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    Maryland CHAMP

    The Maryland Child Abuse Medical Providers' Network


     
     
    Recognizing and Responding to Possible
    Child Maltreatment
    A Guide for Maryland Primary Healthcare Professionals
    Purpose
    The purpose of this Maryland CHAMP guide is to assist pediatric primary care professionals (PCPs) in recognizing and responding to possible child maltreatment.
    Contents
     
     
      
    Introduction
    In recognizing the crucial need to include medical expertise in the evaluation of child abuse and neglect, the Maryland Child Abuse and Neglect Initiative was established in 2005 when the Maryland General Assembly enacted Health General Article §§ 13-2201-2206, Annotated Code of Maryland. The Initiative was renamed Maryland CHAMP in 2008.
    CHAMP Activities
    With support from the Marylan Department of Health, Maternal and Child Health Bureau, CHAMP has developed a statewide network of medical professionals with expertise in child maltreatment, with representatives in most Maryland jurisdictions. This helps ensure a skilled medical evaluation of, and response to, suspected abuse and neglect.
    CHAMP Faculty
    Maryland CHAMP is led by a director and faculty, most of whom are board certified in Child Abuse Pediatrics, and the CHAMP Program Manager
    Howard Dubowitz, MD, MS, Director
    Leena Dev, MD                                              
    Mitchell Goldstein, MD, MBA
    Pamela Holtzinger, MA, FNE-P                      
    Scott Krugman, MD, MS                                      
    Wendy Lane, MD, MPH
    Charles Shubin, MD
    Evelyn Shukat, MD
     
    CHAMP Providers
    Physicians and nurses working in private practices and hospital emergency departments across Maryland commit a portion of their time to the CHAMP program and the evaluation of children alleged to have been maltreated.
    Roles
    • Provide expert medical evaluations of children who may have been maltreated
    • Provide consultation to Child Protective Services (CPS), law enforcement, state's attorney's offices, pediatricians and other professionals
    • Provide training in the area of child maltreatment to community professionals
    • Participate in multidisciplinary teams, assisting in a collaborative response to suspected child maltreatment
    • Participate in CHAMP network activities 

     

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    2.  Defining Child Maltreatment (Family Law Article § 5-701)
    There are both civil and criminal laws. Civil (Family) laws are to protect children; criminal laws are to punish wrongdoing and ensure justice.
    Abuse:
    • Physical or mental injury of a child, or
    • Child was harmed or at substantial risk of being harmed, or
    • Sexual abuse of a child, whether or not there are injuries
    • An act perpetrated by a parent or person responsible for supervision of child, person who is responsible for care and
    • Custody of child, or by household or family member
     
    Child: person under age 18
     

    Mental Injury:

    • Observable, identifiable, and substantial impairment of a child’s mental or psychological ability to function
    • By a parent or person responsible for supervision of child…

    Examples include: terrorizing, scapegoating, isolating for long period

    Neglect:

    • Leaving child unattended or failing to give proper care and attention to a child
    • By a parent, person responsible for supervision of child, person who is responsible for care and custody of child, under circumstances that indicate:
      o    Child’s welfare is harmed or at substantial risk of harm
    • Mental injury to the child or substantial risk of injury

    Examples include: exposure to dangerous people or environment, pattern of inadequate access to food, clothing, and/or shelter

    Sexual Abuse:

    • Any act involving sexual molestation or exploitation of a child
    • Act perpetrated by a parent, person responsible for supervision of child, person who is responsible for care and custody of child, or by household or family member
    • Touching need not occur to be considered sexual abuse
    • Examples include: incest, exposure to pornography

    NOTE: 

    “Abuse” perpetrated by those other than family or household members or those responsible for supervising a child is considered “assault” in Maryland.

     

    3.  Primary Care Provider Roles in Recognizing and Responding to Possible Child Maltreatment (CM)
     
    Screening Prevention  Identification  Treatment  Advocacy
     
    Primary Care Providers (PCPs) typically have good relationships with families and are, therefore, well positioned to know about a child’s home and family environment, offer support and promote children’s health, development and safety.
    Screening and Prevention
    As part of the social history during well-child checks, PCPs can screen for major risk factors for CM, such as parental depression and substance abuse. For more information, visit the Safe Environment for Every Kid (SEEK) project

    Identification

    Treatment

    • PCPs help address medical needs; they are also important in facilitating mental health care and other services for the child and family
    • PCPs are mandated by law to report suspected CM to Child Protective Services (CPS) or law enforcement

    Advocacy

    • PCPs can play a valuable role advocating for the child and family with CPS, other professionals, and, occasionally, in court
    • PCPs can also play a valuable role advocating for policies and programs that support families – at the local and state levels
       
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    Mandated Reporting
    Any person who has reason to believe that a child has been abused or neglected, shall notify Child Protective Services (CPS) or the appropriate law enforcement agency. (adapted from Family Law Article § 5-704)
    Degree of Certainty
    You do not need to be certain that abuse or neglect occurred. Reporting is based on a “reasonable suspicion.” For civil proceedings, the threshold is the preponderance of evidence (i.e., 51% or greater likelihood).  In criminal proceedings, the threshold is “with reasonable medical certainty” or ”beyond reasonable doubt”.
    Statute of Limitations
    There is no statute of limitations in Maryland. This means one should report child abuse and neglect, regardless of when it occurred, even if the alleged victim is now an adult.
    Immunity of Person Making the Report
    There is both civil and criminal immunity for those reporting CM in good faith. This does not mean that one cannot be sued. The suit, however, should be quickly dismissed. 
    Providing Medical Records to CPS
    You must provide pertinent medical records to CPS, if requested as part of their investigation. You can use judgment as to which parts of the record are pertinent. You do not need parental consent to do so.
    Potential Penalties for Not Reporting
    • Malpractice suit
    • Licensing penalties, such as disciplinary action or license revocation
    • Criminal actions are possible although uncommon
      •  
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    The History – Red Flags
    • Unexplained injury
    • Changing histories
    • History does not plausibly explain the injury
    • History does not fit the child’s developmental abilities
    • Delay in seeking care
    • Blaming another child for the injury
    • Child describes abuse
    Bruises
    • In non-ambulatory pre-cruising infants
    • Patterned (eg, belt mark, pairs of bruises from being grabbed)
    • In unusual places (eg, genital area, under neck, inner aspect of arms)
    • Multiple
    • Of varying ages, although it is difficult to age bruises
    Burns
    • Absence of splash marks (for liquid burns)
    • Sharp margins demarcating burned from healthy skin
    • Denial that lesion is a burn
    • Symmetry - glove or sock distribution
    Abusive Head Trauma – usually in infants
    • Lethargy
    • Poor feeding
    • Vomiting
    • Bruising
    • Signs of head trauma – bruising, lacerations, swelling, full fontanelle
    NOTES:
    The above are common manifestations of physical abuse. Almost any physical injury may be the result of abuse. Of note, serious head and abdominal trauma can occur without external injury.
    Children’s behavior may change significantly when they have been abused (e.g., aggressiveness, sleeping/eating, moodiness, or school performance). Behavior problems MAY reflect distress related to abuse. Sometimes this is the only indicator that abuse has occurred. While such behavior changes are not specific for abuse, this POSSIBILITY should be considered.
     
     
    • Child reports abuse
    • Abuse witnessed by others
    • Physical signs
    • Injury
      • Acute: bleeding, bruising, tear
      • Old (or chronic): hymenal transection (little or no hymen posteriorly 3-9 o’clock), scar
    • Infection: genital discharge, rash, warts
    • Pregnancy
    • Inappropriate sexualized behavior
      • Child sexually abuses another child
      • Child uses sexually explicit language
      • Child behaves in sexualized manner outside of developmental norm
    • Other behavior problems
    • Eating, sleeping, withdrawal, aggression
    • Sexual Abuse Includes...

    Deliberately exposing a child to sexual behavior or materials

    Sexual touching or fondling

    Voyeurism

    Incest, rape, sodomy

    Penetration of genital area, anus or mouth, regardless of how deeply, other than for routine care (eg, brushing teeth, changing diaper)

    NOTES:

    Typically, there are no physical findings. In”acute” situations, about 5% of girls have findings. The rate is far lower in “chronic/old” situations.

    Inappropriately sexualized behavior in children may be due to several reasons, including sexual abuse, exposure to sexual activity or sexually explicit materials. However, such exposure may also be inadvertent (e.g. child walking into parents’ room during sexual activity) or neglectful (e.g. adult watches sexually explicit material without regard to possibility that child may see).

    Children’s behavior may change significantly (e.g., sleeping/eating, moodiness, or school performance). This behavior change MAY reflect distress related to sexual abuse. Sometimes this is the only indicator of abuse. While such behavior changes are not specific for sexual abuse, this POSSIBILITY should be assessed.

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     Neglect...
    • Occurs when a child’s basic needs are not adequately met, resulting in actual or potential harm
    • Neglect is usually inferred when there is a pattern of inadequate care, rather than an isolated incident
    • CPS generally only become involved when neglect results primarily from parental or caregiver omissions in care
    Inadequate physical care (e.g., inappropriate clothing for the weather, no heat in house, not bathed, not properly groomed, growth problems)
    Inadequate medical or mental health or dental care (e.g., not receiving needed medication, resulting in actual or potential harm)
    Inadequate supervision (e.g., child under age 8 left alone, ingestions)
    Inadequate emotional care (e.g., pattern of care that does not meet a child’s emotional needs, disengaged parent, limited response to a child’s cues such as seeking comfort)
     
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    What children say is very important when concerns about possible child maltreatment arise. Children’s words are often more useful than the exam. And, children deserve to be heard.
    Your role is NOT to conduct a comprehensive forensic interview. Rather, it is a triage role to ascertain whether there’s enough concern to justify a CPS report and assess how you may help the child and family. And, please remember to inform the child of what may happen next.
     
    Basic pointers for a limited interview
    • Try to talk with child alone, in a quiet private place
    • Away from parents. Explain: “this is how we normally do this.
    • If child (or parent) won’t separate: have parent seated next to child, not facing him or her
    • Sit at same level, consider your tone, language, body posture
    • First, establish rapport
    • Talk about child’s friends, favorite games, school
    • Begin with open-ended questions: “tell me about your friends”
    • Helping child feel comfortable helps the child disclose sensitive information
    • Clarify why the child is being seen
    • “Sometimes adults or other kids touch kids in ways that are not OK.”
    • “I see lots of kids who were touched in ways that are not OK - by other kids or grownups.”
    • “We need to see if something may have happened to you.”  “If it did, we’ll try to help.”
    • Could ask child, “Tell me why you came to see me today?”
    • Continue with open-ended questions
    • “Please tell me what happened.'
    • “What happened next?”
    • “Tell me about that.”
    • Avoid leading questions
    • “Did your uncle hurt you down there?”
    • “So, your uncle hurt you down there?”
    • Don’t interrupt child telling his/her story
    • Praise child for talking with you
    • “It’s hard to talk about stuff like that. Thank you for helping.”
    • If child reports abuse, praise for speaking up  “This is hard, and you’ve been brave.”
    • Don’t react over emotionally to the child’s report
    • Be empathetic, gentle
    • Use active listening; show the child they are really being heard
    • Demonstrate sincere concern and compassion, but not horror
    • Tell child you will help try to keep him/her safe, without promising anything
    • Provide child with as much information as you can about what will happen
    • “Someone from the Department of Social Services will want to talk with you and your family. And, probably a police officer too. It’s best if you just tell them what happened.”
    Afterwards…
    Document carefully the history, exam findings and actions taken. For critical parts pertaining to the alleged abuse, it’s best to document the question and the exact response in quotes.
     
    Follow up with the family. These situations are invariably difficult and a follow-up visit is recommended. There is often a need to facilitate mental health care for the child and perhaps other family members. It is also recommended to assess whether other children in the home may have been abused.
     
     
     

      
     
    • Find quiet, private place to talk
    • Sit at same level
    • Non-verbal cues are important
    • Don’t cross arms
    • Make eye contact
    • Focus on shared concern for safety of child
    • Don’t accuse parents
    • Explain your concern based on the information
    • Convey your interest and responsibility to ensure the child is safe, and to help the family
    • ”CPS is responsible for evaluating what happened to your child. If help is needed, they have useful services for families and kids.”
    • May mention your legal obligation to report
    • Explain what may happen next
    • “Someone from the Department of Social Services will want to talk with you and your family. And, probably a police officer too. It’s best if you work with them, answering their questions honestly.”
    • Recommend that parents cooperate with CPS and law enforcement
    • Recommend that parents be supportive of their child, pointing out how difficult this is for most children
     
     
     

     
    The proverbial gray zone is large; you may be unsure whether a child was abused or neglected. Consulting with a child maltreatment medical expert can be very helpful, guiding you in how to assess and address the situation.
    Below is a partial list of circumstances that may benefit from referring a patient for an expert medical evaluation. Additional information can be found at: http://mdchamp.org/resources/referral-guidelines.
    Child Maltreatment Medical Consultation – Referral Guidelines
    These guidelines are intended to assist in deciding when to seek medical consultation for suspected child abuse and neglect. They serve only as guidelines and careful judgment is needed in every situation.
     
    SEXUAL ABUSE/ASSAULT
    If there is suspicion that a child has been sexually abused or assaulted with direct physical contact, an evaluation by a child abuse medical specialist is recommended.
    Urgent evaluations: In the following situationsthe child should be evaluated immediately. 
    • The last suspected abuse or assault occurred recently (within past 72 hours for children under age 13 or within past 120 hours for those age 13 and over)
    • The child is reporting genital/anal pain or bleeding
    • The child is exhibiting significant mental health concerns (e.g., self-harm, suicidal ideation)
    The urgent medical evaluation should include consideration of the possible need to gather forensic evidence. The evaluation should be done at the closest center with experience in evaluating acutely sexually abused/assaulted children.
    Non-urgent evaluations: outside of the above time frames or serious conditions, evaluations should occur by a medical professional with expertise in child maltreatment in a child friendly environment. Typically, this is the local child advocacy center. The timing for these evaluations should be the next available appointment.
    Sexual abuse/assault evaluation center locations can be found at: http://mdchamp.org/resources/locating-champ-providers.
    PHYSICAL ABUSE
    A child’s medical and mental health status may demand an immediate medical evaluation.  In addition, there may be forensic reasons to gather evidence as soon as possible. 
    Urgent evaluationsIn the following situationsthe child should be evaluated immediately: 
    Any indication of physical injury and suspected child abuse should be evaluated immediately at the nearest emergency department. Below is a partial list of such conditions:
    • Any sign of a possible head injury (e.g., external injury to the head/face, lethargy, irritability, change in consciousness, difficulty walking or talking)
    • Recent burns
    • Possible broken bones
    • Abdominal pain, abdominal bruising, or other reason to suspect abdominal trauma
    • Recent ingestion of a toxic or illicit substance
    Non-urgent evaluations: In the following situationsthe child should be evaluated within 48 hours, preferably by a child abuse medical expert*: 
    • Any bruising in an infant who cannot “cruise” (walk holding onto objects)
    • A concerning or absent explanation for an injury
    • Patterned bruise (e.g., loop marks)
    • Any other suspicious bruise(s)
    • Healing burns
    *If unable to refer directly to a child abuse medical expert, a physician with expertise in evaluating suspected child abuse and neglect, photographs should be obtained for later review. Information on locating child abuse medical experts in Maryland is located at: http://mdchamp.org/resources/locating-champ-providers.
    CHILD NEGLECT
    There are many circumstances when the evaluation and management of child neglect can be enhanced with medical consultation by a physician specialist in child abuse and neglect.
    Unless a child demonstrates an altered mental status or a clearly urgent medical condition, the evaluation by a physician expert is usually not urgent. The following are circumstances for which expert medical consultation is recommended:
    • CPS report for medical neglect (e.g., failure/delay to seek medical care, failure to adhere to recommendations for evaluation or treatment)
    • Neglect in children with a chronic disease or condition
    • Neglect in children with a disability or mental health problem
    • Supervisory neglect related to injuries, ingestions, fatalities
    • Growth concerns – e.g. failure to thrive, severe obesity
    • Concerns of dental neglect

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    It can be difficult to decide whether a situation should be reported to CPS. Remember, one need not be sure that abuse or neglect occurred. Reports are to be made based on “reasonable suspicion”.
    1. Fill out written report (and/or state approved child abuse reporting form, “180 form”)
    2. Call CPS Reporting Hotline
      As soon as possible, call the Hotline in the jurisdiction where you suspect the abuse occurred. A list of all Maryland CPS hotline numbers is found here: http://www.dhr.state.md.us/blog/?page_id=4631
    3. Provide CPS with as much information as possible
      ·        Name and address of child
      ·        Name and address of parent/caregiver
      ·        Where the suspected abuse or neglect occurred
      ·        Description of suspected maltreatment
      ·        Why you suspect abuse or neglect
      ·        Current safety/health status of child
    4. Send written report (and/or 180 form), within 48 hours, to CPS where report was made
    5. Document what you did in child’s medical record
    6. Follow up with the family
    7. Ask CPS to inform you of outcome as you anticipate providing ongoing care to the child(ren)
     
    NOTES:
    CPS can provide families with needed services. It is optimal if you work with CPS to help ensure children’s health and safety.
    When needing to make a report of suspected abuse or neglect to an out-of-state jurisdiction, the report should be made in the jurisdiction where you suspect the maltreatment occurred. You can call the national child abuse reporting hotline: 1-800-4-A-CHILD to get assistance with out-of-state reports.
     
     

     
    The CHAMP network is comprised of medical professionals (physicians and nurses), expert in the area of child maltreatment.
    CHAMP's goal is to help develop medical expertise related to child maltreatment in every Maryland jurisdiction. This is a valuable resource for evaluating suspected abuse or neglect in children, providing consultation and training to community professionals, and for engaging in prevention activities.
    Childhelp.org: 1-800-4-A-CHILD
    You can talk with a counselor and get the phone number of your local hotline at 1-800-4-A-CHILD. You can also find information about prevention, intervention and treatment resources for children who have been abused, neglected or are at risk.
    Maryland Department of Human ResourcesThe Maryland Department of Human Resources has information about foster care and adoptions, food and energy assistance, child support, mental health and numerous other programs.
    Maryland Network Against Domestic Violence – Call 1-800-799-SAFE (1-800-799-7233) 24 hours a day and they will direct you to local resources in your community.
    Maryland Association of Core Service Agencies: http://www.marylandbehavioralhealth.org
    MCASA is a non-profit comprised of 19 core service agencies in Maryland. The Core Service Agencies plan, develop, and manage many treatment and rehabilitation mental health services across Maryland. The MCASA Directory provides contact information to access Core Service Agencies in individual counties, who can then connect individuals to local mental health service resources.
    National Childhood Traumatic Stress Network
    http://www.nctsnet.org/
    The mission of the National Childhood Traumatic Stress Network is to raise the standard and improve access to care for traumatized children. Access the NCTSNET to find resources for helping children who have been traumatized.