WHEN TO CALL DCF: RECOGNIZING THE MEDICAL SIGNS OF CHILD ABUSE FROM A PROSECUTOR’S PERSPECTIVE

1. WHEN TO CALL DCF:RECOGNIZING THE MEDICAL SIGNS OF CHILD ABUSE FROM A PROSECUTOR’S PERSPECTIVE Christina Rainville, J.D. Chief Deputy State’s Attorney Bennington County

2. Mandated reporters • 33 V.S.A. § 4913: “has reasonable cause to believe that any child has been abused or neglected” • Report must be made within 24 hours • $500 fine • If not reported “with the intent to conceal abuse or neglect”: imprisonment up to 6 months

3. “REASONABLE CAUSE” TO CALL • DO NOT NEED TO KNOW WITH CERTAINTY • NOT YOUR JOB TO DETERMINE IF IT IS TRUE • LEAVE THE INVESTIGATION TO THE EXPERTS BY MAKING THE CALL • YOUR INFORMATION IS JUST ONE PIECE OF THE INVESTIGATION

4. 24 HOUR RULE • CALL IMMEDIATELY – DON’T WAIT 24 HOURS • ALL PHYSICAL EVIDENCE OF ABUSE IS FLEETING • BRUISES AND TEARS HEAL • SEXUAL ASSAULT EVIDENCE TYPICALLY GONE WITHIN 72 HOURS • DCF WILL ACT QUICKLY TO REMOVE CHILD FROM HOME IF THERE IS ABUSE AT HOME

5. 20/20 HINDSIGHT FROM CASES • DELAYED DISCLOSURE IN SEXUAL ABUSE CASES RESULTS IN ADDITIONAL SEXUAL ABUSE • ESCALATING PHYSICAL ABUSE LEADS TO MORE SERIOUS INJURIES • TRAUMATIZED CHILDREN DEVELOP PTSD • MEDICAL RECORDS SHOW SIGNS • IN RETROSPECT, ABUSE SIGNS WERE ALL THERE • DCF WAS NEVER CALLED

6. CASE #1: EMERGENCY ROOM VISIT • 14 YEAR-OLD GIRL AT EMERGENCY ROOM • MOTHER AND STEP-FATHER WITH HER • VAGINAL BLEEDING, PAIN • HANGER PROTRUDING FROM HER VAGINA • GIRL REPORTS SHE WOKE UP THAT WAY AND DOESN’T KNOW HOW IT GOT THERE • MEDICAL STAFF INQUIRES: IS SHE SEXUALLY ACTIVE? CONCERNED ABOUT POTENTIAL PREGNANCY? DID SHE DO THIS HERSELF? • THEY REMOVE HANGER AND SEND HER HOME

7. WHAT SHE TOLD US AT 21 • WHY DIDN’T THEY TAKE ME IN A ROOM AWAY FROM MY PARENTS AND ASK ME WHAT HAPPENED? • I WAS WAITING FOR THEM TO ASK ME ALONE • IF THEY HAD DONE THAT, I WOULD HAVE BEEN SAFE • INSTEAD, THEY SENT ME HOME WITH HIM AND HE CONTINUED TO ABUSE ME FOR YEARS • EVEN WORSE: HE REPEATEDLY SODOMIZED MY YOUNG COUSINS • WHY DID THE DOCTORS FAIL US?

8. LESSON LEARNED • IN ANY INJURY CASE WITH A VERBAL CHILD, QUESTION THE CHILD OUTSIDE THE PRESENCE OF CAREGIVERS • PARENTS CAN DO UNSPEAKABLE THINGS TO CHILDREN: NEVER ASSUME IT WAS AN ACCIDENT OR SELF-INFLICTED • CALL DCF

9. CASE #2: FAILURE TO THRIVE • CHILD HAS DRAMATIC WEIGHT LOSS AT WELL-BABY CHECK • TWO SIBLINGS HAVE LOW/NORMAL WEIGHT • NO OBVIOUS MEDICAL REASON FOR SUDDEN WEIGHT LOSS • DOCTOR ARRANGES FOR CHILD TO SEE SPECIALIST AT DARTMOUTH ABOUT WEIGHT LOSS • DCF NOT CALLED

10. EVIDENCE OFdramatic weight loss

11. WHAT HAPPENED • CHILD SEEN AT WIC CENTER: NURSE AT STATE HEALTH DEPARTMENT CALLS DCF ABOUT WEIGHT • FAMILY FRIEND CALLS DCF: REPORTS THAT CHILD “HAS A POT BELLY LIKE STARVING KIDS IN HAITI” • FRIEND TELLS DCF THAT CAREGIVER NOT ALLOWING CHILD TO EAT • INVESTIGATION BY DCF REVEALED THAT CAREGIVER WAS INTENTIONALLY STARVING THIS CHILD • SIBLINGS WERE UNDERWEIGHT, BUT OKAY

12. LESSON LEARNED • REPORT ALL FAILURES TO THRIVE WHEN THERE IS NO OBVIOUS MEDICAL CAUSE • DON’T WAIT TO SEE A SPECIALIST: CALL NOW • ALWAYS CONSIDER THAT PARENTAL ABUSE MAY BE A CAUSE OF FAILURE TO THRIVE • LET DCF INVESTIGATE WHILE MEDICAL WORK CONTINUES

13. CASE #3: BOY SAYS HE WAS RAPED • 9 YEAR OLD REFUSES TO GO TO COUSIN’S HOUSE • TELLS MOM THAT OLDER COUSIN HAS BEEN SODOMIZING HIM • FAMILY CONFRONTS COUSIN, WHO DENIES IT • MOM BRINGS 9 YEAR-OLD TO DOCTOR TO SEE IF REPORT IS TRUE • DOCTOR MEETS WITH CHILD, DOES NO INTERNAL EXAM, AND CONCLUDES THERE WAS NO ABUSE

14. WHAT HAPPENED • BASED ON DOCTOR’S REPORT, FAMILY DECIDES 9 YEAR-OLD IS LYING • CONTINUED CONTACT WITH COUSIN RESULTS IN ADDITIONAL ACTS OF ABUSE • FAMILY FRIEND CALLS DCF TO REPORT ABUSE • DCF INVESTIGATION REVEALS ALLEGATIONS WERE TRUE • COUSIN CONFESSES • 9 YEAR-OLD HAS PTSD • IN THE MEANTIME, COUSIN HAS ADDITIONAL NON-RELATED VICTIM

15. LESSON LEARNED • IF A PARENT SUSPECTS ABUSE, CALL DCF AND GO NO FURTHER: THIS IS AN AREA OF MEDICINE THAT REQUIRES A SPECIALIST • SEND THE CHILD TO THE HOSPITAL FOR A SANE EXAM, OR TO DR. AVERY WOOD (OUR COUNTY’S CERTIFIED SEXUAL ABUSE DOCTOR) • MEDICAL EXAMS MUST BE CONDUCTED BY EXPERTS WHO CAN RETAIN EVIDENCE ACCORDING TO LEGAL GUIDELINES • DO THIS IMMEDIATELY: EVIDENCE WILL BE LOST

16. CASE #4: CHILD WITH BRUISES • MOM BRINGS CHILD TO DOCTOR • MOM SAYS CHILD FALLING A LOT • BRUISES ALL OVER HEAD • BRUISES ON UPPER ARMS • NO REPORT TO DCF

17. WHAT HAPPENS • DAYCARE CALLS DCF • DCF INVESTIGATION SHOWS THAT BRUISES CLEARLY WERE INFLICTED • MOM INITIALLY BLAMES DOCTOR (“THE DOCTOR SAID HE WAS FINE”)

18. LESSONS LEARNED • KNOW WHAT INFLICTED BRUISES LOOK LIKE • CALL DCF IF THERE IS ANY QUESTION • DOCUMENT WHAT YOU SEE IN YOUR RECORDS • MEASURE BRUISES • PHOTOGRAPH BRUISES • DOCUMENT THE EXPLANATIONS FOR THE INJURIES • HOW DID THE CHILD FALL? • HOW HIGH WAS THE SURFACE? • BE SPECIFIC AND DETAILED IN YOUR RECORDS

19. WATCH OUT FOR PARTICULARLY VULNERABLE CHILDREN • CHILDREN WITH DISABILITIES ARE AT ELEVATED RISK OF SEXUAL AND PHYSICAL ABUSE • PHYSICAL ABUSE • BOYS ON THE AUTISM SPECTRUM • SEXUAL ABUSE: • AUTISM • DEAFNESS • INTELLECTUAL DISABILITY • ANY COMMUNICATIONS DISABILITY

20. UNDERSTANDING PTSD • 90% OF CHILDREN WHO ARE SEXUALLY ASSAULTED DEVELOP PTSD • CHILDREN ALSO DEVELOP PTSD FROM PHYSICAL ABUSE AND FROM WITNESSING DOMESTIC ABUSE OF CAREGIVER • PTSD DIAGNOSIS REQUIRES A TRAUMA, BUT CHILDREN DON’T DISCLOSE TRAUMATIC EVENTS • CHILD WILL PRESENT WITH UNDIAGNOSED PTSD SYMPTOMS IN YOUR OFFICE

21. KNOW THE MEDICAL SIGNS OF PTSD • INABILITY TO FOCUS: DIAGNOSIS OF ADD/ADHD • SLEEP DISTURBANCE: NEED PRESCRIPTION MEDS • ANXIETY MEDS • FAINTING AND SUDDEN UNCONSCIOUSNESS • CHANGES IN BEHAVIOR NOTED BY PARENTS • UNPROVOKED AGGRESSION • WITHDRAWAL FROM ACTIVITIES • RUNNING OUT OF CLASS/SCHOOL

22. CASE #5: 4 YEAR OLD WITH ADD AND SLEEP DISTURBANCE • 4 YEAR OLD BROUGHT TO FAMILY DOCTOR • SUDDEN DIFFICULTY SLEEPING: NEEDS SLEEP MEDS • SUDDEN INABILITY TO FOCUS: NEEDS ADD/ADHD MEDS • MONTHS LATER, MOM WALKS IN ON FATHER SEXUALLY ASSAULTING THE CHILD • CHILD DIAGNOSED WITH PTSD MONTHS AFTER MEDICAL VISIT

23. CASE #6: 10 YEAR-OLD WHO FALLS UNCONSIOUS WHEN HER NECK IS TOUCHED • 10 YEAR-OLD TAKEN TO ER, UNCONSCIOUS • HAPPENED WHEN MOM LOVINGLY TOUCHED BACK OF HER NECK • TAKEN TO ER SECOND TIME: SAME THING HAPPENED WHEN WRESTLING WITH BROTHER AND HE TOUCHED HER NECK • PARENT REPORTS CHANGES IN BEHAVIOR: SCREAMING NIGHTMARES, WITHDRAWAL, SUDDEN AGGRESSION, VIOLENT • SENT TO NEUROLOGIST: NO MEDICAL CAUSE • CHILD LATER REPORTS VIOLENT RAPE

24. CASE #7: 14 YEAR OLD WITH ADD, SLEEP DISTURBANCE AND RECTAL BLEEDING • 14 YEAR OLD GOES TO FAMILY DOCTOR • ADD MEDS NO LONGER WORKING: NEEDS INCREASE • CAN’T SLEEP: NEEDS SLEEP MEDS • SENT TO DARTMOUTH FOR RECTAL BLEEDING • LATER, DEVELOPS “SUDDEN UNCONSCIOUSNESS” • BOY EVENTUALLY DISCLOSES REPEATED SEXUAL ABUSE • DIAGNOSED WITH PTSD

25. LESSONS LEARNED • LOOK FOR SIGNS OF PTSD AND CALL DCF IF MORE THAN ONE: • LATE ONSET ADD/ADHD • SLEEP DISTURBANCE • CHANGES IN BEHAVIOR • OPPOSITIONAL DEFIANT DISORDER • AGGRESSION • WITHDRAWAL • DEPRESSION • CUTTING • FAINTING/LOSS OF CONSCIOUSNESS

26. SUMMARY • DCF HAS MUCH MORE INFORMATION, FROM MULTIPLE SOURCES • YOUR INFORMATION PLAYS AN IMPORTANT PIECE IN THE OVERALL INVESTIGATION • A CALL TO DCF CAN PREVENT ABUSE AND PREVENT MORE VICTIMS • NO ONE EVER REGRETS CALLING DCF: MANY REGRET NOT CALLING