SUBJECT: / PATIENT ABUSE, CHILD / REFERENCE # 1107
PAGE: 1
DEPARTMENT: ALL HEALTH SERVICES / OF: 12
APPROVED BY: / LAST REVISION:
MARCH 2004

DEFINITION:

  • Child Abuse - "Any act of omission or commission that endangers or impairs the child's physical or emotional health and development." Child abuse includes physical assault, nutritional neglect, drug abuse (poisoning or drugging), medical care neglect, sexual exploitation, safety neglect (religious exemption) and emotional assault.

Services for Abused and Neglected Children

It is recognized that children are sometimes the object of abuse and neglect. Since children are expected to remain in the home where these acts are being perpetrated, special provisions have been enacted to protect children from the detrimental and unhealthy consequences of such a situation. This protection is extended by state laws which define conditions of physical psychological abuse and neglect, stipulate procedures for reporting such incidents, and designate agencies which are empowered to investigate complaints and act in the best interest of the child to provide relief.

State laws mandate the reporting of all cases of suspected child abuse and neglect in any form and name to the Oklahoma Department of Human Services (DHS) as the responsible agency for acting on behalf of such children. DHS and CNHSA Social Worker will act collectively with other health care providers in the hospital to assure that children suspected as victims of abuse and neglect are appropriately serviced. This may take the form of consultation, assisting in data collection for diagnosis, initiating reporting to the local DHS office, securing temporary shelter, or follow-up counseling with the family.

PROCEDURE:

Child abuse victims are often first seen by the physician as the child is brought for medical attention due to consequences of abuse and/or neglect. The physician will carry out such procedures as deemed necessary to complete the examination. Social Services personnel may be requested to assist in initial data collection by carrying out interviews with parents or relatives. A home/family study should be added to the total information profile. If parents are unwilling for the examination to be completed, a petition can be submitted to the county court to secure such consent. The local office of the DHS, LatimerCounty, (918)-465-3451, can be contacted for assistance and are empowered to take temporary custody of the child so that the examination can proceed. (Outlying clinics to contact their county’s DHS Department).

If attending physician, upon completion of the examination of the child, concludes that the findings suggest child abuse or neglect, a report will made to the local DHS office which will then be responsible for investigation and follow-up. Parents can be offered counseling services through the Social Services Department. Follow-up visits can be arranged by Social Services, Community health Nursing, or Tribal Health Workers. When the examining physician believes the child requires emergency protection, a decision to admit the child to the hospital or placement in temporary shelter may be made.

Local police or the county judge can temporarily remove parental custody, thus allowing emergency protective placement for the child. This procedure can also be used to gain custody of the child when parents remove the child for the examining facility against medical advice. Seeking protective custody can be for the child. Social Services personnel can assist in determining when the home is no longer threatening and it is safe to release the child. When an unresolved difficulty is encountered in serving abused or neglected children, assistance is available by calling the DHS Hotline number: 1-800-522-3511. Choctaw Nation Social Services

Contacts include:

Dana Maxwell918-567-4265Talihina Office

Billy Stevens800-522-6170 Ext. 2236Durant Office

Angela Dancer580-326-3362Hugo Office

Indicators of Neglect (Detection of Possible Abuse/Injury)

  • Neglect is not an area easily defined. The type generally seen in the medical community displays itself in unattended physical problems or medical needs that are deemed to be eventually life-threatening.
  • In considering the possibility of neglect, the following factors must be involved
  • Do not indicators occur rarely, frequently or are they chronic
  • In a given community or sub-population, do all the children display these indicators, or only a few
  • Is this culturally acceptable child rearing or a different lifestyle? Or is true neglect involved

The following are physical indicators of neglect:

  • Malnutrition, dehydration, constant hunger
  • Poor hygiene—extremely dirty, unkempt, no evidence of bathing (i.e., dirty hair, face, persistent body odor)—infants with severe diaper rash on other persistent skin disorders consistent with poor hygiene
  • Inappropriate clothing for weather or season (exposure symptoms, pneumonia, frostbite, severe sunburn, etc).
  • Consistent lack of supervision, especially when engaged in dangerous activities over extended periods of time
  • Left in the care of another child too young to provide adequate supervision/care
  • Constant fatigue or listlessness
  • Unattended physical problems or medical needs, such as untreated or infected wounds, dental carries, etc.
  • Abandonment
  • Failure to follow physician’s instructions
  • Inadequate, unsafe or unsanitary living conditions or shelter

The following are behavioral indicators of neglect.

  • Failure to thrive in an infant
  • Appears to be ignored or pushed aside when attempting to speak with care provider
  • Appears fearful of telling care provider about minor misdeeds
  • Begging or stealing food
  • Engages in role reversal with care provider
  • Evidence of severe developmental lags or arrested developments without physical causative factors
  • Accident history inconsistent with the developmental age of the child
  • Delay in seeking medical care for a significant injury
  • Modeling after dad (or caregiver) “Monkey See, Monkey Do”
  • Constantly falling asleep in class
  • Rare attendance at school—continual fighting at school (especially boys)
  • Coming to school very early and leaving very late
  • Extremes in behavior, ranging from unusually aggressive to exceedingly passive
  • Appears detached from parent
  • Appears unusually affectionate or “clingy” to parents
  • Bed wetting, thumb sucking, excessive and frequent whining
  • Exceptionally disruptive
  • Abuses alcohol or drugs
  • Threatens siblings with violence
  • Stating that there is no one to care for or look after him/her
  • Treats pets cruelly (especially boys)

Indicators of Physical Abuse:

  • Unexplained bruises and/or welts
  • On Face, lips, mouth—loosened or missing teeth
  • Subconjunctival hemorrhages/retinal hemorrhages
  • In various stages of healing (bruises of different colors; old and new scars together)
  • On large areas of the torso, back, buttocks or thighs
  • In clusters, forming regular patterns or reflective of the article used to inflict them (electric cord, belt buckle, etc.)
  • Cephalhematomas and irregular contour of skull

Unexplained burns:

  • Cigar or cigarette burns, especially on the soles of the feet, palms of the hands, back or buttocks
  • Immersion or “wet” burns, including glove or sock-line burns and doughnut shaped burns of the buttocks or genitalia
  • Patterned or “dry” burns which show a clearly defined mark left by the instrument used to inflict them (electric burner, iron, etc.)
  • Rope burns on the arms, legs, neck or torso

Unexplained fractures:

  • To the skull, nose or facial structure
  • In various stages of healing (indicating they have occurred at different times)
  • Spiral fracture
  • Deformity of chest/limitation of motion due to fractured ribs
  • Swollen or tender limbs
  • Any fracture in a child under the age of two (2)
  • Deformity of long bones
  • Multiple fractures at different stages of healing
  • Joint injuries secondary to twisting or pulling a child’s limbs (these can be confirmed with x-rays)
  • Injuries secondary to shaking, squeezing, or throwing of a child, i.e., internal bleeding, subdural hematoma, retinal hemorrhage
  • Cigarette burns (these may be found in unusual places and be at different stages of healing)
  • Scald-type burns, especially if these do not match the explanation of how the injury occurred
  • Signs that the child is afraid of the parents/caregivers or other indicators that a child with injures has a disturbed relationship with his/her caregivers
  • A history of repeated suspicious injuries
  • Unexplained growth failure in a child, i.e., non-organic

Evidence of gross neglect of a child. Such evidence may include:

  • Lack of adequate food, clothing and/or shelter
  • Lack of nurturing and affection, i.e., gross emotional neglect
  • Lack of adequate supervision which has led to a serious accident involving a child
  • Lack of appropriate medical care or use of inappropriate medical care which jeopardizes a child’s health
  • Unexplained lacerations and abrasionsto the mouth, lips, or eyes; ruptured ear drums from blows to head

Indicators of Sexual Abuse:

  • Sexual abuse includes any contacts or interactions between a child and an adult in which the child is being used for the sexual stimulation of the perpetrator or another person
  • These acts, when committed by a person not considered an adult, under the age of eighteen (18), who are either significantly older than the victim or in a position of power or control over another child, may be considered sexual abuse
  • Sexual abuse is not often identified through physical indicators alone. There are both physical and behavioral signs for which to be alert

The following are physical indicators of sexual abuse:

  • Difficulty walking or sitting
  • Torn, stained or bloody clothing
  • Unexplained pain, swelling, bleeding or irritation of the mouth
  • Complaints of pain or itching in the genital area
  • UTI
  • Bruises or bleeding from external genitalia (vagina or anus)
  • Venereal disease, other STD particularly in a child under thirteen (13) years
  • Pregnancy, especially in early adolescence

The following are behavioral indicators of sexual abuse:

  • Appears withdrawn, engages in fantasy or infantile behavior; may even appear retarded
  • Has poor peer relationships
  • Unwilling to change for gym classes or participate in physical activities
  • Engages in delinquent acts or becomes a runaway
  • Displays bizarre, sophisticated or unusual sexual knowledge or behavior
  • Hints, indirect comments or statements about abuse

A child that has been abused may display:

  • A poor self image
  • Fear of dislike of certain people or places
  • Excessive bathing or poor hygiene
  • Inability to trust, show affection or love others, anxious
  • Sexual acting out
  • Aggressive, disruptive and/or illegal behavior
  • Various ranges of anger and/or rage
  • Self destructive or self abusive behavior use of drugs or alcohol
  • Flashbacks or nightmares of the abuse or that are indicative of the abuse-sleep disturbances
  • Passive or withdrawn behavior
  • Eating disorders
  • Symptoms of depression or sadness
  • Suicide attempts

Indicator of Abusive Parents:

There is no one ling of abusive parent and such parents are found among all socioeconomic groups. Before child abuse is ruled out, it should be remembered that there is a common pattern of parent-child relationships usually associated with the child abuse. These factors include:

  • The parent who was emotionally or physically abused as a child
  • The spouse is absent, cooperative with the abuse or fails to supply emotion support for the marital partner
  • The parents feel isolated, with no one to turn to in time of need
  • The parent unrealistically expects the child to gratify his own dependent needs. The child is seen as different from other children
  • Some form of crisis, real or imagined, exists that sets the abusive act in motion
  • Presence of family breakdown

Socioeconomic Factors:

  • Frequent pregnancies with several pre-school age
  • Economic stress
  • Retardation of caregivers
  • History of drug or alcohol abuse

Legal Liability:

  • Persons mandated to report-childcare custodians, medical practitioners and non-medical practitioners are protected from civil and criminal liability. This means that these persons may not be prosecuted or held personally liable, even if subsequent investigation determines that the reported abuse did not occur.
  • Immunity from liability also extends to the taking of photographs and x-rays and dissemination of these photographs with the required reports
  • Persons not mandated to report-persons not mandated to report are nevertheless encouraged to report suspected child abuse and neglect. Such persons who do report are protected from civil and criminal liability. However, making a false report constitutes a misdemeanor.

Criminal Liability:

  • It is a crime to fail to report suspected abuse of children to the appropriate authorities
  • A person mandated to report who fails to report an instance of child abuse, which he/she knows to exist or reasonably should know to exist, is guilty of a misdemeanor and is punishable by confinement in the county jail or by a fine

Civil Liability:

  • Failure to report suspected child abuse could also result in civil liability. A person who is mandated to report suspected abuse, but does not do so, could be held responsible for the cost of any damage to the child.
  • Any medical practitioner or non-medical practitioner, within the scope of his/her employment or professional capacity, who has seen the victim of abuse or neglect shall report the known or suspected instances to law enforcement, local child protection agency or the Health Department. The report will be immediate or as soon as practically possible by telephone with written follow-up.
  • Healthcare professionals are not liable for either civil damages or criminal prosecution as a result of making such a report, unless it is proven that they made a false report with malice.

Reporting Child Abuse and/or Neglect:

  • The law specifies that all licensed nurses, physicians, non-medical practitioners, psychiatrists, psychologist, social workers, MFCC’s, residents, interns and any other person currently licensed in the Business and Professions Code must report suspected child abuse or neglect when acting in his/her professional capacity or within the scope of his/her employment.
  • None of the above-mentioned licensed personnel will incur any civil or criminal liability as a result of making this report.
  • Emergency Department Patients-Any licensed employee suspecting child abuse or neglect of any patient coming into the Emergency Department or being admitted to the hospital should call Child Protective Services immediately. A 24-hour emergency response hotline is available for Child Protective Service referrals at the following number 1-(800)-522-3511.
  • Pediatric Inpatients-Social Service Department will follow-up with written documentation to Child Protective Services that day or the next business day.

Documentation:

  • For suspected physical or sexual abuse, the “Medical Record” is filled out and completed by the Emergency Department nurse and/or physician. A copy is sent to the Department of Human Services (DHS), Child Protective Services (CPS) Unit. A copy shall also be sent to the Social Service Department.
  • For all other suspected abuse, the Medical Record is completed by the Emergency Department staff (if they suspect abuse) or Social Service Department is contacted if the abuse is suspected after admission, forward a copy to Social Service Department and mail a copy to DHS, CPS Unit.
  • If the physician feels the child should not be released into the custody of the parents until sufficient investigation has been made, the physician will sign a form which will be provided by the CPS worker. The child then becomes a ward of the court until such time a hearing can be held and a decision made. The hospital becomes the shelter home until the child is released to the DHS, CPS social worker assigned to the case.

Protective Custody/Use of Abuse Form:

  • The Abuse Form is generated and completed by the CPS social worker. The form should be filled out in its entirety.
  • Under “Reason for Referral”, the following explanations will indicate which reason should be circled
  • Lack of proper parental care and control
  • Parents not providing basics, i.e., food, clothing, warmth
  • Child dangerous to him/herself and/or others, i.e., mental problems
  • Home unfit for child; depravity, sexual or physical abuse
  • All facts must be stated clearly, this form will be standing alone in a court hearing and should not depend on any attached reports

The entire report should be attached to the patient’s medical record

  • One copy will be retained by the hospital as permanent document on the medical record
  • Two copies will be taken by the DHS Social Worker
  • It is very important that this form is on the patient’s medical record. Without it Choctaw Nation Health Services Authority has no authority to keep the child if a parent comes to take the child home
  • Social Service shall be notified of protective custody determination by the Emergency Department staff, if the patient is admitted, or by the floor/pediatric nursing staff, if the form was issued while the child was an inpatient.

Treatment of Child Abuse and Neglect Guidelines for initial management:

  • Hospitalize suspected case
  • Treat child’s injuries or malnutrition
  • Obtain necessary laboratory tests
  • Elicit detailed facts concerning injury
  • Obtain consultation with child abuse specialist within 24 hours if diagnosis in doubt
  • Tell parents the diagnosis and need to report it
  • Examine all siblings with 12 hours
  • Maintain helping approach to parents
  • Involve the mother in child’s hospital care
  • Report to child protective agency by phone within 24 hours
  • Refer parents who need crisis psychotherapy
  • Attend dispositional conference
  • Provide expert medical testimony for cause going to court
  • Make sure that child protective agency is providing psychological follow-up and treatment

Instructions for Documenting Abuse

  • If there is insufficient space, a continuation sheet should be used
  • Complete internal pelvic exam is not usually indicated in a prepubertal child if no visible external signs of trauma are visible
  • When a child is so emotionally traumatized that thorough pelvic or rectal exam or cultures cannot be done without further emotional stress to him/her, consideration should be given to:
  • Delay of exam/cultures if the timing collection of the evidence is not critical; e.g., alleged event occurred many days ago
  • Referral for exam under anesthesia by a contract specialist if injuries or timing necessitate immediate evaluation
  • X-rays of skull and long bones are not indicated on every case of child abuse/neglect. Some guidelines include age less than 5 years with;
  • Bruises and contusions
  • Limitation of use of an extremity
  • Change in level of consciousness
  • Previous history of abuse, delayed referral for injury
  • Bleeding times and coagulation studies should be done on all cases where bruising is apparent (PT, PTT, Platelet Count).
  • In case of rape or incest involving more than fondling, a complete rape kit should be used. (OSBI Kit). Please see Sexual Abuse Protocol for recommendations

OklahomaState Law Relating To The Reporting of Suspicion of Suspicion Of Child Abuse Or Neglect