Introduction to the Child Abuse Response Team (CART) & Medical Findings in Child Abuse

1. Introduction to the Child Abuse Response Team (CART)&Medical Findings in Child Abuse Leslie Strickler, DO FAAP University of New Mexico Children’s Hospital

2. What is CART? • A multidisciplinary team of professionals who provide forensically based consultative services to healthcare providers caring for children who are suspected victims of child abuse and or neglect in the state of New Mexico.

3. CART Objectives • To provide a uniform, evidence-based approach to the diagnosis and management of children who are suspected victims of abuse and neglect.

4. Who is CART? • Co-directors • Dr. Karen Campbell & Dr. Leslie Strickler • Dr. Peter Loomis, forensic odontologist • Jocelyn Ruebel, nurse coordinator • Misty Sanders, MSW • Rebecca Marianetti, LISW • Bridget Ward, LISW

5. When Do I Need CART? • CART consultation should be requested when a child presents to care with injuries causing concern for physical abuse or a situation that is worrisome for neglect.

6. How Do I Request Consultation? • Outpatient consultative service is offered Monday through Friday 9AM-5PM via the Nurse Coordinator: Jocelyn Ruebel • Office number: 272-1898 • Pager 951-2509 (preferred means of contact) • Attending on call may be directly reached through UNM PALS: 272-2000

7. After Hours • For patients seen after hours, contact the CART message line: 925-4495 • Indicate patient name, DOB, brief HPI, and follow-up needs. Indicate whether CYFD and/or law enforcement is involved and any appropriate contact information.

8. Consultation for Evaluation of Possible Sexual Abuse • Determine on-call provider through PALS • Pediatric Sexual Abuse team – Para los Ninos • Immediate consultation typically indicated if alleged assault has occurred < 72 hours prior to presentation to care • For more remote allegations, patients are referred to Para los Ninos Clinic as outpatient • 272-6849 to schedule • CART consult is not necessary for allegations of sexual abuse only

9. Responsibilities of Referring Physician • Report to CYFD • To report child abuse in Albuquerque: 841-6100 • To report Child Abuse Statewide: Statewide Central Intake (SCI) 1-800-797-3260

10. Responsibilities of Referring Physician • Suspected abuse or neglect on tribal land • Report to Appropriate Department of Tribal Social Services • Report to CYFD if necessary for courtesy coverage

11. Responsibilities of Referring Physician • Report to appropriate law enforcement agency immediately if evidence collection may be necessary • Albuquerque Police Department: 242-COPS • Bernalillo County Sherriff: 867-2304 • Alternatively, confirm that CYFD has cross reported to law enforcement

12. Reporting Violation • Misdemeanor • Imprisonment up to one year and/or fine up to $1000

13. Documentation of Reporting • Record in medical record time, date, contact person, agency name, and description of any correspondence.

14. CAN Report Form

16. PART B Indicate all scars, bruises, burns, cuts, scrapes, birthmarks, etc. Measure in Inches.

18. How Do I Know it’s Abuse?

19. By New Mexico Definition… • An abused child is one who is at risk of suffering serious harm because of the action or inaction of a parent, guardian, or custodian • Including physical, emotional, psychological, or sexual abuse

20. Physical Abuse • Any case in which a child exhibits evidence of skin bruising, bleeding, malnutrition, failure to thrive, burns, bone fractures, subdural hematoma, soft tissue swelling, or death

21. Physical Abuse • AND • There is no justifiable explanation for the condition or death • The explanation given is inconsistent with the degree or nature of the condition/death • Circumstances indicate that the condition/death may not be the result of an accident

22. poverty substance abuse single parenthood young maternal age social isolation parental psychiatric illness parental history of child abuse other domestic violence male gender young age chronic illness congenital anomalies prematurity Risk Factors

23. Diagnosis • History • No history of trauma • History inconsistent with injuries • Changes in reported history • History of self-inflicted trauma not consistent with developmental ability • History of trauma inflicted by another child inconsistent with developmental capabilities

24. Diagnosis • Red Flags • Delay in seeking medical care • Multiple organ systems injured, including injuries of various ages • Injuries highly specific for child abuse

25. Documenting the History and Physical • Location, time, and mechanism of injuries described • Denial of trauma • Timeline between injury and presentation to medical care

26. Documenting the History and Physical • Who was present? • caregiver • other household member(s) and household composition • Chaperoned interview of child without caregiver present, if applicable, by forensic interviewer • Can also be helpful to perform forensic interviews of other verbal children in the household

27. The History and Physical • Thorough physical exam • Measurements (English, not metric) of bruises, burns, and scars • description of size, shape, location, and color • High quality photographs as adjunct

28. Bruising • most common injury identified in cases of abuse • involvement of extremities, bony prominence is often normal • Concerning bruises • central location (buttocks, abdomen, chest) • non-ambulatory infant • bruise in the pattern of an object

29. Bruising • Dating – NOT Recommended • resolution varies with location, depth, severity, skin tone, vascularity, patient age • Medical conditions with associated “bruising” • HSP, ITP, Vitamin K deficiency, hemophilia, Mongolian spots

30. HSP Mongolian Spots Bruising Mimics

31. Inflicted Bruising

32. Inflicted bruising

33. Inflicted Bruising

34. Inflicted Bruising

35. Inflicted Bruising

36. Inflicted Bruising

37. Inflicted Bruising: spanking

38. Patterned bruising: open hand slap

39. Patterned Bruising: Belt Buckle

40. Patterned Bruising: Belt Buckle

41. Patterned Bruising

42. Patterned Bruising

43. Patterned Bruising

44. Bites • circular or oval patterned injury that consists of opposing symmetrical arches separated at their bases by open spaces

45. Human Bite

46. Evaluation of Bruising/Bites • CBC • Coagulation studies • Hematology consultation as indicated • detailed description, illustration, photographs

47. Burns • 10-25% of pediatric burns are abusive • hot solid objects (irons, curling irons, radiators, cigarettes), caustic materials, flames, hot liquids, scalding tap water

48. Contact Burn

49. Contact Burn

50. Abusive Immersion Burns • Often associated with soiling (vomiting, incontinence) that requires cleaning the child. • Areas submerged are burned with clear lines of demarcation, whereas areas above the water line are spared • Simultaneous burning of buttocks, perineum, and both feet are highly specific for abuse