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Child Abuse and Maltreatment/Neglect:
Identification and Reporting
New York State Mandatory Training
Chapter Five - Recognizing Child Abuse
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Case Studies
Case #1: Corey
Corey is an 8 year old boy who was brought into the
emergency department where you work, by EMS personnel
after he was hit by a softball during physical education
class at school. Corey lost consciousness for several
minutes. During the physical exam, you note that he
has bilateral bruises to his shoulders, arms and
abdomen. Crying, Corey reports that he was "beaten
up" by classmates. When his father arrives at the ED,
Corey becomes visibly fearful and stops crying. The
father is clearly angry; he begins to shout at Corey
about having to leave work early during an important
business meeting; he was shouting at Corey about not
paying attention to the game, about being a lousy ball
player and acting like a baby. As the physician
in the ED, you note the dad's behavior and how Corey
is responding to it.
- Corey has bilateral bruises
on his shoulders and arms. Accidental injuries tend
to occur on one side or another, not usually on both
shoulders or both arms.
- Corey's explanation that he
was "beaten up" by classmates is not consistent with
what EMS personnel describe about the injury during
physical education class.
- Corey is fearful when his
father appears.
- Corey stops crying when his
father appears.
- Corey's father is angry and
not concerned about his son's injury.
- Corey's father belittles Corey
about his ability to play softball.
- Corey's father uses shame
(ie. "acting like a baby") because Corey had been
crying
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Case #2: Juanita
You are a family nurse practitioner working in a primary
care office. Juanita's mother comes to the office in
follow-up to the hypertension noted at the last visit.
She brings 9-year old Juanita with her to the appointment,
as she usually does. Today you note that Juanita
is withdrawn and has bruises on her face and arms. She
looks like she's been crying. Juanita is typically a
chatty girl who usually engages you in talking about
her love of dancing, often showing off her latest moves
for the staff. Her mother appears irritable and
distracted. You ask her what's wrong and she says she's
fine. You mention that Juanita is so quiet and looks
upset today, to which she replies that Juanita has
been "bad". What would you do if you were the nurse
practitioner this situation?
- She has bruises on her face
and arms.
- Juanita has had a change in
behavior, from outgoing and engaging to withdrawn
and tearful.
- Ms. Flores says Juanita has
been "bad".
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Case #3: Sam
Twelve year old Sam comes to school wearing only
a short sleeved t-shirt and jeans on days when the temperature
is in the 30s. Sam is a quiet, slender young man. He
often seems nervous; he is easily startled. Sam
is a C student. He never seems to be paying much
attention during class; he looks preoccupied. Sam doesn't
make much eye contact. He spends most of his time alone;
he doesn't really have any friends at school. Indeed,
often Sam is the focus of harassment and teasing from
his classmates. About 2 weeks ago Sam came to class
limping. He said he sprained his left ankle. The ankle
didn't get better after a week, so you sent a note home
to have Sam's family get medical attention for Sam.
That was last week and there has been no change.
As the teacher in this 7th grade classroom you wonder
if Sam might be really injured.
- Sam wears a short-sleeved
t-shirt even during cold weather; this is inappropriate
attire for the season.
- Sam's family did not seek
the medical attention that you, as the teacher, suggested
because of Sam's limping and apparent injury to his
left ankle.
- Sam seems nervous and is easily
startled.
- Sam is preoccupied during
class and doesn't pay much attention to the class
work.
- Sam doesn't make eye contact
and is isolated at school; he is often teased at school.
- Sam's ankle is injured and
Sam's family has not sought medical attention for
the injury.
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Case #4: Alicia and Martin
The visiting nurse comes to the home to follow-up on
10 week old Alicia. The baby was born to a 19 year old
mother with a history of cocaine addiction. Alicia weighed
6 lbs. 2 oz. at birth and was not drug addicted. Today,
the first day you have been able to get into the home
since the referral was made 6 weeks ago, you note that
Alicia weighs 4 lbs. 6 oz. The mom tells the nurse
that she ran out of formula yesterday and hasn't had
a chance to get to the store yet today. Alicia is
fretful, but does not cry. Also, during the home visits
the nurse notes that 3 year old Martin has circular
burn marks on his arms and legs. He is a lethargic
child who cries frequently and is very shy and fearful
of adults. The nurse examines Martin and finds that
he also has a patterned bruise on his back which looks
much like a wooden spoon.
- Alicia has lost significant
weight since birth. Although some weight loss is not
uncommon, by 10 weeks, she should have gained more
weight.
- The home is lacking formula
for Alicia.
- Martin has circular burn marks
on his arms and legs; the nurse notes that they look
like cigarette burns.
- Martin has a patterned bruise
on his back which looks like a wooden spoon.
- Martin is lethargic, cries
frequently and seems fearful of adults.
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Case #5: Tisha
5 year old Tisha has been to see her primary care
provider almost weekly for the past month. Each week
Tisha has complained to her mother that her stomach
hurts, so her mother brings her in to be examined.
Tisha's only symptom is abdominal pain. She has no nausea,
vomiting or diarrhea. She is well nourished and developmentally
appropriate for her age; she has clearly has been well
cared for. Multiple diagnostic tests have been run over
the past month. As the family nurse practitioner in
this practice, you must inform Tisha's mother that Tisha
has tested positive for syphyllis.
- Tisha has frequent complaints
about abdominal pain; these complaints often happen
on Mondays, after spending the weekend with her father.
- Five year old Tisha has tested
positive for a sexually transmitted disease.
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Case #6: Leah and Tisha
As a clinical social worker, you are Leah's therapist.
Leah is step-mother to 5 year old Tisha, having been
married to Tisha's father, Michael, for the last 6 months.
The whirlwind relationship has been the frequent topic
of your sessions, particularly Michael's controlling
nature. Leah has also talked about her role as a
step-mother and her discomfort with it. She thinks
that Michael and Tisha are too close; it makes her uncomfortable.
Leah reports that she thinks Michael is too protective
of Tisha, not really allowing her to play with other
children when she is staying at their house, even limiting
her contact and relationship with Tisha. In the last
session with Leah, she told you that she fears that
Michael is sexually abusing Tisha: she saw him leave
Tisha's room early in the morning, when he thought she
was sleeping; she saw him toss a used condom in the
trash. As the therapist, what should you do?
- Tisha's father is seen leaving
Tisha's room and then throwing a used condom in the
trash.
- Michael has a controlling
nature.
- Leah is uncomfortable with
the closeness between Michael and Tisha and his limitation
of Tisha's playing with other children and even Tisha's
getting close to Leah.
- Leah fears that Michael is
sexually abusing Tisha.
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Case #7: Marcus, Amber and
Isaiah
Sometimes, the Shaw children come to school appearing
to be hungry. You are the school nurse who comes
to this school most afternoons, usually getting to the
school at lunchtime. You note that the Shaw children
often don't have any lunch. When they do bring a lunch,
it is often not enough food. Other than this, the
children seem well-groomed and well-behaved. The children
are generally quiet, rather private. As the nurse, you
begin talking to them and learn that their father
does seasonal work and is often between jobs. How
would you handle this if you were the school nurse?
- The children appear to be
hungry when they come to school.
- The children often don't have
any lunch, or if they bring lunch it is not enough.
- The Shaw children, normally
quiet and private, when they speak with the nurse
provide information about their father's underemployment/unemployment.
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Case #8: Tim
At a residential treatment center for boys age 13-16,
recently some of the boys have alleged that they
were sexually abused by staff. The internal investigations
at the facility have never supported these claims. One
of the registered nurses, Jean, suspects that what she
is being told by the boys is correct; she has noted
how some of the aides, mostly males, treat the boys
so roughly on the one hand and then at other times are
often way too familiar. 15 year old Tim showed Jean
his bloody underwear. He also told Jean that one of
the aides, Joe, was forcing him to have sexual relations
with some of the other aides and that Joe was making
money on it. Jean complains to the facility administration
about these allegations, but was told that an internal
investigation has occurred and there is no evidence
that these allegations are based in fact.
- Some of the boys at the residential
treatment center have reported that they have been
sexually abused by staff members.
- Tim showed his bloody underwear
to the nurse, Jean.
- Jean felt uncomfortable with
the way some male staff interacted with the boys,
either to rough or too familiar.
- Tim told Jean that an aide,
Joe, was forcing him to have sex and that Joe was
making money since he was taping the sexual activity
and then selling the tapes.
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Ken Hammond, USDA
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