Child Abuse and Neglect: Mandatory Reporting for EMS Providers

Matt Concialdi, MS, NRP, and Stacee Read, BA, MSW

Original Contribution

Child Abuse and Neglect: Mandatory Reporting for EMS Providers

Matt Concialdi, MS, NRP, and Stacee Read, BA, MSW

May 2016

Out of an estimated 60 million children in the United States, three million cases of child abuse and neglect will be reported each year.¹ In 2012 1,640 children died as the result of child abuse and neglect, and there are concerns not all deaths are reported.² Thousands of children abused and neglected every year fall through the cracks. We are all taught in EMS education that it is mandatory to report, but how do we recognize child abuse and neglect, and how do we report it?

Congress has reported that “the failure to coordinate and comprehensively prevent and treat child abuse and neglect threatens the futures of thousands of children and results in a cost to the nation of billions of dollars in tangible expenditures, as well as significant intangible costs.”²

According to the Child Maltreatment 2012 report, 81% of the children abused were abused by one or both of their parents, and 88% were biological parents. These are the people taking care of children on a daily basis who are supposed to love and care for them—and the people we are likely to come across.

Over 80% of perpetrators of child abuse and neglect were between the ages of 18–44, and, shockingly, 53% were females, 45% were males. The majority of the victims were children younger than 3, the lion’s share being under a year old. Both neglect and physical abuse have their highest rates in the age group of birth to age 2. The second-highest rate of abuse is found among kids 3–5.³ The 12–14 age group experiences the most sexual abuse.

Of the reported cases of child abuse, neglect accounts for roughly 78%, physical abuse 18%, sexual abuse 9%, and emotional abuse 6%.^1,3 But what training on recognizing neglect do EMS providers receive?

What Is Child Abuse and Neglect?

In 1974 the federal government passed the Child Abuse Prevention and Treatment Act (CAPTA), which created a federal definition of maltreatment, or what is often referred to as child abuse and neglect. This was subsequently amended and expanded on by the CAPTA Reauthorization Act of 2010, which created a minimum set of acts or behaviors to give states as a guideline to define child abuse and neglect. That describes it as:

“Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation”; or “An act or failure to act which presents an imminent risk of serious harm.”⁴

A child is generally referred to as a person younger than the age of 18. Within the child abuse definition, there are four main types of maltreatment: neglect, physical abuse, sexual abuse and emotional abuse.

Mandatory Reporting Laws

CAPTA also mandates that all states have laws requiring mandatory reporting of child abuse and neglect. These laws vary by state, but in general mandatory reporters are people who are required by law to make a report when they, in their official capacity, suspect or have reason to believe a child has been abused or neglected, or when conditions could reasonably result in harm to a child.

Every state has mandatory reporting laws for those working in healthcare, including EMS and fire personnel. To view the specifics of your state’s mandatory reporting laws, go to the Child Welfare Information Gateway at https://www.childwelfare.gov/topics/systemwide/laws-policies/state/.

Many states struggle with underreporting. Many EMS providers have been told in primary EMS education or by agency supervisors to report to the hospital, and that counts as the mandatory reporting. Other reasons include:⁵

Lack of awareness of who is a mandatory reporter;
Fear of unnecessary removal of children;
Fear of being involved in a lengthy court case;
Uncertainty what information to report or how to report it;
Stigma in smaller communities against being a “snitch”;
Perceived lack of response by child welfare and law enforcement agencies.

Recognizing Child Abuse and Neglect

Most professionals are trained to identify obvious child abuse. Child injuries are often easily observed, easily explainable and easily understood. Children are known to fall and bump their heads learning how to walk; it is understandable for children to break arms skateboarding; it is easily understood that children could burn their hands exploring what is on the stovetop, etc. But what happens when child abuse is not obvious or typical? What happens if what we are looking at falls into that 68% of neglect cases? Will we miss it?

There are some telltale signs that need to raise our spidey senses. Ask yourself, is the story consistent with the injury?⁶ Also consider the child’s developmental stage. Does it seem likely that this type of injury could occur to this child? For instance, should an infant who cannot walk or crawl have bruises on their body? Could a child fall off a couch and get bilateral subdural hematomas? Is it really possible that a child received a spiral fracture of the femur from falling off their bike?

Let’s review examples of abuse and neglect:

Shaken baby syndrome—Shaken baby syndrome is the deliberate or unintentional act of inflecting nontraumatic head injuries. The mechanism of injury is vigorous shaking with a sudden deceleration. Typically this syndrome is found in infants 6 months or younger, but it can also be found in children up to age 2 or 3. Signs and symptoms include irritability, lethargy, vomiting, decreased feeding, unexplained seizure, apnea and/or respiratory distress. Retinal hemorrhages are seen in the majority of the cases, in addition to subdural hematomas and posterior rib and long bone metaphyseal injury as well. Very rarely are there any external signs of trauma. The rate of morbidity and mortality is 30% in infants who suffer from shaken baby syndrome.¹

Fractures—Fractures in children are not uncommon; however, depending upon the type of fracture, it may indicate a degree of foul play. Rib fractures are the most common fractures seen in abuse and are often found in shaken baby syndrome. These fractures normally occur bilaterally on the chest and include multiple ribs. The mechanism is typically compression forces from anterior to posterior. In addition, posterior fractures are typically only seen in abuse cases, not in everyday childhood accidents. Any fracture in an infant under 6 months is highly likely to be inflicted and should raise a concern of abuse.⁶ Spiral fractures of long bones like the femur or humerus due to twisting or jerking are considered suspicious injuries and should be investigated further. Corner or chip fractures of the growth plate in long bones can indicate twisting or jerking motions in infants who who have been vigorously shaken. Complex or depressed cranial fractures could be the result of high-energy or focused impact from direct blows. These types of skull fractures typically do not occur in everyday falls. Pay attention also to multiple, symmetrical or fractures that are in different stages of healing, as these can be signs of abuse as well.⁷

Bruises and swelling—Skin signs like bruising or swelling are at times the easiest to look for. We know children bruise during various play and life activities. But where are the locations of the bruising, and what are the shapes? Where is the redness and swelling? Normal childhood bruises occur over anterior bony prominences including on knees, shins, elbows, forearms and foreheads.⁵ Signs of multiple bruises in various stages of healing should raise an initial concern. Bruises to the lower mid back, flank, side of the thigh and under the eyes should raise a level of concern and be investigated further. Any bruising to a child’s ears or behind the ears can also suggest abuse. Infants typically do not bruise accidently since they are not yet standing, walking or even moving significantly at all.⁶ Any sign of patterned or shaped (like an object) bruises should be investigated further.¹ Pay attention also to redness and swelling and the location on the body.

Burns—Burn patterns on a child are not normal and need further investigation. Two types of burns to pay attention to are splash and scalding burns. The most common shaped burn patterns to look for are cigarette or curling iron burns. Often these will be found on arms, legs or the back, but anywhere on the body should raise your suspicion. The “donut hole” pattern burn is a sign the child was held in scalding water. In addition, sock burns also indicate the child was held feet first in hot water—this looks like a sock on the foot. Typical unintentional burns occur on the hands and face, areas that are not usually covered, and are normally smaller and less deep than intentional burns. Once again, does the story match up with the signs and symptoms?

Hair loss—Hair loss is one area that does not get discussed much in child abuse topics. Loss of hair can either be self-inflicted or done by another person. Self-inflicted hair pulling may be a result of the child relieving personal stress.⁶ Trauma to the hair may also be caused by forceful brushing by a parent or sibling. A tip to look for in abuse cases is blood beneath or at the surface of the scalp.⁶

Sexual abuse—Sexual abuse is often difficult to talk about. Children who are victims of this type of abuse will, at times, complain within 72 hours of the incident due to pain, bleeding or an unexplained discharge from the rectum, urethra or vagina.⁶ Often victims will not complain, as there may not be physical injuries and therefore no physical evidence. Other complaints over a longer period of time could be nonspecific abdominal pain, vaginal inflammation or difficulty urinating.⁶ It is recommended that if child sexual abuse is suspected at all, EMS providers not exam the genital area but report it to the hospital on the patient care report and in documentation to child protective services.

Neglect—When people think of neglect, they usually think of a lack of food, a cluttered house or a lack of supervision. But what really is neglect? Is it more than just that? Have you missed neglect because you really haven’t been looking for it? Do you know what to look for? Neglect is an “ongoing pattern of inadequate care and is readily observed by individuals in close contact with the child.”⁸ Neglect can be the alcoholic parent who is passed out in the garage while the children are left to survive on their own. Signs to look for are inadequate or poor hygiene, lack of medical care when needed, frequent absence from school and poor weight gain. According to Psychology Today, more children suffer from neglect than from physical and sexual abuse combined.⁸ In 2005 14.3% of child abuse victims suffered various types of neglect, such as abandonment, threats of harm and congenital drug addiction.⁸Neglect can be hard to spot but is just as damaging to a child as physical and sexual abuse.

What Do I Report?

In some states there are two entities to which to report child abuse and neglect, depending upon the circumstances and state law. These are child protective services/child welfare and law enforcement. Check with the laws in your state and be familiar with which entity to contact. In order to provide a complete report, provide the following information, if known:

The name, address, age, sex and race of the child;
The name(s) and address(es) of the person(s) responsible for the suspected abuse or neglect, if known;
The nature and extent of the child’s injuries, if known;
Knowledge of previous cases of known or suspected abuse or neglect of the child or the child’s siblings;
The family composition, including any siblings;
The name, address and/or contact phone number, and occupation of the person making the report;
Relation of the person making report to the child and/or how information was obtained;
Any action taken by the reporting source;
Any other information reporting person feels is important.

Let’s ask ourselves if this information is enough. Do you as an EMS provider have more information you have heard, observed or been given? If child welfare and law enforcement had more information, it could be the difference between intervention and having the abuse/neglect continue. Providing as much information as possible can strengthen the case against the abuser. Here are some additional details of the encounter that can be passed along:

Description and chronology of events;
Statements made by the child or parent/caretaker;
Statements made by others;
Actions observed of the child or caretaker;
History known by law enforcement;
Current resources, services and/or supports of family and/or child;
Attitude of family members/caretakers;
Access the alleged perpetrator has to the child;
Child’s current medical, mental, social, cognitive abilities/levels;
Current family stressors;
Current criminal charges and/or law enforcement investigation;
Any impact on the children of any of the above.

Despite common belief, it is not enough to just pass on your findings to the emergency room nurse or physician upon patient dropoff. It is also the responsibility of the EMS provider to contact child welfare and/or law enforcement as well as fill out and submit the proper paperwork for reporting. If law enforcement is already on scene and aware of the situation due to a criminal investigation, this is the only time when reporting directly to child protective services is not needed, since the law enforcement officer will file the paperwork as part of their report. However, verify with law enforcement that they will submit the paperwork. It is recommended, though, to still fill out the child abuse paperwork since the EMS perspective is different from law enforcement’s and may enhance the case against the abuser.

It is crucial to document your findings in detail in your patient care report, as this may be used in court and/or to refresh your memory if you’re asked to testify at a later date. Use caution not to assume a certain party is guilty in the PCR; just document the facts of what you saw and heard while performing your patient assessment.

If the EMS provider encounters a possible child abuse situation, it is advisable not to confront the parent or guardian. It is not your job to investigate the situation in any way. Pay attention to specific details and document all findings. If further questions are needed to investigate a medical situation, use nonjudgmental questions and a cautious tone of voice. Make sure questions are appropriate for the situation. If needed, separate the child from the parent and transport the child to the closest emergency room that accepts pediatrics. Once the child has be delivered to the emergency room for evaluation, make sure you advise the hospital staff of the specifics of the incident and that you, the EMS provider, are filing a child abuse report and contacting child welfare. If the parent is with the child upon delivery to the emergency room, separate the hospital staff from the parent and discuss your concerns in private. It is important not to escalate or pass unfounded judgment in front of the child or the parents.

Conclusion

Child abuse calls are infrequent but among the most emotional calls we may go on as EMS providers. Some cases are obvious, and others may sneak past us. Abuse covers physical, sexual, mental and neglect. If we encounter a potential child abuse situation, it is our duty as EMS providers to report through the appropriate channels so the correct authorities can intervene and stop the abuse from continuing. If we do not report the child abuse, the cycle continues and leads to the following:⁵

Delayed intervention: crisis, removal;
No services or a delay in services: therapy;
Abuse and/or neglect may continue;
Child may suffer long-term effects from abuse/neglect;
Serious injury or fatality may occur to the child.

EMS providers have an obligation to report directly to their local child welfare service by making the phone call and filing the necessary paperwork. Your information matters and can assist law enforcement in removing children from dangerous situations and putting abusers behind bars, where they belong.

References

1. Adelgais K. Mandated Reporting. Lecture at EMS Leadership Conference, Glenwood Springs, Colo., 2014.

2. Department of Health and Human Services. Child Abuse Prevention and Treatment Act, PL 111-320, CAPTA Reauthorization Act of 2010.

3. Department of Health and Human Services. Child Maltreatment 2012. Washington, DC: Administration on Children, Youth and Families, Children’s Bureau, 2013.

4. Child Welfare Information Gateway. Definitions of Child Abuse and Neglect in Federal Law, https://www.childwelfare.gov/can/defining/federal.cfm.

5. National Alliance for Drug Endangered Children. Drug Endangered Children Guide for Law Enforcement: Key Insights for Partnering with Child Welfare, Medical Providers, Treatment Providers, Prosecutors, and Civil Attorneys. Washington, DC: Office of Community Oriented Policing Services, 2014.

6. Markenson D, Tunik M, Treiber M, Cooper A, Skomorowsky A, Foltin G. Child Abuse and Neglect: A Prehospital Continuing Education and Teaching Resource. New York, NY: Center for Pediatric Emergency Medicine, 2003.

7. Lukefahr J. Child Abuse and Neglect. Fractures. Department of Pediatrics. University of Texas Health Science Center, 2008.

8. Psychology Today. Child Neglect, https://www.psychologytoday.com/conditions/child-neglect.

Matt Concialdi, MS, NRP, has been in EMS since 2000, working in Southern California and most recently in the Denver metro area. Besides working as a field paramedic, he is the EMS system development coordinator for the state of Colorado.

Stacee Read, BA, MSW, is currently working for the National Alliance for Drug Endangered Children (National DEC) where she trains disciplines on how to respond to children at risk, develops curriculum and publications, provides technical assistance to a national network, and provides expert consultation on child welfare and substance abuse/drug issues.

Comments

I find it troublsom that lack of law enforcment is even in the catagory mentioned with why people dont report. No wonder we are living in the society we do. Feeling the need for self protection everywhere.

—Nikki Lewin-Dabbs