DFCS Online Policies & Procedures

  DFCS Online Policies & Procedures

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Handbook 3: Assessment Guides
3-14 Assessing Allegations of Physical Abuse
Assessment Guides
3-14 Assessing Allegations of Physical Abuse
Reference Points
Overview
Physical and Behavioral Indicators of Physical Abuse
When an Allegation of Physical Abuse is Received Through the CANC
When Medical Examinations are Indicated)
When Diagnostic Imaging Is Indicated
When Cross-Reporting is Required
When a Staffing Is Required
When Detention is Required
Other References


Reference Points
Effective Date: 03/01/2006
Last Updated: 1/18/07
 Legal Basis:
Popup Window Penal Code Sections 11165 (.3, .4) 11171 (a), 11175.5 (a)
Popup Window Welfare and Institutions Code (WIC) Section 300, Subdivisions (a), (e), (f) and (j)
Popup Window Welfare and Institutions Code (WIC) Section 324.5, Subdivision (a)
 Non CWS/CMS Forms:
PDF Structured Decision-Making (SDM) Tool
 CWS/CMS Forms:
bullet Contact Notebook


Overview   Physical abuse damages children not only physically, but also emotionally. It can include a single incident of “over-discipline” (in which the caregiver, in a moment of anger, loses control and inflicts a small mark or bruise on a child), to the extreme case of child death. The longer the physical abuse continues, the more serious the consequences. Physical abuse contributes to long-term physical disabilities and psychological damage affecting the formation of an adult who is unable to function and often repeats the cycle of violence. Numerous studies have repeatedly shown that child physical abuse is a significant factor in adults who are incarcerated, mentally ill, substance abusers, batterers in domestic violence households, child abusers, unemployed, and/or homeless. It is imperative that identification of and effective intervention with child physical abuse occur at the earliest possible time, so that children will be protected from harm and be able to live in a safe environment, resulting in fewer adults to perpetuate the violence.

Physical abuse is defined in the Penal Code as a criminal offense. The Welfare and Institutions Codes categorizes physical abuse in the civil courts as a basis for removing custody of a child from a parent/legal guardian.

The Welfare and Institutions Code describes physical abuse as consisting of any non-accidental bodily injury that has been or is being willfully inflicted on a child, such as cruel or inhuman corporal punishment or injury, or acts which cause unjustifiable suffering of physical or emotional pain, or endanger the child’s health. Severe physical abuse includes any single act of abuse which causes physical trauma of sufficient severity that, if left untreated, would cause permanent physical disfigurement, disability or death. This can include repeated acts of physical abuse, each of which causes bleeding, deep bruising, significant external or internal swelling, bone fracture or unconsciousness or any single act of sexual abuse which causes significant bleeding, deep bruising or any significant external or internal swelling. See OPP Handbook 1: 1-3 Definitions of Abuse and Neglect.

New allegations of physical abuse received at the Child Abuse and Neglect Center (CANC) may involve children who are not served by DFCS at the time of the referral, as well as children who have an open referral/case. However, in all contacts with DFCS-supervised children, the SW must be familiar with the physical and emotional indicators of physical abuse by being observant and conducting interviews which address the issues of discipline, punishment and physical abuse.
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Physical and Behavioral Indicators of Physical Abuse  
Physical Indicators Behavioral Indicators

Unexplained bruises and welts:

  • on face, lips, mouth, torso, back buttocks or thighs
  • in various stages of healing
  • clustered, forming regular patterns
  • reflecting shape of object used to inflict injury (electric cord, belt buckle, hand)
  • on several different surface areas
  • regularly appear after absence, weekend or vacation
  • Wary of adult contacts
  • Apprehensive when other children cry
  • Behavioral extremes: aggression, compliance or withdrawal
  • Frightened of caregiver
  • Afraid to go home

Unexplained burns:

  • cigar, cigarette burns
  • especially on soles, palms, back or buttocks immersion burns (sock-like, glove-like, doughnut shaped)
  • on buttocks or genitalia
    patterned like electric burner, iron, etc.
  • rope burns on arms, legs, neck or torso
  • Reports injury by caregiver
  • Exhibits low self-esteem
  • Blames self for abuse

Unexplained fractures:

  • to skull, nose, facial structure
  • in various stages of healing
  • multiple or spiral fracture
 

Unexplained lacerations or abrasions:

  • to mouth, lips, gums, eyes
  • to external genitalia
 

Some indicators, taken separately, are not symptomatic of abuse or neglect. They must be examined in context with other characteristics of the family in order to determine that a child is in need of help.

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When an Allegation of Physical Abuse is Received through the CANC  
  1. Assess all children in the household, even if only one child is referred for physical abuse.  
     
  2. With the child’s clothing on, look for immediately observable marks, bruises, burns on the exposed areas of the child’s body, such as arms, legs, face, and neck.

    NOTE: When conducting a visual examination of the child, another adult must always be present. Ask the parent/caregiver for assistance or, if the child is in school at the time of the interview, ask a school employee for help. If the parent/caregiver refuses to cooperate, immediately and from a safe place, contact and request the assistance of law enforcement.

    a) Bruises/welts in unusual configurations may pattern the instrument used to inflict them (linear marks-stick/cane, loop marks-belt, hand/finger prints, teeth marks).

    b) Lacerations/abrasions to the head, face, mouth and other body parts may indicate the implement used, such as finger nail scratches leaving parallel marks.

    c) Cluster bruises of various colors may indicate repeated abuse over time.

    d) Burns/scalds may show the shapes of the item used to inflict them or the type of burn, such as “stocking” or “glove” burns where feet or hands were immersed in an extremely hot liquid.

    NOTE: If any of these situations are observed, obtain immediate medical examination and treatment. Call 911, if the injuries are severe and require emergency medical treatment. Always involve local law enforcement by following existing procedures.

     
  3. Observe if the child is wearing clothing that is inappropriate for the weather, such as long sleeves and long pants in very hot temperatures to possibly hide injuries.  
     
  4. Interview each child separately and away from the caregiver and consider the child’s:
    • age and developmental stage
    • physical and mental health
    • intellectual, verbal and cognitive capacity
    • Approach the child in a non-threatening manner to establish rapport and build trust in that the child may:
      • be wary of all adults
      • be fearful of the parent/caregiver who may have threatened him or her
      • accommodate him/herself to a high level of family violence with the belief that physically abusive behavior is normal
      • be protecting a parent who is also a victim in a domestic violence situation
      • blame him/herself, thinking the abuse was deserved
    • Assess for emotional affect such as:
      • compliant, withdrawn, uncommunicative, depressed
      • aggressive, agitated
      • fearful, vigilant
    • Assess for behavioral indicators such as:
      • destructive behaviors towards self/others
      • regression (bed wetting, soiling)
      • poor school attendance/performance
      • for the adolescent: running away, substance abuse, criminal violations
    • Ask the child how (s)he is experiencing punishment/discipline in the home.
    • Follow-up on any and all disclosures of physical abuse even when it may be indirect, such as a child describing abuse as happening to a friend or someone else.
    • Be especially alert to the possibility of physical abuse when:
      • the nature or extent of the injury does not fit with the explanation given
      • the child’s age or developmental stage is inconsistent with the type of injury
      • there is a high incidence of accidents or frequent injuries
      • the explanations given by the child, his/her sibling(s), and parent/caregiver(s) do not match
      • the severity or type of injury itself is of concern
       
  5. Interview the parent/caregiver.
    • If there is more than one parent/caregiver, interview each separately, away from the other and the child(ren). This is critical in situations involving domestic violence.
    • Assess for and consider that parents/caregivers who physically abuse their children may have:
      • been reared in or are currently in a domestic violence situation
      • substance abuse or mental health issues
      • low impulse control
      • unrealistic expectations of children and/or a limited or incorrect knowledge of child development
      • a negative view of children or a fear of spoiling them
    • Consider that a child is often targeted and is a scapegoat for abuse when:
      • Bonding and attachment have been disrupted, such as in an unwanted or difficult pregnancy, a lengthy hospitalization of a child with severe medical problems at birth, or separation of a newborn from the parent/caregiver due to the parent/caregiver’s incarceration, illness or immigration.
      • The child’s appearance is perceived as different, such as the ‘wrong’ gender, not attractive/intelligent, having a darker skin tone, and/or resembling the father/mother with whom the parent has difficulty.
      • The child presents behaviors that require special attention and care, such as pre maturity, excessive crying, poor/fussy eaters, unresponsiveness, or born with physical disabilities.
      • Difficulties occur at developmental stages, such as toilet training, early socialization, and adolescence.
    • Be especially alert to the possibility of physical abuse when:
      • The nature or the extent of the child’s injury is inconsistent with the explanation given by the parent/caregivers.
      • The explanations are unbelievable, inadequate, and/or illogical or change over time and do not match those of the child, the child’s siblings or the other parent/caregiver.
      • The child-victim is accused of lying about the abuse.
      • The parent/caregiver appears unconcerned about the child’s condition.
      • The parent/caregiver appears to have concealed the physical abuse by delaying medical assistance, going to several different doctors/hospitals out of their area, failing to attend regular school or health center appointments or keeping the child out of school frequently.


  6. In evaluating physical abuse, consider that there are differences in the way specific cultures, ethnicity, races and/or religions view the role of children, parental authority, and discipline

    Be aware that physical discipline is permitted in the form of “reasonable and age appropriate spanking to the buttocks”…as long as there is “no evidence of serious physical harm” (WIC 300, a.).

     
  7. If there is any reason to believe that physical harm has occurred, and there is no other way to verify the allegation, weigh the child’s right to privacy with his/her right to protection from harm in:
    • rearrangement of the child’s clothing
    • removal of the child’s clothing

      NOTE: This is especially critical for infants, toddlers and other non-verbal children.
       
  8. Document all observations and findings in the Contact Notebook.
     
  9. Complete the Structured Decision Making, California Safety Assessment.  
     
  10. If any marks or bruises are observed on the child, complete the Body Chart and document the date it was completed in the Contact Notebook.
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When Medical Examinations are Indicated  

Regular medical examinations are necessary to ensure the health and safety of all children. In situations of suspected physical abuse, medical examinations are imperative, not only to document the nature and extent of the injuries, but to determine the need for and type of treatment. These examinations can also prevent further trauma to a child, by substantiating the cause(s) of the injury, and can be used as evidence to remove a child from a dangerous situation.

The conclusion that physical abuse occurred, as defined in the Welfare and Institutions and Penal Codes, is obtained from a variety of sources. However, in all instances of physical abuse, a medical examination is a required component. A diagnosis of an illness/injury as resulting from physical abuse can only be made by a medical professional.

Social Worker

  1. Obtain immediate medical attention, including hospitalization if necessary, for all children when there:
    • is evidence of significant injuries or use of extreme discipline methods suggesting the possibility of serious injury
    • are visible bruises, burns, welts, abrasions, lacerations, old scars/marks, including healing wounds
    • are possible internal injuries, broken bones, fractures, injuries to the head, abdomen areas
    • are odd or bizarre behaviors that could lead to injuries, such as hitting with hammers/boards or other instruments, hitting on the bottom of the feet, using restraints, placing objects or chemicals in the eyes
      •  
  2. Obtain a medical assessment for all victims of suspected physical abuse under the age of 5 (age 59 months and under) and on all non-verbal and/or developmentally delayed children when the situation is unclear as to the cause of injury or illness. The medical assessment should occur as soon as practically possible, but no later than 72 hours of the initial face-to-face contact.  
     
  3. Be aware that some forms of physical abuse present no visible evidence of trauma. Children with:
    • old fractures/broken bones may have accommodated these injuries by hiding the displacement of the affected limb.
    • internal injuries, such as to the head/abdomen, may produce symptoms such as vomiting, decreased/poor feeding, lethargy/rigidity, difficulty breathing, irritability. If internal injuries are suspected, call 911 and obtain medical treatment immediately.

      See Assessment of Shaken Infant Syndrome.

  4. Involve the parent/caregiver in arranging for the child to be seen by a physician immediately or at the earliest possible date.
    • If the parent/caregiver refuses to cooperate, enlist the assistance of law enforcement in securing a medical examination.
       
  5. Involve the Public Health Nurse (PHN) in obtaining a medical examination.  
     
  6. Assess children age 5 and older who do not seem to require medical evaluation or treatment when the injuries do not include possible internal injuries, broken bones, fractures or apparent burns and the injuries are:
    • superficial
    • located on extremities, such as hands, arms, feet
    • few in number
    • surface scrapes, abrasions or bruises
    • not darkly colored or deep tissue bruises
      • Further support the decision not to obtain a medical evaluation/treatment by an appropriate assessment as outlined in the previous section.
  7. Note that medical assessments are not mandatory when:
    • the allegations in the referral are patently unfounded;
    • independent and reliable witnesses can verify that an injury was accidental; and/or
    • a physician will verify that (s)he has seen the child after the incident alleging that an inflicted injury occurred and will share the results of his/her examination including the extent and cause(s) of any injury.
      •  
  8. Complete the Structured Decision Making California Safety Assessment. 
     
  9. Document all observations and findings in the Contact and Health Notebooks.
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When Diagnostic Imaging Is Indicated  

Research has shown that 55%-70% of all inflicted injuries are in infants younger than age one and 80% of abuse fractures are found in infants less than 18 months old. Multiple fractures are found in over half of physically abused children. These, as well as other injuries, such as those found in the Shaken Infant Syndrome, can only be evaluated and diagnosed with various forms of diagnostic imaging. Diagnostic imaging includes a skeletal survey or full body x-ray, Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). This medical procedure is critical in detecting previous or hidden injuries and in obtaining accurate diagnosis and treatment for children. It is an essential element in documenting the evidence needed in both Juvenile and Criminal Court to protect a child from further injury and death.

Social Worker

  1. Whenever the child needs treatment for a traumatic injury or untreated medical condition, discuss with the physician or health care provider the possibility of abuse.  
     
  2. Request that the examining physician arrange for diagnostic imaging as part of the medical evaluation when a physical abuse situation appears to exist, and  
    • there are obvious injuries/symptoms as described in Medical Examinations, 1. and 3., and
    • all children who are the subject of an allegation of physical abuse under the age of two years, and/or
    • all older children who are developmentally delayed and/or non-verbal.
  3.  
  4. If diagnostic imaging is indicated by the physician or medical provider, attempt to enlist the assistance of the parent/legal guardian in making the child available for this procedure. 

  5. If the physician questions the need for diagnostic imaging, discuss the reasons for the request and the joint responsibility of the physician and social worker to ensure the safety of the child.
    • If the parent/legal guardian refuses to cooperate, the doctor, surgeon or dentist or his/her agent (by their direction) are permitted by law to take skeletal x-rays without parental consent when there:
    • are allegations of child abuse/neglect, and/or
    • is a need to determine the extent of child abuse and neglect.
     
  6. If the physician questions the need for diagnostic imaging, discuss the reasons for the request and the joint responsibility of the physician and social worker to ensure the safety of the child.
     
  7. If, after initial attempts to explain the rational for such an assessment procedure, the physician refuses to direct that diagnostic imaging be done, confer with the social work supervisor and obtain the assistance of the PHN.
     
  8. Note that diagnostic imaging is not required when medical assessments are contraindicated, as described under Medical Examinations, 4. and 5.
     
  9. Complete the Structured Decision Making California Safety Assessment. 

  10. Document all observations and findings in the Contact and Health Notebooks.

NOTE: Thoroughly document in the case records when x-rays and other forms of diagnostic imaging are done to eliminate the possibility of repeated exposure to the child should the same allegations resurface at a later date.

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When Cross-Reporting is Required   As mandated reporters, SW’s must cross-report all allegations of physical abuse. Cross reports must be made when any new allegations are received at the CANC or when the SW investigating a referral discovers new allegations in the course of his/her investigation. In addition, the SW must also complete the Suspected Child Abuse Report and/or the SS 8583, Child Abuse Investigation Report, at the conclusion of his/her investigation.

These reports are sent to various agencies and individuals at both the initial and concluding phases of the investigation of physical abuse.
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When a Staffing Is Required   A staffing is required for all referrals of physical abuse when all of the following exist:
  • The child is under 6-years-old.
  • The attending physician:
    • States that the explanation of the injury is inconsistent with the injury.
    • Does not state that the injury was inflicted intentionally.
  • There are no criminal charges against the parents.
  • The child may or may not have been in the care of the parent(s) at the time of injury.
  • A 300 petition is not filed.
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When Detention is Required  

Social Worker

  1. Investigate the allegation of physical abuse and assess each child in the household following the steps found under section:  
  2. Complete the Structured Decision Making California Safety Assessment.  
     
  3. Always involve law enforcement in any detention for physical abuse.
  4. If the child has physical injuries or symptoms/illness which may be indicative of physical abuse, consider detention if: 
    • these physical injuries/symptoms are verified by medical evaluation to be the result of physical abuse
    • the child is verbal:
      • discloses being physically abused
      • describes the perpetrator as being a parent/caregiver or other person who has access to him/her
      • is fearful of going home or remaining in the home
      • has observable marks, bruises and/or symptoms or other evidence of physical abuse
       
    • there is evidence that the child has been physically abused and the alleged perpetrator, who is the parent/caregiver:  
        • has access to the child
        • discloses that (s)he abused the child
        • displays symptoms of mental illness, and/or substance abuse
        • denies, excuses and/or justifies the abuse by not taking responsibility or blaming the child
        • is involved in a domestic violence situation
           
  5. Always consult with the SCSW before taking a child into protective custody and removing him/her from his/her home.  
     
  6. Prior to placement, assure that the child is medically examined or, if hospitalized, obtain a written discharge summary from the hospital.  
  7. Prior to the Initial Case Plan being completed, complete the Structured Decision Making California Family Risk Assessment.
  8.  
  9. Document all information in the Contact and Health Notebooks.  
     
  10. Follow procedures outlined in Taking Children into Temporary Custody.
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Other References  
bullet2 Definitions of Abuse and Neglect
bullet2 Assessment of Shaken Infant Syndrome
bullet2 Taking a Child into Temporary Custody
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