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The Role of First Responders in Child Maltreatment Cases: Disaster and Nondisaster Situations
Office on Child Abuse and Neglect, Children's Bureau. Cage, Richard., Salus, Marsha K.|
|Year Published: 2010|
Recognizing Child Maltreatment
In This Chapter
- Federal child welfare laws
- Recognizing the types and signs of child maltreatment
- Physical abuse
- Psychological abuse
- Sexual abuse
- Child fatalities
- Co-occurring issues
- Domestic violence
- Substance abuse
First responders have various levels of experience and training regarding the detection of possible child abuse and neglect. While some effects of child maltreatment are easily observable, many require a more indepth assessment by first responders. The physical, emotional, and behavioral effects of child abuse or neglect are wide-ranging, but many of these also may be caused by something other than maltreatment. First responders should be able to recognize and to assess any possible maltreatment within the context of other problematic situations that may occur in the home, such as domestic violence or substance abuse.
Appendix D, Reference Guide for Responding to Cases of Suspected Child Maltreatment, synthesizes key points from this chapter and Chapter 3, Initial Response and Investigation, into a two-page handout.
|Federal Child Welfare Laws|
|State laws, sound professional standards for practice, and strong philosophical underpinnings should guide any intervention into family life on behalf of children. The key principles guiding State child protection laws are based largely on Federal statutes, primarily the Child Abuse Prevention and Treatment Act (CAPTA), as amended by the Keeping Children and Families Safe Act of 2003 (P.L. 108-36), and the Adoption and Safe Families Act (ASFA) of 1997 (P.L. 105-89). CAPTA provides definitions and guidelines regarding child maltreatment issues, and ASFA promotes three national goals for child protection:
For additional information on Federal and State child welfare laws, visit the Child Welfare Information Gateway website at http://www.childwelfare.gov/systemwide/laws_policies/.
Types of Child Maltreatment
There are four commonly recognized forms of child maltreatment—physical abuse, neglect, psychological abuse, and sexual abuse. The definitions of these types of child maltreatment may vary depending on the State or the locality in which the first responder works. First responders should become familiar with the definitions that apply in their jurisdictions.
Additionally, the signs of child maltreatment listed in this manual, such as the behavioral clues listed in Exhibit 2-1, do not indicate absolutely that child maltreatment has occurred. They are meant to act as general guidelines for identifying the possibility of each type of maltreatment. Actual child maltreatment, as well as the perpetrator's identity, can be determined only after a thorough response and investigation.
Behavioral Clues That May Indicate Possible Child Maltreatment
|Children who possibly are maltreated may:|
The physical abuse of children includes any nonaccidental physical injury caused by the child's caretaker. Physical abuse can vary greatly in frequency and severity.7 It may include injuries sustained from burning, beating, kicking, or punching. Although the injury is not an accident, neither is it necessarily the intent of the child's caretaker to injure the child. Physical abuse may result from punishment that is inappropriate to the child's age, developmental level, or condition. Additionally, it may be caused by a parent's recurrent lapses in self-control that are brought on by immaturity, stress, or the use of alcohol or illicit drugs.8 Caretakers may physically abuse children during discipline or as a way to "teach the child a lesson."
Signs of possible physical abuse include:
- Fractures unexpectedly discovered in the course of an otherwise routine medical examination (e.g., discovering a broken rib while listening to the child's heartbeat)
- Injuries that are inconsistent with, or out of proportion to, the history provided by the caretaker or with the child's age or developmental stage (e.g., a 3-month old burning herself by crawling on top of the stove)
- Multiple fractures, often symmetrical (e.g., in both arms or legs), or fractures at different stages of healing
- Fractures in children who are not able to walk
- Skeletal trauma (e.g., fractures) combined with other types of injuries, such as burns
- Subdural hematomas, which are hemorrhages between the brain and its outer lining that are caused by ruptured blood vessels
- Burns on the buttocks, around the anogenital region, on the backs of the hands, or on both hands, as well as those that are severe.9
Some injuries that may have been caused by physical abuse have distinct marks. Exhibit 2-2 shows marks that may be indicative of physical abuse. Some injuries, however, may not be visible without a complete medical examination. For instance, injuries caused by abuse directed to the abdomen or to the head often are undetected because many of the injuries are internal. For a more complete list of the possible physical signs of child abuse, see Appendix E, Signs of Possible Physical Abuse.
Marks from Burns or Instruments10
|Injuries from physical abuse may appear in distinct shapes, especially in cases involving an instrument or burns.|
Marks from Instruments:
Marks from Burns:
Reprinted from Pediatric Clinics of North America, volume 37, C.F. Johnson, Inflicted Injury Versus Accidental Injury, pp. 791-814, 1990, with permission from Elsevier.
The first response in child physical abuse cases is handled predominately by social service agencies, such as child protective services (CPS). Many jurisdictions across the country have interagency agreements and protocols that define when a joint investigation by law enforcement and CPS will be conducted. Some have put guidelines in place for law enforcement to respond to all physical abuse cases involving young children, as well as to all cases of serious physical abuse. Serious physical abuse cases generally are defined as those requiring medical treatment or hospitalization. A response by law enforcement is also often required in cases involving any blows to the face or the head or the use of a particular instrument (e.g., clubs, bats, sticks, chains), which can indicate an attempt to do serious harm.
|Distinguishing Physical Abuse from Nonintentional Injury|
Children may receive bruises during the course of play or while being active. The areas that are bruised most commonly during normal play include the leading or bony edges of the body, such as knees, elbows, forearms, or eyebrows. The soft tissue areas, such as cheeks, buttocks, and thighs, are not normally injured during play. Additionally, bruises received during the normal course of childhood activity rarely are in distinct shapes, such as a hand, a belt buckle, or adult teeth marks. Bruises in soft tissue areas or in distinct shapes may be indicative of physical abuse.
Graphic reprinted from Reaching Out: Working Together in Identifying and Responding to Child Victims of Abuse by RIMER/PRAGER. 1998. Reprinted with permission of Nelson, a division of Thomson Learning: www.thomsonrights.com. Fax 800 730-2215.
For more information about how to distinguish physical abuse from accidental injury, see Appendix F, Distinguishing Physical Abuse from Nonintentional Injury, or visit http://www.ncjrs.gov/pdffiles1/ojjdp/160938.pdf. Additionally, some common folk-medicine practices may give the appearance of physical abuse. See Appendix G, Common Folk-Medicine Practice Injuries That May Resemble Abuse, for an explanation of some of these practices.
Neglect involves a caregiver's failure to meet the basic needs of a child, such as food, clothing, shelter, medical care, or supervision. Types of neglect include physical, environmental, emotional, and educational neglect, as well as inadequate supervision. Neglect follows a continuum from mild to severe and often is very difficult to define.11 Most laws today include some mention of "failure or inability to provide" in their definitions. There is still a lack of consensus, however, as to what constitutes failure to provide adequate food, shelter, protection, or clothing. Some State definitions include "failure or inability to protect," which refers to a situation in which a child is exposed to someone who may harm him, such as being left with a parent's drug dealer or a known child molester.12 In addition, parents might be accused of failing to provide a safe environment by not protecting a child from unsanitary or hazardous living conditions.
Caregivers may not provide proper care for a variety of reasons, including a lack of knowledge or understanding about meeting the child's needs, inadequate bonding with the child, or impairment due to substance abuse or to mental illness. Although there are cases of co-occurring maltreatment and poverty, living in poverty, in and of itself, does not mean that a child is being neglected.
|Signs of Possible Neglect|
|Children who possibly are neglected may:
Additionally, the first responder should check the home environment for signs of neglect, such as health or safety hazards, no heat, or unsanitary conditions.
For more information on neglect, refer to Child Neglect: A Guide for Prevention, Assessment, and Intervention.
Psychological maltreatment by a caretaker includes blaming, belittling, or rejecting a child; constantly treating siblings unequally; and demonstrating a persistent lack of concern for the child's welfare.14 It often accompanies physical abuse. The five categories of psychological maltreatment are:
- Spurning (e.g., belittling, ridiculing)
- Terrorizing (e.g., threatening)
- Isolating (e.g., confining the child from any family or friends)
- Exploiting or corrupting (e.g., encouraging or permitting prostitution or substance abuse)
- Denying emotional responsiveness (e.g., failing to express or to show affection).15
Psychological maltreatment often causes behavior problems in children and, in some cases, may cause developmental lags, psychosomatic symptoms (i.e., bodily symptoms caused by a mental or emotional disturbance), and other effects, such as speech disorders. First responders may not detect the physical or behavioral signs of psychological maltreatment easily.
|Signs of Possible Psychological Maltreatment|
|Children who possibly are psychologically maltreated may exhibit:
Sexual abuse is defined as adult sexual behavior with a child. It can include fondling a child's genitals, making the child fondle the adult's genitals, digital penetration, intercourse, incest, rape, sodomy, exhibitionism, sexual exploitation, or exposure to pornography. Sexual abuse also may be committed by a person younger than age 18. This occurs when that person is significantly older than the victim or is in a position of power or control over the child, such as an older youth babysitting a child or a sibling. Sexual abuse may take place within the family (referred to as incest), by a parent's boyfriend or girlfriend, by a caretaker outside the family (e.g., family friend, babysitter), or by a stranger. Contrary to the myth of abuse by strangers, however, sexually abused children usually know their abusers and have some form of a relationship with them.17
|Additional Information About Sexual Abuse|
|The following information about sexual abuse may be helpful for first responders:
Child sexual abuse can come to the attention of authorities in a number of ways. The child might disclose the abuse to the authorities, to another adult, or to a child, or may display abnormal behaviors (e.g., inappropriate sexual behaviors, such as constantly rubbing the genital area). Additionally, the child may have unexplained injuries or other medical conditions that could be caused by sexual abuse.19
|Signs of Possible Sexual Abuse|
|Children may have been sexually abused if they:
Additionally, children may have been sexually abused if they exhibit:
|The Internet and Child Sexual Abuse|
|A relatively recent phenomenon is the sexual abuse of children via the Internet. Children of all ages now have access to computers at home and in schools and libraries. Computers are invaluable tools for learning, but there is a growing problem of children's exposure (accidentally or intentionally) to pornography, as well as to online solicitations from sexual offenders. One study indicated that 49 percent of youths being solicited and 44 percent of those unintentionally exposed to pornography did not report the incidents.22
The following information may be useful to first responders who encounter possible online sexual abuse:
Internet crimes can be reported to the Cyber Tipline (http://www.cybertipline.org or 1-800-843-5678), which is a federally funded system operated by the National Center for Missing & Exploited Children.
The ultimate tragedy in a child maltreatment case is the death of a child. In 2008, an estimated 1,740 children died from abuse or neglect. This is a rate of 2.33 deaths per 100,000 children, which is comparable to the rate of 2.32 per 100,000 children in 2007.24 The rates for child fatalities are much higher for younger children. In 2008, 79.8 percent of child fatality victims were younger than 4 years.25 It has been estimated that many child deaths that are determined to be accidental, caused by disease, or classified as having some other cause were actually the result of child maltreatment. For example, studies of child deaths in Colorado and North Carolina found that approximately 50 percent and 62 percent, respectively, of child deaths caused by child maltreatment were not recorded as such.26
Child fatalities from maltreatment usually result either from chronic neglect or abuse or from a single, severe incident of abuse or neglect. In 2008, 39.7 percent of child fatalities were attributable to multiple types of maltreatment, 33.4 were caused by neglect only (including medical neglect), and 22.9 were due to physical abuse only.27 When children die from neglect, it often is because they have been without proper nourishment, medical treatment, or supervision.28 Additionally, acute incidences of neglect, such as leaving a young child unsupervised in a bathtub, near a pool, in a room with a loaded gun, or in some other potentially dangerous environment, may lead to a child's death.29 The most common injury that results in a child fatality is severe head trauma.30
|Child Death Review Teams|
Child death review teams (also known as child fatality review teams) examine the causes and circumstances of child maltreatment fatalities and other suspicious child deaths. Forty-nine States and the District of Columbia have child death review teams.31 Teams consist of multidisciplinary professionals, including CPS workers, coroners or medical examiners, prosecutors, law enforcement personnel, and others. The information gained through the reviews may be used to help family members receive services, correctly classify the causes of deaths, prosecute suspected perpetrators, and develop recommendations to prevent future deaths and improve child safety.
For more information about child death review teams, visit the National Center for Child Death Review Policy and Practice website (http://www.childdeathreview.org/).
|Sudden Infant Death Syndrome (SIDS)|
SIDS is the "sudden death of an infant under one year of age which remains unexplained even after a thorough case investigation, including performance of a complete autopsy, an examination of the death scene, and a review of the clinical history."32 SIDS is not child maltreatment. External suffocation, vomiting and choking, minor illnesses, or vaccines or immunizations do not cause SIDS, and it is not contagious. In addition, SIDS is unexpected, usually occurring in apparently healthy infants aged 1 month to 1 year. Most deaths from SIDS occur by the end of the sixth month, with the greatest number taking place between ages 2 and 4 months. SIDS is the leading cause of death in the United States among infants between the ages of 1 month and 1 year.33
In sudden, unexplained infant deaths, investigators, including medical examiners and coroners, use forensic medicine, which is the application of medical science for legal purposes, to arrive at a diagnosis. Often, the cause of an infant's death only can be determined by carefully collecting and evaluating information from the death scene and by conducting forensic tests. The child and family's history of previous illnesses, accidents, or behaviors also must be reviewed carefully. It is important to note that SIDS is not listed as the cause of every unexplained infant death. Basic steps that first responders can take when responding to the death of an infant are outlined in Chapter 3, Initial Response and Investigation, and criteria for distinguishing SIDS from death caused by child maltreatment are presented in Appendix H, Criteria for Distinguishing SIDS From Fatal Child Maltreatment. For additional information, visit http://www.sidscenter.org.
Domestic Violence And Child Maltreatment
Over the past few decades, there has been a growing awareness of the co-occurrence of domestic violence and child maltreatment. Children who live in families experiencing domestic violence are at risk of exposure to traumatic events, neglect, and direct abuse. Research suggests that in an estimated 30 to 60 percent of families where either domestic violence or child maltreatment is identified, both may exist.34 A review of CPS cases in two States identified domestic violence in more than 40 percent of cases in which there was the critical injury or death of a child.35 Research indicates, however, that child welfare workers are not identifying the occurrence of domestic violence in their cases.36 This also may be happening in other professions working with these families. One study found that although 31 percent of female caregivers self-reported at least one incident of domestic violence in the past year, child welfare workers only identified it in 12 percent of those cases.37
Caregivers who are victims of domestic violence may be abused to the point of being unable or unwilling to keep their abusers from also abusing the children. This may be considered neglect in some States and is often referred to as "failure or inability to protect the child from harm." In some cases, abused caregivers are afraid to defend the children in their care because doing so might put the caregiver's or children's lives in further danger or provoke more abuse. Whether caregivers are charged with "failure or inability to protect" often depends on whether the caregivers knew or should have known that their children were being abused.38
Because of the coexistence of domestic violence and child maltreatment, first responders called to a domestic violence complaint should be alert to the possibility of child abuse or neglect, look for signs of possible child maltreatment, and assess the safety of the victim and the children. Children can be harmed in cases of domestic violence even if they are not the actual targets of the violence. For information about interviewing children in cases of domestic violence and factors to consider when assessing their safety, see Chapter 3, The Initial Response and Investigation.
For more information on the co-occurrence of domestic violence and child maltreatment, see Child Protection in Families Experiencing Domestic Violence, the National Resource Center for Child Protective Services at http://www.nrccps.org/resources/domestic_violence.php, and The Greenbook Initiative at http://www.thegreenbook.info/.
|Risk Factors for Maltreatment|
|Factors that may place a child at increased risk for being abused or neglected include:
Substance Abuse and Child Maltreatment
Even though it may be exacerbated by other problems, such as domestic violence or mental illness, there already is a strong relationship between substance abuse and child maltreatment. The 2007 National Survey on Drug Use and Health reports that 8.3 million children live with at least one parent who abused or was dependent on alcohol or an illicit drug during the previous year. This includes 13.9 percent of children aged 2 years or younger, 13.6 percent of children aged 3 to 5 years, 12.0 percent of children aged 6 to 11 years, and 9.9 percent of youths aged 12 to 17 years.40 These children face a heightened risk of maltreatment.41 One study, for example, showed that children of parents with a substance use disorder are nearly three times more likely to be abused and more than four times more likely to be neglected than children of parents who do not abuse substances.42 Additionally, while estimates vary, most studies suggest that parental substance abuse is a contributing factor for between one-third and two-thirds of children involved with CPS.43
For more information on child maltreatment in substance-abusing families, see Protecting Children in Families Affected by Substance Use Disorders, or the National Center on Substance Abuse and Child Welfare at http://www.ncsacw.samhsa.gov/.
|Methamphetamine Use and Its Impact on Children|
Methamphetamine is a powerfully addictive drug, and individuals who use it can experience serious health and psychiatric conditions, including memory loss, aggression, violence, psychotic behavior, and potential coronary and neurological damage.44 Methamphetamine is also known by ever-changing street names, such as speed, ice, crystal, crank, tweak, glass, bikers' coffee, poor man's cocaine, chicken feed, shabu, and yaba.45 Methamphetamine use in the United States has become an issue of great concern to professionals working with children and families. In 2007, there were an estimated 529,000 current users of methamphetamine aged 12 or older. Approximately, 5.3 percent of the population reported using this drug at least once in their lifetime.46
Like children of parents with any substance use disorder, children whose parents use methamphetamine are at a particularly high risk for abuse and neglect. What compounds the problem for children of methamphetamine users is that the drug is relatively easy to make, and therefore, many of these children are exposed to the additional risks of living in or near a methamphetamine lab. During 2008, an estimated 1,025 children were injured, killed at, or affected by methamphetamine labs.47 The manufacture of methamphetamine involves the use of highly flammable, corrosive, and poisonous materials that create serious health and safety hazards. Children affected by methamphetamine labs may exhibit symptoms such as chronic cough, skin rashes, red or itchy eyes, agitation, inconsolable crying, irritability, or vomiting.48
Many communities have Drug Endangered Children (DEC) programs that assist CPS caseworkers, law enforcement, and medical services to coordinate services for children found living in environments where drugs are made. For more information on DEC programs, visit http://www.whitehousedrugpolicy.gov/enforce/dr_endangered_child.html.
For more information about methamphetamine, visit http://www.childwelfare.gov/systemwide/substance/drug_specific/meth.cfm, http://www.methresources.gov/, or http://www.ncsacw.samhsa.gov/.
|Signs of Methamphetamine Use and Manufacture49|
|With the increased use of methamphetamine, first responders are now more likely to work with clients who are users or manufacturers of this drug. The following information can assist them in identifying methamphetamine use or manufacturing.|
Signs of possible methamphetamine use include:
Signs that methamphetamine is possibly being manufactured in a home include:
|Safety Issues When Encountering a Suspected Methamphetamine Lab|
First responders should use extreme caution and seek assistance from law enforcement, fire/rescue personnel, hazardous materials crews, or other appropriate individuals or groups if they are visiting a home that has a suspected methamphetamine lab because these homes may have:
First responders who enter a methamphetamine lab that has not been properly ventilated and cleaned—or who are not properly equipped to avoid exposure to chemicals (i.e., have respirators, protective clothing)—may experience shortness of breath, coughing, chest pain, dizziness, vomiting, lack of coordination, burns, and, in some cases, death. If first responders do come into contact with possibly dangerous chemicals, they should wash the exposed skin with liquid soap and water or, depending on the type of chemical exposure, a chemical solution. They also should remove contaminated shoes and clothing. First responders should also be knowledgeable about agency protocols for the evacuation, decontamination, and health screenings for children and others found at the home, including which, if any, of the child's possessions (e.g., medications, eyeglasses) should be retrieved from the home and how they should be decontaminated.
First responders who determine they are in a home that has a suspected methamphetamine lab should immediately leave the residence, taking care not to:
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