Penalties for Not Reporting Most states have criminal penalties for not reporting suspected abuse or neglect. IMAGE: 5007.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 7 of 9

5008 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 8 of 9

5009 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 9 of 9

Glossary # Term Definition chain-of-evidence protocols external locus of control maltreatment neurological trauma intestinal perforation pancreatic injury bilateral injuries epidemiology shaken baby/shaken impact syndrome 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 Inflicted head trauma caused by direct blows to the head, dropping or throwing a child, or shaking a child

Pre-Assessment 1. The most visible form of child maltreatment tends to be: a. Neglect b. Sexual abuse c. Physical abuse d. Emotional abuse Correct: Physical abuse Rationale: Physical abuse tends to be most visible. 2. A father physically abuses a child. If the abuse is not identified and stopped by a third party, it is likely that: a. The abuse will become less and less severe over time. b. The abuse will become more and more severe over time. c. The father will stop the abuse if he ever injures the child severely. d. The father will choose to stop the abuse within six months in 90% of cases. Correct: The abuse will become more and more severe over time. Rationale: If physical abuse is not stopped, it tends to become more and more severe over time. 3. Child prostitution is a form of: a. Neglect b. Sexual abuse c. Physical abuse d. Emotional abuse Correct: Sexual abuse Rationale: Child prostitution is sexual abuse. 4. A type of emotional abuse is: a. Punching a child b. Terrorizing a child c. Sexual contact with a child d. Failing to provide food for a child Correct: Terrorizing a child

Rationale: Terrorizing a child is emotional abuse. 5. With regard to PSYCHOLOGICAL effects, child abuse has: a. Long-term effects only b. Short-term effects only c. Both short-term and long-term effects d. Neither short-term nor long-term effects Correct: Both short-term and long-term effects Rationale: Child abuse does both short-term and long-term psychological damage. 6. Of the following, abused children are most likely to feel: a. Safe b. Loved c. Isolated d. Confident Correct: Isolated Rationale: A short-term psychological effect of child abuse is isolation. 7. Consider the behavioral consequence of child abuse. Which statement is correct? a. Victims of child abuse tend to perform well in school. b. Victims of child abuse tend to be law-abiding citizens. c. Victims of child abuse are unlikely to become abusive parents. d. Victims of child abuse are at increased risk for substance abuse. Correct: Victims of child abuse are at increased risk for substance abuse Rationale: One long-term effect of child abuse is increased risk of substance abuse. 8. Which of the following is a risk factor for child abuse? a. The child is a boy. b. The child is outgoing. c. The child is aggressive. d. The child is over the age of ten. Correct: The child is aggressive. Rationale: Aggressive children are at increased risk for abuse. 9. A parent is more likely to abuse a child if:

a. The parent is married. b. The parent is a teenager. c. The parent has social supports. d. The parent has few children living at home. Correct: The parent is a teenager. Rationale: Teen parents are more likely to abuse their children. 10. Choose the true statement about burns as a sign of child abuse a. All kids have accidents. Burns are never a sign of abuse. b. Burns can be a sign of abuse. Patterned burns are highly suspicious. c. Burns are a sign of abuse only if the child says he or she has been abused. d. Burns are always a sign of abuse and should be reported to your supervisor immediately. Correct: Burns can be a sign of abuse. Patterned burns are highly suspicious. Rationale: Burns can be a signs of abuse. Suspect possible abuse if burns form a pattern (e.g., in the shape of an iron or grill). 11. STDs are very likely to be signs of sexual abuse in children before puberty, if the STD did not come from the mother at or around the time of birth. Which of the following STDs is a CERTAIN sign of sexual abuse? a. HIV b. Gonorrhea c. Genital herpes d. Bacterial vaginosis Correct: Gonorrhea Rationale: Both gonorrhea and syphilis are certain signs of sexual abuse. Other STDs are possible or probably signs. 12. Which of the following behavioral signs is most consistent with sexual abuse? a. High self-esteem b. Distorted body image c. Good grades in school d. Strong peer relationships Correct: Distorted body image Rationale: Sexually abused children may have a distorted body image. 13. A child abuse or neglect assessment has two basic parts. One part is a physical health check of the child. The other part is:

a. Police investigation of the child's caretakers b. A physical health check of the child's siblings c. Interviews with the child and his or her caretakers d. Taking statements from the child's neighbors, school teachers, etc. Correct: Interviews with the child and his or her caretakers Rationale: One part of the child abuse assessment is a physical exam. In addition, the child and his or her caretakers should be interviewed. 14. When physically examining a possible victim of child abuse, a best practice is: a. Use restraint as needed b. Do not explain the exam c. Ask for the child's permission before each step of the exam d. If sexual abuse is suspected, perform the exam in private without anyone else present Correct: Ask for the child's permission before each step of the exam Rationale: During a child abuse assessment, it is very important not to re-traumatize or re-victimize the child. Ask for permission before each step of the exam. 15. Healthcare providers are in a position to identify many cases of child abuse and neglect. Choose the true statement about REPORTING these cases of maltreatment: a. Providers must report all cases of suspected maltreatment to the proper authorities in their state. b. Providers may use their own judgment in choosing whether or not to report suspected maltreatment. c. Providers may be sued for reporting suspected maltreatment, even if the report is made in good faith. d. Providers are not permitted to report suspected maltreatment if reporting would violate patient confidentiality. Correct: Providers must report all cases of suspected maltreatment to the proper authorities in their state. Rationale: Healthcare providers are mandated reporters of child abuse and neglect.

FINAL EXAM 1. Beating or burning a child is a form of: a. Neglect b. Sexual abuse c. Physical abuse d. Emotional abuse Correct: Physical abuse Rationale: Beating or burning a child is physical abuse. 2. A parent repeatedly tells a child that she is useless. This is a form of: a. Neglect b. Sexual abuse c. Physical abuse d. Emotional abuse Correct: Emotional abuse Rationale: Degrading a child is emotional abuse. 3. An example of neglect is: a. Punching a child b. Terrorizing a child c. Sexual contact with a child d. Failing to provide food for a child Correct: Failing to provide food for a child Rationale: Failing to provide for a child's basic needs is neglect. 4. Long-term abuse can cause a stress response. This can lead to: a. Paralysis b. Blindness c. Hyperactivity d. Cerebral palsy Correct: Hyperactivity Rationale: Abused children may have problems with hyperactivity due to an overactive stress response.

5. Of the following, abused children are most likely to be: a. Fearful b. Content c. Trusting d. Unconcerned Correct: Fearful Rationale: Fear is a common psychological effect of abuse. 6. Consider the behavioral consequence of child abuse. Which statement is correct? a. Victims of child abuse tend to perform well in school. b. Victims of child abuse tend to be law-abiding citizens. c. Victims of child abuse are unlikely to abuse drugs or alcohol. d. Victims of child abuse are more likely to become abusive parents. Correct: Victims of child abuse are more likely to become abusive parents. Rationale: Victims of child abuse are at increased risk for abusing their own children. This is referred to as the cycle of violence. 7. Which of the following is a risk factor for child abuse? a. The child is outgoing. b. The child was born prematurely. c. The child has a long attention span. d. The child is the product of a wanted pregnancy. Correct: The child was born prematurely. Rationale: Children with birth-related problems (premature birth, birth defects) are at increased risk for abuse. 8. A parent is more likely to abuse a child if: a. The parent is trusting. b. The parent is married. c. The parent is impulsive. d. The parent is employed. Correct: The parent is impulsive. Rationale: Parents with a tendency to be impulsive are at increased risk for abusing their children.

9. Choose the true statement about bruises as a sign of child abuse: a. All kids get bruises. Bruises are never a sign of abuse. b. Bruises can be a sign of abuse. Patterned bruises are especially suspicious. c. Bruises are a sign of abuse only if the child says he or she has been abused. d. Bruises are always a sign of abuse and should be reported to your supervisor immediately. Correct: Bruises can be a sign of abuse. Patterned bruises are especially suspicious. Rationale: All kids get bruises. In some kids, bruises may be a sign of abuse. Suspect abuse if bruises are in the pattern of an item used to beat a child (e.g., hand, belt buckle). 10. Physical injuries are more likely to be a sign of abuse when: a. The child has unilateral injuries. b. The child has injuries in different stages of healing. c. The child has an injury in an early stage of healing. d. The child has an injury on a single area of the body. Correct: The child has injuries in different stages of healing. Rationale: All kids have accidents and get hurt. However, suspect abuse if a child has many injuries in different stages of healing. 11. STDs are very likely signs of sexual abuse in children before puberty, if the STD did not come from the mother at or around the time of birth. Which of the following STDs is a CERTAIN sign of sexual abuse? a. Syphilis b. Chlamydia c. Genital herpes d. Yeast infection Correct; Syphilis Rationale: Syphilis and gonorrhea are the two STDs that are certain signs of abuse. Other STDs are possible or probable signs of sexual abuse. 12. Which of the following behavioral signs is most consistent with emotional abuse? a. Failure to thrive b. High self-esteem c. Overachievement d. Strong trust in adults Correct; Failure to thrive Rationale: Emotional abuse of infants can lead to failure to thrive.

13. A possible victim of child abuse is identified. It is critical to perform the physical health check right away: a. In most cases b. In cases of emotional abuse c. If the child is unusually agitated d. If forensic evidence needs to be collected Correct: If forensic evidence needs to be collected Rationale: A physical health check should be performed right away if there is a need to collect forensic evidence of abuse. Otherwise, the health check may be scheduled for a follow-up visit. 14. When interviewing a possible victim of child abuse, a best practice is: a. Interview the child with his or her caretakers present b. Coax the child to answer your questions by offering a reward c. Explain the reason for the interview in words the child can understand d. Avoid answering if the child has questions about what will happen to his or her parents Correct: Explain the reason for the interview in words the child can understand Rationale: It is important to explain the reasons for the interview. Answer any questions the child might have about the interview or any other concerns. 15. Photographs can help document evidence of abuse. A best practice for taking photos of injuries is: a. Use black-and-white film b. Take a single picture of every major injury c. Include the victim's face in at least one photo d. Photograph injuries only after treatment is provided Correct: Include the victim's face in at least one photo Rationale: To properly document evidence of abuse in photographs, include the victim's face in at least one photo. 16. A healthcare provider chooses not to report a case of suspected child abuse. Choose the true statement: a. This is a misdemeanor crime in most states. b. This is not a crime, but is considered malpractice. c. The healthcare provider is protected from legal liability by rules of patient confidentiality. d. The healthcare provider has the right not to report based on his or her own best judgment. Correct: This is a misdemeanor crime in most states. Rationale: Healthcare providers are mandated reporters of child abuse. If a provider fails to report, this is a misdemeanor.