1 Signs of Maltreatment: Dynamics of Physical Abuse, Sexual Abuse & NeglectWelcome/Introductions Today we are going to cover a lot of important material about the dynamics of abuse and neglect. It is important for you to assess for signs of maltreatment at any point in the life of a case. If you identify maltreatment, you must take efforts to ensure child safety. Today we are going to learn the legal definitions of abuse and neglect, we will take a look at incidences of abuse/neglect both in Washington State and Nationwide, and we will identify tools to help you assess for, identify, and address child abuse/neglect. We are going to cover a lot of information for the bulk of the day. We will end our day with a Guest Speaker [local Medical Consultant]. They will have a brief presentation about the role of a Medical Consultant as well as a question/answer session. Tomorrow we will finish up our work around the Dynamics of Abuse and Neglect as we cover the Effects of Abuse and Neglect on Child Development. Tomorrow you will have some opportunities to practice assessing for maltreatment and planning for the effects on child development.

2 Purpose of this TrainingSigns of Maltreatment Tools to identify and determine: If a child has been abused or neglected (CPS Investigations) The risk of future abuse or neglect If a child is safe, or, Planning to ensure safety Purpose of this Training When you are assigned cases in the Children’s Administration, you will be asked to determine if: A child has been abused or neglected (CPS Investigations) What the risk is of future abuse or neglect Whether a child is safe in their family’s home, and If a child is not safe, what planning is needed to ensure the child’s safety in the future. These are separate, but related issues. In this training, you will get some of the tools needed to identify child maltreatment. Discussion of risk and safety will occur later in Regional Core Training (RCT).

3 Signs of Maltreatment: Credits and competenciesProvide basic information to help understand: The scope and types of maltreatment The differences between poverty, homelessness, substandard conditions and neglect The recognition of child maltreatment is important in your assessments throughout all programs in the Children’s Administration. It is a necessary part of our ongoing assessments of families, from intake throughout permanency planning. Competencies Content on Signs of Child Maltreatment is adapted from content created by the Harborview Center for Sexual Assault and Traumatic Stress Credits Competencies: Provide basic information to help understand: The scope and types of maltreatment The differences between poverty, homelessness, substandard conditions and neglect The recognition of child maltreatment is important in your assessments throughout all programs in the Children’s Administration. It is a necessary part of our ongoing assessments of families, from intake throughout permanency planning. Credits: Content on Signs of Child Maltreatment is adapted from content created by the Harborview Center for Sexual Assault and Traumatic Stress

4 This training has a lot of examples to help you build understanding.Key Takeaways This training has a lot of information. … but these are the key takeaways: If you see what might be physical signs of abuse or neglect (such as a bruise), consult with a medical expert. Understand the definitions and signs of: Physical abuse Sexual abuse Neglect Understanding what is NOT a sign of abuse or neglect. This training has a lot of examples to help you build understanding. This training has a lot of information in it. It might seem overwhelming. But to keep it organized in your mind, remember these key takeaways: If you see what might be physical signs of abuse or neglect (such as a bruise), consult with a medical expert. This training has information on how to get appropriate medical consultation. Understand the definitions of physical abuse, sexual abuse, and neglect. This training has a lot of examples to help you build understanding of what each can look like. Finally, you need to understand what is NOT a sign of abuse or neglect.

6 Section 1: Definitions and Incidence of Child Maltreatment

7 Federal Definition of Child MaltreatmentAny 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. (42 U.S.C.A. § 5106g) The federal government has a broad definition for child maltreatment: "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."

8 The scope of child abuse nationallyFourth National Incidence Study The scope of child abuse nationally Good news: Both physical abuse and sexual abuse have decreased since the prior National Incidence Study. Bad news: In the study year , 1,256,600 children experienced maltreatment. This is one child out of 58 in the US. The National Incidence Study provides information about the scope of child abuse and neglect nationally. It uses data from a variety of sources in multiple carefully selected sites across the country to create an extremely large and robust data set, and is updated every decade. To learn more about the study, which is funded through the federal government, click on the link. The most recent NIS data was collected in 2005 and 2006. The good news is that the NIS 4 showed a decrease in abuse, both sexual and physical, over the previous decade. Though less physical abuse was reported, there has been an increase in admissions to hospitals for abuse-related injuries including head trauma. Some have suggested that this increase is due to better medical diagnosis of child abuse rather than a real increase in significant harm to children. There was no statistical difference in neglect. Despite the decrease in abuse, the overall incidence of child maltreatment remains high. One out of every 58 children in the United States is abused or neglected.

9 This graph provides a breakdown of the data from the NIS-4 by maltreatment type.Note that the percentages add to more than 100%. Can you think of why that is? That’s right, some children experience multiple maltreatment types.

10 1258 Child Fatalities in 2011 in 45 StatesNumber Percent Medical Neglect 96 7.6 Neglect 895 71.1 Other 277 22 Physical Abuse 602 47.9 Psychological Abuse 24 1.9 Sexual Abuse 9 0.07 Total 1903 150.57 This chart shows the percent of child deaths by maltreatment type. Because more than one form of maltreatment was involved in many of these incidents, the total adds to more than 100%. Note that the majority of child deaths from maltreatment are related to neglect, though a large percent also involve physical abuse. Though not depicted in this chart, the vast majority – over 80% - of child fatalities occur to children under the age of 4, with nearly half of those being children under the age of 1. Child Maltreatment 2011, US Department of Health and Human Services Administration for Children and Families

11 Statistical Review 2011 The Children’s Bureau completed a very thorough review of child maltreatment statistics nationally for https://www.acf.hhs.gov/sites/default/files/cb/cm11.pdf For those of you who have interest in statistics, a very thorough review of national child abuse and neglect statistics was completed by the Children’s Bureau. This is a link to that report.

12 Washington Definitions of Abuse and NeglectApproximate Percentages of Reports, by Abuse Type Here’s some information about the prevalence of maltreatment by type in Washington state, based on reports to CA’s intake line: About 27% of children are reported for physical abuse. About 5 % of children are reported for sexual abuse. This reflects, in part, our state’s classification of third party sex abuse as neglect. In other words, we accept intakes that allege sexual abuse by someone other than a parent or caregiver as allegations that the parent or caregiver may be negligent in not protecting the child from the sexually abusive third party. This difference makes our states statistics related to sexual abuse look very different than the NIS statistics. About 63% of children are reported for neglect. In our state, this includes physical neglect, medical neglect and occasionally emotional neglect. Washington state does not accept calls about educational neglect only, as there are other systems in place to address these in our state. Intakes related to potential immediate harm are not counted as any of these intake types in our state, but classified as CPS risk only intakes.

13 Washington Definitions of Abuse and NeglectRCW 26.44 statutes concerning child maltreatment. RCW defines child maltreatment. Washington Administrative Code (WAC) Definitions of abuse and neglect “Child” is defined as a person under 18 years of age. Provides the basis for… You will work with the definitions of child abuse and neglect included in the Washington Administrative Code. Thus, CPS does not intervene in families where a child has not yet been born or where the alleged victim is over the age of 18, unless the allegation indicates a child in the family may be at risk of serious harm at the time.

14 Incidence of Child Abuse and Neglect in Washington State (Fiscal Year 2011)1,550,000 children in Washington State… 77,882 reports of CAN 37,992 screened in intakes 4,677 dependency cases filed In 2011, 1.55 million children resided in Washington State. That same year, Children’s Administration Intake received almost 78,000 reports of child maltreatment. almost 38,000 reports were screened in. 4,677 dependency petitions were filed. That’s about 12% of all accepted intakes.

15 Disproportionality: All Intakes https://www. dshs. waDisproportionality: Over representation of African American and Native American children in all stages of Children’s Administration’s involvement with families. The link above is to an excellent report on the efforts of the Washington State child welfare system to reduce disproportionality in Washington. In child welfare, disproportionality most often refers to the over representation of African American and Native American children in all stages of Children’s Administration’s involvement with families. Let’s look at some of the data. 43 out of every thousand Caucasian children were reported to CPS in This compares to 64 multi-racial children, 76 African American children, and 96 Native American children of every one thousand living in Washington.

16 Disproportionality: Through the CW System (2012) https://www. dshs. waNow let’s look at African American and Native American children’s experiences in the Child Welfare System compared to White children. We are going to display this as a comparison ratio. For example, African American children are 1.52 times and Native American children are 1.57 times as likely as white children to be in placement for more than two years. As we can see, disproportionality persists through the child welfare system for African American and Native American children.

17 Disproportionality: What is CA Doing?In other trainings, you’ll learn about your role in reducing disproportionality. To find out what CA is doing to decrease disproportionality, click here. In other trainings, you’ll learn about your role in reducing disproportionality. To find out what CA is doing to decrease disproportionality, click the link you see here.

18 Which of these statements is true?Most intakes to CPS involve physical abuse allegations B) Most deaths related to abuse or neglect occur before a child's third birthday C) Native American children are more frequently referred to CPS and remain in out of home placement longer than any other group of children. Let’s read through these statements, call out which of these statements you think are true.

19 Let’s Check Our UnderstandingMost intakes to CPS involve physical abuse allegations The first statement is false - Most CPS intakes involve neglect allegations. Native American children are more frequently referred to CPS and remain in out of home placement longer than any other group of children The third statement is True. Most deaths related to abuse or neglect occur before a child's third birthday The second statement is True.

20 Section 2: Physical Abuse27% of intakes have a physical abuse allegation in Washington State 18% of intakes nationally are for Physical Abuse Before you proceed to learn more about physical abuse, click to the next slide to learn about the pre-quiz.

21 Pre-Quiz: Indicators of Physical AbuseWork in table groups Report back to the group Pre-quiz 20 minutes We are going to take 20 minutes for you to work at your table groups to complete this pre-quiz on the indicators of physical abuse. Before we dive into the physical abuse section, we will report back to the group and go over the correct answers. Trainers Note: Allow minutes for this activity, 20 minutes for table groups to complete the quiz and minutes to review correct answers. Any answers that have significant disagreement or additional questions can be noted on flip chart paper and addressed as they come up in this section.

22 Physical Abuse Is: The non-accidental infliction of injury to a child.It can include: Striking a child with a closed fist Shaking, interfering with breathing, or threatening a child Any action that is likely to cause harm greater than transient pain or minor temporary marks Physical abuse is the nonaccidental infliction of injury to a child. It can include striking a child with a closed fist, shaking, interfering with breathing, or threatening a child. It includes any action that is likely to cause harm greater than transient pain or minor temporary marks. For example, if a caregiver strikes a child in the belly with his or her fist with force, whether or not injuries are detected, this is considered to be abuse. The action was likely to cause bodily harm, whether or not that was the intention of the caregiver. Likewise, a caregiver who chokes a child, whether or not marks are left, is considered to have abused a child as he or she interfered with a child’s breathing. On the other hand, a parent that strikes a child with an open hand, such as in a spanking, and leaves a transient red mark that does not result in bruising, would not be considered to have abused the child. WAC (1)

23 Physical Signs of Physical Abuse Include:Unexplained burns, bites, bruises, broken bones or black eyes Fading bruises, especially after a child has been isolated from mandated reporters A pattern of injuries, especially if the caregiver has sought attention for injuries from different medical providers Most signs of physical abuse do include identifiable injuries as it is these injuries that are noticed and reported to intake. These may include unexplained burns, bites, bruises, broken bones or black eyes. Fading bruises, especially after a child has been isolated from mandated reporters, are also concerning. Clearly, accidents do happen. Many of us recall being accidentally burned or having severe falls as children, even with an adult closely supervising us. That is why it is important to compare the injury to the explanation of the parent as well as examining other evidence and reports, such as information from relatives, schools, and the children’s statements and behavior. Don’t look at injuries in isolation. A caregiver may have an explanation that is consistent with a cause for one injury, but there may be a pattern of injuries that is concerning. This is especially true if the caregiver has sought attention for injuries from different medical providers. For example, a child may have suffered a broken leg. The parent may explain that this was caused in a fall from a tree, and the doctor may say that the injury is consistent with the explanation. However, if records indicate that the child has suffered several other broken bones or injuries, the entire record of the child’s injuries should be examined to determine if there is a pattern of maltreatment. It takes a team to help protect children – a theme we will refer to often in your training. In looking at injuries, medical experts are a significant resource to help you determine if an injury is consistent with a parent’s explanation.

24 Example A CPS worker made a critical difference.The injury did not appear to be due to lack of supervision. There were no identified safety threats or major risk factors. The child had suffered a skull fracture. This had not been reported to CPS. The CPS worker let the hospital know of information that indicated the child had had other injuries related to allegations but that had also been considered consistent with explanations. The CPS worker consulted with the child abuse consultant. Together, they proceeded with a scan. Healing fractures were discovered in the child’s ribs, arms, and a leg. Here is an example of a case in which a CPS worker made a critical difference in protecting a child occurred when the social worker was looking into an allegation of neglect. Let’s listen to the CPS worker describe the situation. The injury the child suffered did not appear to be due to a lack of supervision and there were no identified safety threats or major risk factors. However, I found out that the child was in the hospital, and when I called found the child had suffered a skull fracture. This had not been reported to CPS in that the injury was considered to be consistent with the caregiver’s explanation that the child had fallen from her bike and hit her head on the curb. I let the hospital know of information that indicated the child had had other injuries related to allegations of lack of supervision and that these prior injuries had also been considered consistent with the explanations provided. Given the pattern of injury, I consulted with the child abuse consultant who had already reviewed the most recent injury. Together, we decided to proceed with a scan of the child. Healing fractures were discovered in the child’s ribs, arms and a leg. Without identifying this pattern of injury and conferring with the hospital, this child would not have been protected.

25 Behavioral Indicators of Physical Abuse Include:Parents offer an explanation that is not consistent with the injury. Parents offer conflicting reports, or explanations that change over time. Parents blame the child or justify discipline that has clearly caused injuries. Child seems frightened of parents, shrinks from adults, or states that the injury was non-accidental. There are behaviors which also should alert you to the possibility of physical abuse. We have already discussed that the parents might offer an explanation for the injury that is not consistent with the injury itself. You might also find that the parents offer conflicting reports or are unconvincing. Or their explanation for the child’s condition may change over time It may also be indicative of an abusive situation if parents describe the child in extremely negative terms, especially if they use harsh discipline. If parents blame the child or justify discipline that has clearly caused injuries, this presents a situation in which the abuse is more likely to recur. Finally, if the child seems frightened of the parents, shrinks from adults, or states that the injury was non-accidental, these signs are also indicative of physical abuse. Children who have been traumatized sometimes show signs of anxiety and hypervigilance. Even though you may not see these behaviors or the child may not disclose to you, the observations of these behaviors by collateral resources should be considered. We gather information from a number of sources and do not rely on children to tell others that their parents have abused them.

28 Physical Abuse Is Not: Consider:Physical discipline is not considered abusive, as long as nothing more than transient pain or minor temporary marks are left. Consider: The age and developmental level of the child The size of the child Any special conditions of the child The location of the injuries Physical discipline is still a legally acceptable means of discipline, and is used in many cultures and communities. Physical discipline is not considered abusive as long as nothing more than transient pain or minor temporary marks are left. You should consider the age and developmental level of the child, the size of the child, any special conditions of the child, and the location of the injuries. For example, disciplining an infant by spanking or slapping is of concern, even if marks are not left in a particular instant. Causing even transient pain to a child’s genitals is also a concern.

29 Small but Sentinel InjuriesSmall and medically insignificant Typically seen in infancy Often noted in a child’s medical record prior to a serious, sometimes fatal episode of abuse We are now going to review some specific injuries to which you should be alert. Sentinel injuries are small, medically insignificant injuries typically seen in infancy. They likely stem from abuse, but don’t raise red flags for medical providers not trained in their significance. Sentinel injuries are often are noted in a child’s medical record prior to a serious, sometimes fatal episode of abuse. Knowing what they are, and knowing to look for them, can help you save a child’s life. Let’s look at a few examples of sentinel injuries.

31 Of Special Concern/Sentinel InjuriesEars Face Neck Bottom Genitals Torso Note on this infant the marks are on the face and eye. Bruises on the ears, face, neck, bottom, genitals or torso of any child are concerning for abuse as these are areas of the body that are less likely to receive trauma through accidents. These injuries are especially concerning in infants and should be considered as sentinel injuries.

33 Of Special Concern/Sentinel InjuriesBruising over a variety of locations on the body Bruising in a pattern Sentinel injuries may also involve bruises over a variety of locations on the body or bruising in a pattern. Again, these are injuries that are rarely caused by normal accidental falls. Note that none of the sentinel injuries that we have shown you are life-threatening. However, they are also concerning for the age and vulnerability of the child, and because they often signal more significant injuries to come. Sentinel injuries are not life-threatening, but they often signal more significant injuries to come.

34 Abdominal Injuries Often involves an adult who delays seeking careAre witnessed Match the description Accidents Often involves an adult who delays seeking care Abuse Abdominal injuries include any injuries to the torso and the organs that are in the abdomen. They can and do result from accidents such as auto accidents, being hit by a car as a pedestrian, or a bike accident when hitting the handlebar. When such accidents occur, they are normally witnessed and the injuries clearly match the explanation. Abdominal injuries that result from abuse often involve an adult who delays seeking care for the child, fearing that the abuse will be discovered – or – because the adult who is seeking care does not know what the other caregiver has done. This delay in care can seriously complicate a child’s medical condition, and even lead to death. When you observe or are assessing any abdominal injury, it is critical to have the child medically evaluated to ensure that internal injury is ruled out or is attended to quickly.

35 Head Trauma Accidents Abuse Are often caused by falls.Rarely cause major head trauma. Abuse Is often caused by shaking or throwing child, or doing anything which causes child’s head to impact a hard surface. Increases when children are between two and six months – the normal peak of crying. Head trauma can also be accidental, such as from a fall out a window or a car accident. Injuries from falls often present differently than those caused by child abuse, and children who fall do not normally show other signs of abuse or have other injuries. An infant falling from less than 5 feet rarely has major head trauma. Abusive head trauma can result from shaking or throwing a baby or young child, or doing anything which causes the child’s head to have a major impact with a hard surface. There is an increase in frequency of head trauma when children are between the ages of two to six months. What else is happening with infants at this time of life? Right – this is the normal peak of crying. Inconsolable crying, called purple crying, can be especially trying for parents. When working with a family that has an infant, especially if that infant is between two and six months, it’s very important to be asking about how they are coping with inconsolable crying.

36 Section 3: Sexual Abuse and Sexual Exploitation5% of intakes have a sexual abuse allegation in Washington State 9% of intakes nationally are for sexual abuse

37 Pre-Quiz: Indicators of Sexual AbuseWork in table groups Report back to the group Pre-quiz 20 minutes We are going to take 20 minutes for you to work at your table groups to complete this pre-quiz on the indicators of sexual abuse. Before we dive into the sexual abuse section, we will report back to the group and go over the correct answers. Trainers Note: Allow minutes for this activity, 20 minutes for table groups to complete the quiz and minutes to review correct answers. Any answers that have significant disagreement or additional questions can be noted on flip chart paper and addressed as they come up in this section.

38 Sexual Abuse AllegationsCPS Perpetrator is parent or in loco parentis DLR CPS Facilities licensed by DSHS Law Enforcement Non-parent or caregiver CPS investigates allegations of child sexual abuse when the alleged perpetrator is a parent or someone acting in loco parentis. DLR CPS investigates those allegations in facilities, like day care centers and foster homes, that are licensed by DSHS. Law enforcement investigates these referrals in conjunction with the Children’s Administration and also are responsible for investigating sexual offenses when committed by someone other than a child’s parent or caregiver. Allegations range from sexual intercourse with a child to touching in a sexual manner. Note that sexual abuse allegations are assigned to CPS investigation units, not to Family Assessment Response. This is because of the need to coordinate with law enforcement and to ensure staff interviewing children have been trained in forensic interviewing. If a caregiver is aware of sexual offenses against their child and does not intervene to protect, that is considered negligent treatment or maltreatment. It does not fall under the classification of sexual abuse in Washington State. We’ll talk about that more in the next section. WAC (3)

39 Sexual Exploitation Is:“ ” Allowing or encouraging children to engage in prostitution or pornography Sexual exploitation is a bit different. It is allowing or encouraging children to engage in prostitution or pornography. Although infrequent, Children’s Administration has investigated instances when children are exploited by their caregivers for child pornography or prostitution. WAC (4)

40 The Laws Rape (RCW 9A.44.040; RCW 9A.44.060)Rape of a Child (RCW 9A ; RCW 9A ; RCW9A ) Incest (RCW 9A ) Indecent Liberties (RCW 9A ) Child Molestation (RCW 9A ; RCW9A ; RCW 9A ) Sexual Misconduct with a Minor (RCW 9A ; RCW 9A ) Public Indecency (RCW 9A ) Communication with a Minor for Immoral Purposes (RCW 9.68A.090) Sexual Exploitation of Children (RCW 9.68A.040) Note that the child abuse definition refers to sex crimes codified in the state statutes, the Revised Code of Washington. Above are listed the sex crimes that, if committed by the victim’s parent, one acting in loco parentis, or a licensed caregiver, are investigated by Children’s Administration as sexual abuse or sexual exploitation. Because law enforcement is also investigating these situations, coordination is critical.

41 “Consensual” Sex Is Illegal If:VICTIM ASSAILANT < 12 years old 24 month older 12 – 13 years old 36 months older 14 – 15 years old 48 months older 16 – 17 years old 60 months older, in a significant relationship, and abuses a supervisory position in that relationship < 18 years old Relative Sometimes the age of consent comes up when youth report that the sexual relationship is consensual. For the purposes of investigating child sexual abuse, consent by the child is not the issue we are looking at. We are looking at whether an alleged assailant is a parent or caregiver who is using their position to have sexual contact with the child or to sexually exploit a child.

42 Children’s Statements…each time an intake is received indicating sexual abuse …by people with specific training …the least amount of times and by the most qualified professional Forensic interviews are conducted Sexual abuse often comes to the attention of CPS because a child has made a statement about what is happening. Each time an intake is received indicating sexual abuse, a child will be interviewed about that allegation in a forensic interview. These interviews can only be conducted by people with specific training, and in some areas are not typically completed by CA workers. When concerns of sexual abuse arise, you will work with your supervisor, law enforcement, and other resources in your county to ensure the child is interviewed the least amount of times and by the most qualified professional.

43 Why Children Delay or Do Not TellFear that abuser may hurt child and/or family members Fear that child won’t be believed, will be blamed, or will get in trouble Worry that child’s parents will be upset Fear that reporting will disrupt the family Fear that child will be separated from their family Shame or embarrassment Conflicted loyalties Confusion Not knowing it is wrong It’s under the guise of “play” Previous experience with not being believed or not being helped Mistrust of the system or of “helpers” Culture of not going outside the family for help Grooming by offender When assessing a child’s safety and considering whether an allegation is true, you may be concerned because a child didn’t immediately report the abuse, told different things to different people, or reported the abuse and then recanted. It’s important to know that these are all very common among children who have been sexually abused. This slide presents the complex factors that influence children’s choices about what to tell, who to tell, and when to tell. When listening to a child’s disclosure, it is important to hear what they are saying and to not pass judgment on their possible motivations for saying it. This is not to say that children don’t lie – we know that they do sometimes. However, when children lie about sexual abuse, it is much, much more common for them to deny or not disclose sexual abuse that did occur, then for them to allege sexual abuse that did not occur.

44 Example An alert CPS social worker gathers evidence of sexual abuse.Family consisted of the mother, her boyfriend, and two girls ages 6 and 8. Mother was happy. Her boyfriend had a good job, was very attentive, and gave the girls nice presents. CPS social worker helped create better supervision plans. CPS social worker checked with boyfriend’s ex-wife and court records. There had been allegations of sexual abuse. CPS social worker interviewed each of the children at school and found sexual abuse. Let’s look at an example of the alertness of a CPS social worker in gathering evidence of sexual abuse. An intake was received for a family concerning lack of supervision. Listen to the CPS worker describe the rest. The family consisted of the mother, her boyfriend, and two girls ages six and eight. The mother was very happy with her new relationship. Her boyfriend had a good job, lifting the family out of poverty. He was also very attentive to the mother. The girls also reported that they liked the boyfriend and that he gave them nice presents. I worked with the family to create better supervision plans when the mother and her boyfriend went out. I also checked with the boyfriend’s ex-wife and older children and looked at family court records as part of her assessment of the adults in the home. I found that there had been allegations of his sexually abusing his children in his former family. Having been trained in the interviewing of children, I interviewed each of the children at school and found out that both had been sexually abused by the mother’s boyfriend. The social worker was then able to work with the mother to protect her children and to get them needed treatment. Without assessing all persons in the family home, the social worker would not have been able to partner with the mother by ensuring she had the needed information to protect her children. The mother also was able to identify changes in the children’s behaviors which appeared to dissipate following separation from her boyfriend.

45 Reporting Challenges for Young ChildrenHave developmental challenges in recalling events, providing contextual information, and communicating May give unclear and inconsistent statements Are susceptible to suggestion Often have difficulty expressing the difference between touch involving normal care and touching for sexual gratification Younger Children: Interviews of young children can be particularly challenging due to developmental challenges in recalling events, providing contextual information, and communicating. The younger the child, the more likely their statements are to be unclear and inconsistent, even when sexual abuse did occur. Young children are also much more susceptible to suggestion than are adults, which can have an impact on their statements, a particular risk when interviewed by someone who is not skilled in forensic interviewing. Finally, children often have difficulty expressing the difference between touch involving normal care (i.e., bathing) and touching for the sexual gratification of the perpetrator.

46 Physical Indicators of Sexual Abuse1. Sexually transmitted diseases and pregnancy: Are clear indicators, but unusual Are typical, but not specific to child sexual abuse 2. Chronic somatic complaints: 3. Medical exams Rarely “prove” sexual abuse Unlike physical abuse, there are rarely clear physical indicators of sexual abuse. Sexually transmitted diseases and pregnancy are clear indicators of sexual contact and are, thankfully, unusual. Chronic somatic complaints are much more typical, but of course are not specific to child sexual abuse. While medical exams aide in ruling out physical trauma and sexually transmitted diseases, it is important to remember that in situations where a child has been sexually abused, the medical exam will rarely include findings that “prove” sexual abuse has occurred. This is normal even when we know children have been sexually abused.

47 Behavioral Signs of Sexual Abuse in a Child Include:Age-inappropriate sexual behavior Sudden change in affect or behavior Behavioral problems at home, school, or with peers Sleep disturbances, e.g. nightmares or bedwetting Regressive behaviors, e.g. clinginess Withdrawal from normal activities and friends Emotion regulation problems, including self harm Increased anxiety or symptoms of depression Sexually provocative behavior or extreme modesty Behavioral signs of sexual abuse are more common than physical symptoms. However, many of the behavioral symptoms of sexual abuse are also indicators of many other issues, so care must be taken to understand the behavior in context. These include the signs listed here. Often, family members will say that they noticed something was “off” or “wrong” with the child prior to disclosure of sexual abuse, but that they did not know what caused the changes.

48 Sexual Exploration in Children Is Normal-When Is It a Problem?Signs of Abuse and Neglect Training for RCT Sexual Exploration in Children Is Normal-When Is It a Problem? Force Penetration Oral sex Continuation after told to stop Significant difference in ages Acts that include the following are concerning: We know that sexual exploration in children is normal, but certain activities are of concern. Acts that include force, penetration, oral sex, and/or that continue after the youth has been told to stop are concerning and intervention is needed. It is also not normal for children to engage in sexual exploration if there is a significant difference in their ages (two or more years for younger children).

49 Signs of Sexual Abuse in Parents’ Behavior Include:Signs of Abuse and Neglect Training for RCT Signs of Sexual Abuse in Parents’ Behavior Include: Overly protective of the child Secretive Isolating the child Jealous of family members Overly controlling Parents or caregivers may also have behaviors that raise concern for child sexual abuse. These include being overly protective of the child, especially when this limits the child’s contacts with other children or adults. Parents may be secretive, isolating of the child from others, and may display jealousy of family members. Sexual abusers may be overly controlling. Again, these behaviors raise concern, but do not prove that the parent is sexually abusing their child.

50 Be Aware: Behavioral IndicatorsWhen considering the behaviors of children or adults, try to be aware of your own biases and don’t presume abuse is occurring without information that supports that conclusion. Collateral information and consultation with important partners like medical and law enforcement specialists is essential in assessing child sexual abuse. When you work as a team with your supervisor and other specialists in your community, you make the best decisions. Be aware of your own biases and don’t presume. Collateral information and consultation with important partners like medical and law enforcement specialists is essential.

51 What Is Not Sexual AbuseNeither sexual abuse nor indicators of sexual abuse: Urinary tract infections, yeast vaginitis, or bacterial vaginosis Common curiosity in their bodies, or interest in touching their genitals and enjoying how that feels Parents, caregivers, and medical providers touching a child in a sexual or intimate part of their body to clean the child or provide medical treatment Urinary tract infections, yeast vaginitis, and bacterial vaginosis are not sexually transmitted and commonly occur in children who have not been sexually abused. Common curiosity in their bodies, including their genitals and in toileting is very normal in toddlers and preschoolers and is also not a sign of sexual abuse. As is interest in touching their genitals and enjoying how that feels. This typically subsides and responds to appropriate parental limit setting about when and where it can occur. None of this in and of itself an indicator of sexual abuse. In addition, parents, caregivers, and medical providers may need to touch a child in a sexual or intimate part of their body to clean the child or provide medical treatment. This is also not sexual abuse.

52 Section 4: Neglect 63% of intakes are for neglect in Washington StateThree-quarters of reports nationally concerned neglect

53 Pre-Quiz: Indicators of NeglectWork in table groups Report back to the group Pre-quiz 20 minutes We are going to take 20 minutes for you to work at your table groups to complete this pre-quiz on the indicators of neglect. Before we dive into the neglect section, we will report back to the group and go over the correct answers. Trainers Note: Allow minutes for this activity, 20 minutes for table groups to complete the quiz and minutes to review correct answers. Any answers that have significant disagreement or additional questions can be noted on flip chart paper and addressed as they come up in this section.

54 Neglect Is: WAC (5) Negligent treatment or maltreatment means an act or a failure to act, or the cumulative effects of a pattern of conduct, behavior, or inaction, on the part of a child's parent, legal custodian, guardian, or caregiver that shows a serious disregard of the consequences to the child of such magnitude that it creates a clear and present danger to the child's health, welfare, or safety. A child does not have to suffer actual damage or physical or emotional harm to be in circumstances which create a clear and present danger to the child's health, welfare, or safety. Negligent treatment or maltreatment includes, but is not limited, to: (a) Failure to provide adequate food, shelter, clothing, supervision, or health care necessary for a child's health, welfare, or safety. Poverty and/or homelessness do not constitute negligent treatment or maltreatment in and of themselves; (b) Actions, failures to act, or omissions that result in injury to or which create a substantial risk of injury to the physical, emotional, and/or cognitive development of a child; or (c) The cumulative effects of a pattern of conduct, behavior or inaction by a parent or guardian in providing for the physical, emotional and developmental needs of a child's, or the effects of chronic failure on the part of a parent or guardian to perform basic parental functions, obligations, and duties, when the result is to cause injury or create a substantial risk of injury to the physical, emotional, and/or cognitive development of a child. Child neglect is an act or a failure to act, or a pattern of conduct that creates a clear and present danger to the child’s health, welfare or safety. It includes a failure to provide adequate food, shelter, clothing, supervision, or health care necessary for a child's health, welfare, or safety. Note that a child does not have to be damaged or harmed if the behavior creates a clear and present danger to the child, and that the injury or harm may be physical but it may also be emotional or cognitive.

55 Physical Signs of Neglect Include:Poor hygiene Being left alone or without appropriate supervision Lack of necessary medical treatment Injuries from hazards in the home Malnutrition Signs of neglect may be obvious or subtle. Poor hygiene – typically ongoing and significant Being left alone or with people unable to provide appropriate supervision Lack of necessary medical treatment Injuries from hazards in the home or from general lack of supervision And Malnutrition

56 Behavioral Signs of Neglect Include:Frequent absences from school or child care Appearing lethargic or falling asleep Begging for food or stealing Developmental delays (speech, motor skills) Expectation that no one will care for them Reports that they are unsupervised There are many behaviors that may be present in children who have experienced neglect. When the failure to meet basic needs and to provide adequate care is a longstanding pattern within the family, that’s called chronic neglect. Children who have experienced chronic neglect more frequently show the behavioral and developmental impacts described here. Behavioral signs of neglect include: Frequent absences from school or child care Appearing lethargic or falling asleep during times the child would be expected to be alert Begging for food or stealing in order to get needed items Developmental delays are also common, including speech and both fine and gross motor skills delays. Behaviors associated with ADHD and hyperactivity also appear to be more common in children who are chronically neglected Children whose basic needs are routinely unmet grow to expect that no one will care for them and may not use behaviors that typically prompt adults to offer care. For example, an infant may not cry when hungry or wet. A toddler may not seek comfort after a bad fall. A school age child may cook meals for themselves rather than say they are hungry. Children may also report that they are unsupervised or that they are supervised by adults who are significantly impaired Now let’s take a look at some specific issues in child neglect.

57 What Is Inadequate Supervision?Length of time the child is alone Frequency of caregiver absences Dangers in the environment Whether there is a backup plan if there is an emergency Inadequate supervision? Consider: Was the parent aware, or should the parent have been aware, of the circumstance that made this caregiver dangerous or inappropriate? Did the parent know that abuse or neglect occurred? Did the parent understand that the child remained in danger? Did the parent have the capacity to protect the child? Are they also being victimized? Are there other issues which prevent them effectively protecting the child? What efforts did the parent make to protect the child – did they try to interrupt the abuse or neglect? Failure to protect? Consider: One frequent allegation of neglect is lack of supervision. Supervision practices, including when and under what circumstances a child can be left alone, vary among families, communities and cultures. It’s important to be curious about the parent’s cultural norms regarding supervision. When you assess for adequate supervision, you are assessing for conditions that pose safety threats to children, not whether a parent’s care meets an arbitrary cultural or community standard. A child’s age and abilities to self-protect are critical in determinations about possible safety threats stemming from lack of supervision. Other important considerations are the length of time the child is alone, the frequency of caregiver absences, dangers in the environment and whether there is a back-up plan if there is an emergency. Related to lack of supervision is leaving a child with an inadequate, impaired, or dangerous caregiver. Parents or caregivers who make this choice when they understand that this individual is not able to provide adequate care and supervision, or is dangerous to their child, have neglected their child. This is often called “failure to protect.” In determining whether the parent has failed to protect the child, you will ask: Was the parent aware, or should the parent have been aware, of the circumstance that made this caregiver dangerous or inappropriate? Did the parent know that abuse or neglect occurred? Did the parent understand that the child remained in danger? Did the parent have the capacity to protect the child? Are they also being victimized? Are there other issues which prevent them effectively protecting the child? What efforts did the parent make to protect the child – did they try to interrupt the abuse or neglect?

58 Medical Neglect “ Medical neglect occurs when the child has a condition for which the parent or caregiver is not seeking appropriate treatment, and the impact will be significant to the child’s health or wellbeing. ” Medical neglect is more than not taking a child in for well child exams, or failing to get recommended immunizations. Medical neglect occurs when the child has a condition for which the parent or caregiver is not seeking appropriate treatment, and the impact will be significant to the child’s health or wellbeing. Again, this may not be an easy determination. Many medical issues may not cause significant harm if not addressed. Here again, it’s extremely important to get medical consultation so that you understand both the medical condition and the consequences of the decisions being made by the child’s caregivers. There are some ethnic and religious communities that do not support the use of Western medicine. When this is the context in which medical treatment is refused, it is important to work with the parents to understand their beliefs and to seek consultation from elders or other cultural experts to see if the situation can be resolved with minimal impact to the child in a way that works for the family and their values system.

59 Condition of the Home Many allegations of neglect include concerning reports about the conditions of the home. It is not neglectful to fail to do the dishes from the night before or to have a cluttered, messy home. However, when the home’s condition has clear hazards, including animal feces, exposed wiring, drugs or weapons within the reach of children, and other conditions which may cause health problems for the children, then the physical conditions of the home may constitute neglect. The age and developmental level of the child is critical in considering if the condition of the home also poses a safety threat to the child.

60 Malnutrition Malnutrition is when the body doesn’t get or can’t use sufficient nutrients to grow and develop normally. If you suspect malnutrition, you should: Refer children for medical consultation. Do a thorough assessment to determine why the child is malnourished. Malnutrition is when the body doesn’t get or can’t use sufficient nutrients to grow and develop normally. There are some medical conditions which create malnutrition, but it is most often caused by an inadequate diet. Malnutrition is not necessarily obvious upon looking at a child. It is important to refer children for medical consultation whenever lack of food or food withholding has been reported as a concern, to assess whether the child is getting the proper calories and nutrients. It’s also important to do a thorough assessment to determine why the child is malnourished, as there are many reasons parents may fail to provide adequate nutrition.

61 Failure to Thrive It can exist when caregivers do everything right, but can also be caused by caregivers not providing adequate food. Failure to thrive is a condition where children fail to grow and achieve developmental milestones at expected rates. It’s typically seen in infancy, when it can be extremely dangerous, but it can occur throughout childhood. It has both organic and social causes, meaning that it can exist when caregivers do everything right, but can also be caused by caregivers not providing adequate food. Providing little to no social interaction and affection, even when the child has adequate food, has also been demonstrated to cause failure to thrive. In complex cases, both organic and social causes exist. Once diagnosed, medical providers will work together with the child’s caregivers to try to understand the causes of the condition and to address it. Children who have failure to thrive that is caused by inadequate care taking typically gain and maintain weight quickly when placed in consistent and caring environments where they also get adequate nutrition.

63 Physical Signs of Severe MalnutritionDry and peeling skin Dry, thin, and brittle hair Increased soft light body hair Decaying teeth and swollen gums Bloated stomach Decrease in appetite Fragile bones Increased susceptibility to infection When malnutrition is severe, there are some physical signs to look for such as: Dry and peeling skin Dry, thin and brittle hair Increased soft light body hair Decaying teeth and swollen gums A bloated stomach A decrease in appetite Fragile bones Increased susceptibility to infection

64 Behavioral Indicators of MalnutritionInfants and Toddlers Children Listless and poorly responsive Don’t smile, laugh, cry, or play May not turn to parent for support Lack interest Tend to self-comfort or self-stimulate, through rocking, head banging, or suck on hair or fingers Increased fatigue Hyperactive Frequently hungry May hoard food Eating in large gulps and over-eat junk food When malnutrition is severe, there are some physical signs to look for such as: Dry and peeling skin Dry, thin and brittle hair Increased soft light body hair Decaying teeth and swollen gums A bloated stomach A decrease in appetite Fragile bones Increased susceptibility to infection

65 Example An alert CFWS social worker intervened to prevent serious damage from malnutrition. A seven-year-old in foster care was not growing. Foster mother said behaviors were out of control from sugar. No wheat or dairy Foster mother was working on allergies and diet. Child stole and hoarded food and was punished. CFWS worker called doc to confirm info. CFWS worker consulted with a child abuse expert. Child was moved. Here’s an example of a time an alert CFWS social worker intervened to prevent serious damage from malnutrition. Listen to the CPS worker describe the rest. A seven year old in foster care was not growing and appeared to be getting thinner. I reviewed the diet of the child with the foster mother. The foster mother reported that the child’s behaviors were out of control anytime he had even a little bit of sugar. He also needed to avoid a number of other foods such as wheat and dairy. The foster mother reported that she was working with the child’s doctor to determine if the child had allergies and that he was on a strict diet. She also was working with the school as the child would steal and hoard food, and he was frequently punished for this when he came home and she found food in his backpack. She was not concerned about his loss of weight. I called the child’s doctor, who confirmed that he was working with the foster mother and that she thought that the foster mother was very attentive to the child’s diet. She said she had not found that the child had any allergies, except to dust and pollen. She said that the child’s weight was concerning, but that she did not feel the need to intervene unless it continued to get worse. I remained concerned and asked for a medical consult with a child abuse expert. When the two doctors consulted and the daily routine of the child was shared, it was determined that the child was being malnourished. The foster mother remained insistent that the diet was necessary. The child had to be moved from the foster home. Thanks to this alert CFWS social worker, the child did not suffer serious damage due to the malnutrition though would have if he had remained on this diet. The child was able to stabilize in his next placement where he was adopted.

66 What Is Not Neglect? Poverty Food that is less than optimally nutritious Homelessness Messy houses Parents who are violent with each other Driving with a child unrestrained Educational neglect Let’s take a minute to consider what is not neglect. When parents struggle with social and personal issues, this does not constitute neglect unless these issues impact the care of the child in such a way that the child is likely to suffer harm. For example, the following conditions do not constitute neglect in and of themselves: Poverty Food that is less than optimally nutritious Homelessness Messy houses or those that are less than clean Parents who are violent with each other Driving with a child unrestrained in a car seat Educational neglect In determining neglect, we need to look at whether the situation or on-going conditions pose a significant threat of harm to the child. For many families, these conditions overlap and create circumstances where children are harmed or are unsafe. For others, they are able to manage one or more of these conditions and use other protective factors to ensure their children receive minimally adequate care. Do the situation or ongoing conditions pose a significant threat of harm to the child?

67 Emotional Maltreatment and Child NeglectWAC (5)(c) includes in the definition of neglect: “The cumulative effects of a pattern of conduct, behavior or inaction by a parent or guardian in providing for the physical, emotional and developmental needs of a child…when the result is to cause injury or create a substantial risk of injury to the physical, emotional, and/or cognitive development of a child.” Unlike many states, Washington does not include a separate category for neglect called emotional neglect or emotional abuse. However, our existing definition of neglect can include children whose emotional needs are so neglected as to cause or threaten serious harm.

68 Yes, the parents’ behavior meets out definition of Neglect.Check Your Understanding A 12 year old child attempted suicide. At home, the child is made to stay in his room for long periods of time, not allowed out to interact with the rest of the family or to engage in other activities. This occurs almost every night. His room has no items in it that might offer distraction. His parents have taken away his computer, phone, books, and the posters from his wall. There is no TV or other diversion. The parents have felt the child was evil since he was a toddler and have taken away all items that they feel might “provoke” him. The consulting psychiatrist for the boy, as well as your medical consultant, report that the pattern of conduct by the parents has created a substantial risk of injury to the child’s mental health and was a major factor in his attempt to commit suicide. Does the parents’ behavior meets our definition of neglect, Yes or No? Yes, the parents’ behavior meets out definition of Neglect.

69 Yes, the parents’ behavior caused a safety threat to the child.Check Your Understanding Consider the same situation that was presented on the previous slide: A 12 year old child attempted suicide. At home, the child is made to stay in his room for long periods of time, not allowed out to interact with the rest of the family or to engage in other activities. This occurs almost every night. His room has no items in it that might offer distraction. His parents have taken away his computer, phone, books, and the posters from his wall. There is no TV or other diversion. The parents have felt the child was evil since he was a toddler and have taken away all items that they feel might “provoke” him. The consulting psychiatrist for the boy, as well as your medical consultant, report that the pattern of conduct by the parents has created a substantial risk of injury to the child’s mental health and was a major factor in his attempt to commit suicide. Has the parents’ behavior caused a safety threat to the child, Yes or No? Yes, the parents’ behavior caused a safety threat to the child.

70 Look for Unmet Basic NeedsMedical and dental care Nutrition Appropriate clothing Household conditions Supervision practices Capabilities of caregivers and those providing supervision Behavior of the children indicating basic needs have not been met In summary, when assessing if child neglect is an issue in a family, look at: Medical and dental care Nutrition Appropriate clothing Household conditions Supervision practices Capabilities of caregivers and those providing supervision Behavior of the children indicating basic needs have not been met

71 Important Information for Assessments of Child NeglectHistory of child maltreatment – all household members Parents statements Medical/Dental/Mental Health provider input Collateral statements Major risk factors of caregivers – addiction, mental illness, cognitive delays, etc. Reports from service providers Condition and behaviors of the child Considerations when assessing Neglect: History of child maltreatment – all household members Parents statements Medical/Dental/Mental Health provider input Collateral statements Major risk factors of caregivers – addiction, mental illness, cognitive delays, etc. Reports from service providers Condition and behaviors of the child

72 Section 5: Developmental Effects of Child MaltreatmentWhile we have discussed some behaviors that may be signs of types of maltreatment, there are also effects on the child’s development that can have life-long consequences. We will discuss some of those effects here. We will also take a look at a couple case scenarios on [insert date of session 2.2] to give you an opportunity to practice assessing the effects of maltreatment on child development.

73 Attention, Academic Achievement and AttachmentHigher rates of ADHD Impulsivity and inattention Academic Achievement Lower reading and IQ scores Academic underachievement Higher rates of special education Attachment Disorganized attachment, which is associated with externalizing symptoms Major impacts to the development of children who have been abused or neglected can often be seen in the areas of Attention, Academic Achievement, and Attachment. Children who experience maltreatment are at especially high risk of deficits in executive functioning, which has implications for behavioral regulation. Studies have found higher rates of ADHD among children who have experienced child abuse and neglect. Among children with ADHD, those with a history of abuse and neglect demonstrate more severe impulsivity and inattention than their non-abused counterparts. Children who have experienced child abuse and neglect have lower reading scores, IQ scores, and academic underachievement, even when controlling for other factors. Children who have experienced maltreatment enter into special education services at higher rates than children with no record of abuse or neglect even when controlling for other factors. Attachment provides a child with a frame of reference for how to deal with distress. Secure attachment provides a safe and nurturing relationship to which the child can retreat when they are in distress. A history of experiencing child abuse and neglect is associated with disorganized attachment, which in turn is associated with externalizing symptoms.

74 Additional Effects on OutcomesDifficulties with regulating and controlling emotions Difficulties in peer relationships Elevated rates of externalizing symptoms Elevated rates of internalizing behaviors Elevated rates of Post-Traumatic Stress disorder Personality disorders later in life Additional effects of child maltreatment on development include: Difficulties with regulating and controlling emotions Difficulties in peer relationships Elevated rates of externalizing symptoms such as aggression, bullying, and conduct disorders Elevated rates of internalizing behaviors such as withdrawing from relationships and anxiety and depression Elevated rates of Post-Traumatic Stress disorder, especially among survivors of sexual abuse, physical abuse, and children who witnessed domestic violence in combination with neglect Some evidence also links experiencing childhood abuse and neglect with a variety of personality disorders later in life.

75 Adverse Childhood Experiences (ACES)Child abuse and neglect are not alone in having negative effects on children’s development. There has been a growing area of research in the effects of adverse childhood events on the physical and mental health of individuals. Child maltreatment is considered an adverse childhood event. But there are other events that can have profound impacts on children such as domestic violence, substance abuse and/or mental illness in the home, and separation from a parent. The more exposure to adverse childhood events the greater the likelihood that the individual will show the affects including mental disorders. It is estimated that between 13 and 20 percent of children in the US experience a mental disorder in any given year. These disorders include ADHD as well as anxiety, autism spectrum and substance use disorders, to name a few. There are interventions for childhood mental disorders and treatment should be targeted to the issues the children are facing. When getting an assessment for a child, be sure to discuss what the appropriate treatment interventions are and ask which have evidence to support the intervention. Some interventions that are discussed next.

76 Appropriate InterventionsTrauma Focused Cognitive Behavior Therapy (TF-CBT) Positive Parenting Programs PCIT Triple P Incredible Years CBT for Behavioral Problems Alternatives for Families Cognitive Behavior Therapy (AF-CBT) Fortunately, many children who experience abuse and neglect still go on to function well and lead rich and happy lives. One way that we can help support children who have experienced maltreatment to have the best outcomes is by ensuring that they and their caregivers get interventions with a strong track record of success. These interventions will be discussed later in RCT. For now, if you are interested in learning more you can click on the links provided.

77 Section 6: Working with community partnersChild maltreatment most frequently takes the form of child neglect. Even in families referred for other forms of child maltreatment, it is often found they are also neglecting their children either sporadically or chronically. The child welfare system was set up to respond to physical abuse. It’s struggled to effectively respond to issues of neglect – particularly if those issues that are ongoing or chronic. To some degree, this is because the societal issues of poverty, inadequate substance abuse and mental health supports, and community and family violence have so much impact on families who chronically struggle to meet their children's basic needs.

78 Medical Consultation Contracted Regional Medical Consultants can be located through: https://www.dshs.wa.gov/sites/default/files/CA/csp/documents/MedicalConsultationContactSheet.pdf Children’s Advocacy Centers are located throughout Washington and all have medical personnel that specialize in conditions caused by abuse or neglect. If there is a Child Advocacy Center located in your office’s county, it can be located at Medical consultation is a required and critical part of assessing the safety and condition of the child across maltreatment types. In physical abuse cases, medical consultation can determine whether an injury is consistent with the caregiver’s explanation, and whether a pattern of injuries may be suspicious. In sexual abuse cases, medical consultations can determine whether a medical exam is needed and how to understand the results, and can provide a bridge to appropriate mental health services for the caregiver and child. In neglect cases, medical consultations can provide critical information about the overall health or mental health of the child, and diagnose conditions like failure to thrive or malnutrition. When consulting with physicians, the information you have is important to a doctor’s assessment. The information you have will help the doctor know what to look for and how to put in context the reports from the parents and other caregivers.

79 County Protocols: Response to Serious Physical Abuse and Sexual AbuseLocate your county protocol Review the Quick Reference Guide located at In cases involving serious physical abuse or sexual abuse of children, law enforcement and prosecutors have a key role to play. Each county is legislatively mandated to develop and implement protocols to guide how CPS, law enforcement, and other community partners work together to create the best outcomes for child victims. Be sure to locate and review your county protocol (Module 2 Checklist Activity) Some key issues addressed in most county protocols include: A medical examinations by a physician who is a Medical Consultant or affiliated with a Child Advocacy Center if there is a serious injury or a pattern of injuries. Any interviews of the child, alleged perpetrator, and other possible witnesses should be coordinated with law enforcement. Generally, a child is scheduled for a forensic interview and law enforcement interviews the subject.

80 Final Quiz Now it’s time to check our understanding of the dynamics of physical abuse, sexual abuse and neglect one last time. We have 20 questions to go through, the first ten are true or false, just call out your answers and we can go through any questions as they come up. For the last ten questions, you will need to decide which of the screened in intake scenarios contain allegations of physical abuse, sexual abuse, neglect, or no allegations at all.

81 True or false: Most intakes to CPS involve physical abuse allegations.

82 FALSE Most CPS intakes involve neglect allegationsMost intakes to CPS involve physical abuse allegations

83 True or false: Most deaths related to abuse or neglect occur before a child’s third birthday.

84 TRUE Both nationally and in Washington, young children are most at risk for death. One period that is especially high risk is infancy Most deaths related to abuse or neglect occur before a child’s third birthday.

85 True or false: Native American Children are more frequently referred to CPS and remain in out of home placement longer than any other race of children.

86 TRUE While both African American and Native American children are over-represented at all stages in the child welfare system, Native American children are disproportionately represented more than any other racial group of children Native American Children are more frequently referred to CPS and remain in out of home placement longer than any other race of children.

87 True or false: CPS history is important to your assessments for all forms of child maltreatment.

88 TRUE History is important to know in order to determine the propensity of the caregivers to maltreat their children as well as understanding the effects of the maltreatment on the children CPS history is important to your assessments for all forms of child maltreatment.

89 True or false: Findings that a person has abused or neglected a child are only shared internally to determine risk of future maltreatment.

90 FALSE Findings that a person has abused or neglected a child are part of a background check for persons who are volunteering or applying for employment to work with children and vulnerable adults Findings that a person has abused or neglected a child are only shared internally to determine risk of future maltreatment.

91 True or false: Only intakes that include an allegation that a child has been abused or neglected are accepted by CPS for investigation.

92 FALSE Intakes that include concern that a child is at high risk for serious harm due to the caregivers’ behaviors or history, even if the child has not been abused or neglected, are accepted for CPS investigation and assessment Only intakes that include an allegation that a child has been abused or neglected are accepted by CPS for investigation.

93 True or false: Children who suffer from malnutrition are often difficult to identify because not all are underweight.

94 TRUE Children who are malnourished may have deficits in certain nutrients which may not be reflected in low weight and some may even be obese. Children who suffer from malnutrition are often difficult to identify because not all are underweight.

95 True or false: Children are resilient and overcome adverse childhood experiences if they have not been abused or neglected.

96 FALSE Adverse childhood experiences that include being exposed to domestic violence, a parent having mental illness or a substance use disorder, and separation from a parent, are all associated with negative effects on children’s development Children are resilient and overcome adverse childhood experiences if they have not been abused or neglected.

97 True or false: Medical consultation is rarely used in CPS to determine if a child has been maltreated.

98 FALSE Medical consultation is so important in determining the cause of injuries and the effects of maltreatment on children that the Children’s Administration has contracted with a network of physicians who are experts in child abuse and neglect and who are available to consult with the department Medical consultation is rarely used in CPS to determine if a child has been maltreated.

99 True or false: Specialized training is required prior to interviewing a child who is alleged to have been physically or sexually abused.

100 TRUE Children should only be interviewed by an individual with training in forensic interviewing of children. This may be a CA social worker, or may be an individual employed by a community agency such as law enforcement or a Child Advocacy Center Specialized training is required prior to interviewing a child who is alleged to have been physically or sexually abused.

101 Which of the following screened in intakes contain allegations of physical abuse, sexual abuse, neglect, or contain no allegation but are high risk?

102 Neglect Physical Abuse Sexual Abuse No AllegationA doctor's office calls with concerns for a six month old infant. The child has been diagnosed as failure to thrive. No medical reason for the child's failure to thrive has been discovered. The mother worked with a nutritionist and a visiting nurse, but the child has only gained weight in three of the last eight weeks. The mother did not appear for her doctor's appointment today, has not returned phone calls, and was not home for the visiting nurse two days ago. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer - Neglect

103 Neglect Physical Abuse Sexual Abuse No AllegationAt school today, six year old Jimmy said he was scared to go home. His mother's boyfriend takes care of him after school. Jimmy was tearful and stated that he does not like how mother's boyfriend touches him in his private areas. The teacher did not interview Jimmy further. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – Sexual Abuse

104 Neglect Physical Abuse Sexual Abuse No AllegationA hospital called about a newborn baby. The baby and mother both tested positive for methamphetamines. The baby has developed some signs of withdrawal. The mother did not receive prenatal care except for two appointments during the first trimester. The father of the baby lives with the mother. He has appeared at the hospital appearing to be under the influence. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – No Allegation

105 Neglect Physical Abuse Sexual Abuse No AllegationThree year old Sarah came to child care today with two bruises on either side of her face. There were also red lines that appeared to be the shape of an adult hand. Sarah has come in before with injuries and the mother never explains the injuries or just says that Sarah falls a lot. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – Physical Abuse

106 Neglect Physical Abuse Sexual Abuse No AllegationJon is eight years old with significant behavioral and developmental issues. He is impulsive and physically aggressive with other children. He is in special education for these behavioral issues as well as for developmental delays. Jon does not yet read and has an IQ of about 70. Today Jon reported to his teacher that he is home alone after school until his mother gets home from work, which he describes as dinner time. He states he knows how to call her if there is a problem, but he could not recite her phone number. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – Neglect

107 Neglect Physical Abuse Sexual Abuse No AllegationNineteen year old Jean called to report concern for her sister. Jean just left home, leaving her sister and her father as the only members of the household. The girls’ mother resides in another state and is out of contact with the family. Jean reported that her father started having sex with her when she was fifteen, and had frequently rubbed up against her before the sex began. Jean is worried about her sister and that he might do the same to her. Her sister denies that anything is happening, even when Jean said her sister could come live with her. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – No Allegation

108 Neglect Physical Abuse Sexual Abuse No AllegationThe grandmother of Sarah, a six month old infant, called today with concerns for the child. The mother has just returned to work. She has had difficulty finding a day care. Until she finds day care, she is leaving the baby with a neighbor. The neighbor uses illegal drugs and prescription medications. This is a chronic issue for the neighbor and the mother is aware of it. She told her mother she had no other choice but to leave the baby with her neighbor. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – Neglect

109 Neglect Physical Abuse Sexual Abuse No AllegationA three month old baby came to child care today with faint bruises on her upper arms. Otherwise the baby seems fine. The parents did not let the child care know of the bruises. They were noticed when they were changing the baby’s clothes. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – Physical Abuse

110 Neglect Physical Abuse Sexual Abuse No AllegationFour year old Robin is frequently seen outdoors in the apartment complex, even in winter or when it is raining. Her mother seems to keep an eye on her, but is not with her. The neighbors have brought toys and books to the mother so that Robin can play indoors, but she still is outside in all kinds of weather. Recently Robin has asked neighbors for food and if she can come to their house to sleep and watch TV. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – Neglect

111 Neglect Physical Abuse Sexual Abuse No AllegationSeven year old Jon’s mother was shocked when she walked in on Jon sucking on his two year old brother’s penis. She told him to stop and not do that again. She talked to him about why it was not appropriate. Today, she walked in again on him doing the same thing. She asked him, this time, why he was doing it. He said Daddy wanted him to. Neglect Physical Abuse Sexual Abuse No Allegation Correct Answer – Sexual Abuse

112 Thank you and remember:Signs of Abuse and Neglect Training for RCT Thank you and remember: Identifying abuse and neglect is only one stage in the process of determining a child’s safety You are a mandated reporter Thanks to the Harborview Center for Sexual Assault and Traumatic Stress (www.hcsats.org) Thank you for your participation today. While CPS investigations and FAR respond to allegations, all social workers need to recognize signs of maltreatment and abuse. Remember – you are a mandatory reporter. If you suspect a child may have been abused or neglected, you must report to Intake. This is true of children on your caseloads, as well as, children you may know in your personal life. We are going to shift now to our Guest Speaker [local Medical Consultant] – at this point, cue up the MedCon’s power point presentation and allow them to take the lead. Make sure there is a 10 minute break mid-way through the MedCon presentation.