Child Maltreatment Identification Part 1: Neglect, Emotional ......Common Core | Child Maltreatment Identification, Part 1 Trainer's Guide | Version 1.25, January 2009 1 Child Maltreatment

Common Core | Child Maltreatment Identification, Part 1 Trainer's Guide | Version 1.25, January 2009

Common Core | Child Maltreatment Identification, Part 1 Trainer's Guide | Version 1.25, January 2009 1

Child Maltreatment Identification Part 1: Neglect, Emotional Abuse, & Physical Abuse

TRAINER’S GUIDE

Training Tips, Activities, & Transfer of Learning (TOL) Exercises Day 1

Table of Contents Segment Page

General Training Tips ......................................................................................................... 3

Overview and Child Maltreatment Statistics.................................................................... 4

Defining Child Abuse and Neglect..................................................................................... 7

Child Maltreatment in a Cultural Context ......................................................................... 9

Introduction to Neglect .....................................................................................................11

Challenges and Dilemmas of Neglect .............................................................................. 17

Challenges in Identifying Emotional Abuse ..................................................................... 19

Introduction to Physical Abuse ........................................................................................ 21

Information Gathering and Physical Abuse .....................................................................25

Introduction to Types of Injuries- Part 1 .......................................................................... 31

Empathy............................................................................................................................ 35

Introduction to Types of Injuries- Part 2 & 3 ...................................................................37

Review of the Day ............................................................................................................ 43



Day 2

Table of Contents

Welcome Back .................................................................................................................. 45

Continued Introduction to Types of Injuries- Parts 4 & 5 .............................................. 47

Skill Practice/Embedded Evaluation ................................................................................ 51

Wrap-Up and Closure ....................................................................................................... 55



General Training Tips

• In addition to the tips provided in this tab, the Trainee Content contains much of the information to be used by the trainer to present the topics. Please read the Trainee Content carefully.

• Trainers must be thoroughly familiar with the Evaluation Protocols in the Evaluation tab in order to conduct the pre- and post-tests properly.

• The following icons indicate content related to California’s themes of practice:

Fairness & Equity

Family & Youth Engagement

Strength-based Practice

Outcomes-informed Practice

Evidence-based Practice

• Information related to a California theme of practice should be highlighted during the training.

• Bold italic text indicates expected trainee responses. Encourage trainees to provide the expected content.

• The curriculum contains content related to the two types of formal assessment in use in California: Structured Decision Making (SDM) and Comprehensive Assessment (CAT). Content specific to a particular assessment system is designated using the icons below.

SDM Indicates content to be covered only in those counties using the Structured Decision Making assessment tools.

CAT Indicates content to be covered only in those counties using the Comprehensive Assessment Tools.

If you are training a group of SDM users, refer only to the SDM list. If you are training a group of CAT users, refer only to the CAT list. If your group includes both SDM and CAT users, highlight several items from each list.

• Content related to specific legal and policy requirements for case planning is designated with the icon below. Emphasize this content.

Rules and Regulations



DAY 1, SEGMENT 1

Overview and Child Maltreatment Statistics Total Segment Time: 15 min

TRAINING ACTIVITY 1A

ACTIVITY: Welcome, Overview and Introductions

Activity Time: 5 min

Materials: Trainee Content: Suggested Agenda for the day Trainee Content: Competencies and Learning Objectives tab in the trainee manual Large strips of paper at each table Markers Masking tape PowerPoint Slides: 1-2

(Trainers: Make sure all trainees have 1 copy of the entire 128-slide PowerPoint presentation, printed 3 slides per page)

Training Tips and Discussion Points:

Step #1. Before the training starts: Put the “Competencies and Learning Objectives” for this curriculum on the walls of the training room.

Step #2. Explain the purpose of the training, go over the agenda, ground rules, logistics, and trainee manuals/packets.

Step #3. Then, have trainees read through the “Competencies and Learning Objectives” on the walls, and have them place post-its on the ones they feel are most important to them.

Step #4. Point out the varying selections, and how this affects outcomes of their cases because they’re looking for different things.

Step #5. Tie in F&E factors into this discussion.

Step #6: Processing this activity: Explain to the class that you will revisit their choices at the close of the training.



End of Activity

PowerPoint Slide, Activity 1A: Slides 1-2

CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 11

CHILD CHILD

MALTREATMENTMALTREATMENT

IDENTIFICATION IDENTIFICATION

11

TRAINER: TRAINER:


WelcomeWelcome

Learning Objectives and CompetenciesLearning Objectives and Competencies



TRAINING ACTIVITY 1B

ACTIVITY: Child Maltreatment Statistics


Materials: Trainee Content: Child Maltreatment Statistics (page 5 in the Trainee’s Guide) PowerPoint Slides: 3-4 Training Tips and Discussion Points:

Step #1. Introduce subject of child maltreatment by sharing statistics (refer to Trainee Content).

Step #2. Point out the breakdown of numbers related to different types of abuse.

Step #3. Point out the prevalence of child neglect as a segue into the first part of the training day.

Step #4. Processing this activity: Statistical orientation:

• Present data on prevalence of child maltreatment, pointing out the increased numbers relating to child neglect.

• Also, as a lead-in to the next segment, present data relating to disproportionality in California.

• The trainer can elect to also include data relating to the specific counties being trained as the disproportionality may look somewhat different from county to county. For example, in Imperial County, where the demographics show a majority of Latinos, this influences the placement statistics compared to a county where Latinos are a smaller percentage of the whole population.

End of Activity



Neglect

63%

Phys Ab

17%

Other

14%

Psych Ab

7%

Sex Ab

9%

Med Negl

2%

Types of Maltreatment Identified by CPS in 2005

899,000 children CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 44

National numbersNational numbers…………..

▪▪ In 2005, 899,000 children were victims of In 2005, 899,000 children were victims of abuse or neglectabuse or neglect

▪▪ For 2005, a nationally estimated 1460 For 2005, a nationally estimated 1460 children died of abuse or neglect children died of abuse or neglect –– a rate a rate of 1.96 children per 100,000 in the of 1.96 children per 100,000 in the national population national population

(U.S. Dept. of Health & Human Services, Adm. Of Children, Youth (U.S. Dept. of Health & Human Services, Adm. Of Children, Youth & & Families. 2005)Families. 2005)


Remove this page and insert

Trainee Content

Page 5


This Page Intentionally Left Blank



7

Day 1, SEGMENT 2

Defining Child Abuse and Neglect Total Segment Time: 30 min


ACTIVITY: What is Child Abuse and Neglect?


Materials: Trainee Content: California Welfare & Institutions Code, Section 300 (a-j) (pages 6-9

in the Trainee’s Guide) Trainee Content: California Penal Code, Sections 11164 and 11165 (pages 10-13 in the

Trainee’s Guide) Trainee Content: California Health & Safety Code, Section 1255.7 (pages 14-17 in the

Trainee’s Guide) Trainee Content: Guide to CA W&I Code and CA Penal Code (page 18 in the Trainee’s

Guide) PowerPoint Slides: 5 & 6 Training Activity:

Trainer elicits responses from trainees regarding the following questions:

• What are the elements of the definition of child neglect?

• What are the elements of the definition of child physical abuse?

• Does there need to be intent?

• How do the trainees’ own definitions of neglect and physical abuse compare to the legal definitions?

• Trainer will divide relevant W&I and Penal Codes among the tables instructing trainees to read their assigned code and highlight what they consider the most pertinent elements.

• Trainer will then go to each group to report out and discuss these elements as they relate to child maltreatment identification.

Trainer Reviews:

California W&I Code, Section 300 (a-j) California Penal Code, Sections 11164 and 11165 California Health & Safety Code, Section 1255.7 Refer to Guide to CA W&I Code and CA Penal Code (a type of ‘cheat

sheet’) Weave in statistics from slides for this segment



8

Trainer Discusses:

• Remind trainees that neglect cases are the most difficult to discern

• Remind trainees to consult with their supervisors if there are questions re: does what they see meet the definitions of abuse or neglect?

• Remind trainees that CA Penal Code laws can change annually in July of each year (when new laws go into effect); trainees can go on website to confirm changes, but county personnel should provide updated information.

• Discuss relationship between W&I Code and Penal Code

• Discuss the fact that some terms are subjective, e.g. “severe”, and they need to acquaint themselves with the parameters their county uses in applying definitions. If they have questions, they should discuss it with their supervisor and/or county counsel.

• Special Note to trainers: Do not cover content on sexual abuse, as this content is covered in a separate curriculum.

End of Activity

PowerPoint Slide, Activity 2A: Slide 5-6


What is Child Abuse?What is Child Abuse?

▪▪ Legal definitions: Legal definitions:

▪▪W&I Code (aW&I Code (a--j)j)

▪▪Penal Code (11164 & 11165)Penal Code (11164 & 11165)

▪▪Health and Safety CodeHealth and Safety Code


ExerciseExercise3A3A

▪▪W & I CodeW & I Code

▪▪Code of EthicsCode of Ethics



Trainee Content

Page 6–18





9

Day 1, SEGMENT 3

Child Maltreatment in a Cultural Context Total Segment Time: 35 min


ACTIVITY: Child Maltreatment in a Cultural Context


Materials: • Trainee Content: Risk Factors and Determinants of Child Maltreatment (pages 19-20

in the Trainee’s Guide) • Trainee Content: Child Maltreatment in a Cultural Context (pages 21-22 in the

Trainee’s Guide) • Trainee Content: Related Sections of the NASW Code of Ethics (page 23 in the

Trainee’s Guide) • Trainee Content: Partners in Identifying & Assessing Child Maltreatment (pages 24-25

in the Trainee’s Guide) • PowerPoint Slides: 7 & 8 Training Activity: • Review content in Risk Factors and Determinants of Child Maltreatment. • Review content in Child Maltreatment in a Cultural Context. • Review related content from the NASW Code of Ethics. • Briefly review Partners in Identifying & Assessing Child Maltreatment. • Trainer refer trainees back to 300(b) and discuss possible case examples affiliated

with “serious physical harm” as it relates to spiritual beliefs and practices.

Trainer Discusses: • Remind trainees that disproportionality has been discussed in Framework. • Discuss with trainees how cultural context can affect the process of identification

of abuse. For example: how one’s biases impact our assessments. • Remind trainees that even though something might be a cultural practice, a given

cultural practice may still be considered abuse particularly when the perpetrator goes beyond the cultural norm.

• Discuss with trainees that, on the whole, our society does not offer a lot of opportunities for new immigrants to find out the “rules of the road”. For example, there is little written in a language other than English describing our cultural norms for child rearing practices.



10

• Remind trainees to refer to “Partners in Identifying & Assessing Child Maltreatment” document, which outlines with whom child welfare workers should partner in the process of identifying child maltreatment (includes families & community).

End of Activity



Context for Child Context for Child

MaltreatmentMaltreatment

▪▪ Cultural contextCultural context

▪▪ Child rearing standardsChild rearing standards

▪▪ Environmental factorsEnvironmental factors


COLLABORATIONCOLLABORATION

▪▪ WHO IS ON YOUR WHO IS ON YOUR

TEAM?TEAM?



Trainee Content

Pages 19–25





11

DAY 1, SEGMENT 4

Introduction to Neglect Total Segment Time: 40 min


ACTIVITY: Introduction to Neglect


Materials: • Trainee Content: Child Neglect (pages 26-27 in the Trainee’s Guide) • PowerPoint Slides: 9-23 Training Activity:

Step #1. Trainer discusses with trainees: Why neglect is important:

Child neglect continues to be the largest single category of child maltreatment, representing over 58% of the 2.97 million reports of child maltreatment nationwide (Chalk, Gibbons, & Scarupa, 2002). Among children confirmed by child protective service agencies as being maltreated, 61% experienced neglect (DHHS, 2005). If medical neglect is added, this number goes up to 63.2% (U.S. DHHS, Administration of Children, Youth & Families, 2003).

Mortality- Maltreatment deaths were more associated with neglect (35.5%) than with any other type of abuse. There were 1,500 identified fatalities nationwide due to child maltreatment in 2004. Fatalities resulting from multiple maltreatment types account for another 30.2%. Children under the age of four account for 80% of all child abuse deaths, while children under one year old account for 44% of all child abuse fatalities. By and large, children who die as a result of child maltreatment are the youngest and most vulnerable who are unable to 1) fend for themselves, 2) identify situations which place them at risk of harm, or 3) report neglect situations to individuals who can effectively intervene.

Child neglect can affect all facets of a child’s development: emotional health, social development, cognitive development, as well as physical health.

Step #2. Trainers, refer back to:



12

The California W&I Code Section 300 (b), (e), (f), and (j) definitions of neglect as well as the California Penal Code Sections 11165.2, 11165.5 and 11165.6 covered in the earlier section, emphasizing SEVERE NEGLECT (b) or (e):

Withholding of food and/or water on a prolonged willful basis Severe malnutrition Non-organic failure to thrive Failure to provide medical treatment which will result in permanent and/or

severe illness or death.

End of Activity



CHILD NEGLECTCHILD NEGLECT


Why Child Neglect is ImportantWhy Child Neglect is Important

▪▪ ItIt’’s common in child welfares common in child welfare

▪▪ MorbidityMorbidity

▪▪ MortalityMortality

▪▪ Our opportunity to interveneOur opportunity to intervene

▪▪ Our responsibility to interveneOur responsibility to intervene

▪▪ The lawThe law CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 1111

Child neglect affectsChild neglect affects

▪▪Emotional healthEmotional health

▪▪Social developmentSocial development

▪▪Cognitive developmentCognitive development

▪▪Physical healthPhysical health


▪▪ 62.8% of victims experience neglect. 62.8% of victims experience neglect.

If we add medical neglect, this number If we add medical neglect, this number goes up to 64.8%! goes up to 64.8%! (U.S. Dept. of Health & Human (U.S. Dept. of Health & Human

Services, Adm. Of Children, Youth & Families. 2005)Services, Adm. Of Children, Youth & Families. 2005)

▪▪ Child neglect continues to be the largest Child neglect continues to be the largest single category of child maltreatment single category of child maltreatment representing over 58% of the 2.97 million representing over 58% of the 2.97 million reports of child maltreatment nationwide. reports of child maltreatment nationwide. (Chalk, Gibbons, & Scarupa, 2002)(Chalk, Gibbons, & Scarupa, 2002)

Neglect is # 1


Fatalities due to Child Fatalities due to Child

MaltreatmentMaltreatment

~1,460 a year~1,460 a year

AbuseNeglect

Mixed


▪▪ Maltreatment deaths were more Maltreatment deaths were more associated with neglect (42.2%) than associated with neglect (42.2%) than with any other type of abuse. with any other type of abuse.

▪▪ Fatalities resulting from multiple Fatalities resulting from multiple maltreatment types account for maltreatment types account for another 27.3%another 27.3%

▪▪ Children under age 4 account for Children under age 4 account for 76.6% of all child abuse deaths76.6% of all child abuse deaths

▪▪ Children under 1 account for 42% of Children under 1 account for 42% of all child abuse fatalitiesall child abuse fatalities

(U.S. Dept. of Health & Human Services, Adm. Of Children, Youth (U.S. Dept. of Health & Human Services, Adm. Of Children, Youth & Families. 2005)& Families. 2005)


How we define child How we define child

neglect neglect

Shapes our response to the Shapes our response to the

problemproblem


What is it?What is it?Act of omission or commission which Act of omission or commission which

results in minimal sufficient standards results in minimal sufficient standards

of care of minor(s) not being met.of care of minor(s) not being met.

Basic needs include: adequate food, Basic needs include: adequate food,

clothing, health care, supervision, clothing, health care, supervision,

protection, education, nurturance, love, protection, education, nurturance, love,

& a home.& a home.


How do we know what children How do we know what children

need?need?

▪▪ Scientific evidenceScientific evidence

▪▪ epidemiological data (epidemiological data (egeg, infant car seats), infant car seats)

▪▪ Community standards, valuesCommunity standards, values

▪▪ Not without questionNot without question

▪▪ ExperienceExperience ((egeg, history of severe asthma), history of severe asthma)

▪▪ Common senseCommon sense ((egeg, hunger), hunger)


New Knowledge New Knowledge

New Forms of NeglectNew Forms of Neglect

▪▪ exposure to 2nd hand smokeexposure to 2nd hand smoke

▪▪ inadequate treatment of HIV/AIDSinadequate treatment of HIV/AIDS

▪▪ not using car seats/beltsnot using car seats/belts

▪▪ access to a gunaccess to a gun

▪▪ exposure to domestic violenceexposure to domestic violence

▪▪ unsupervised Internet access ?unsupervised Internet access ?


Why do we want to define Why do we want to define

child neglect?child neglect?

To protect children To protect children

& improve their well& improve their well--beingbeing

NOTNOT

to blame parentsto blame parents


AdvantagesAdvantages of a Childof a Child--focused, focused,

Broad DefinitionBroad Definition

▪▪ Moves us beyond the narrow focus on Moves us beyond the narrow focus on parents to consider other contributorsparents to consider other contributors

▪▪ Leads us to consider a broader array of Leads us to consider a broader array of services, responsesservices, responses

▪▪ A more constructive, less blaming approachA more constructive, less blaming approach

▪▪ Fits with our broad interest in the Fits with our broad interest in the health, health, safety & wellsafety & well--being of childrenbeing of children


General NeglectGeneral Neglect

Penal Code

300 (b) Welfare &

Institutions Code


SEVERE NEGLECTSEVERE NEGLECT

300 (e) W I or 300 (b)300 (e) W I or 300 (b)

▪▪ Withholding food/water on a prolonged, Withholding food/water on a prolonged, willful basiswillful basis

▪▪ Severe malnutritionSevere malnutrition

▪▪ NonNon--organic failure to thriveorganic failure to thrive

▪▪ Failure to provide medical treatment Failure to provide medical treatment which will result in permanent and/or which will result in permanent and/or severe illness or death.severe illness or death.


Contributors to Neglect

Neglect

Child

Parent

Family

Community

Society



Trainee Content

Pages 26–27





13


ACTIVITY: Poverty and Neglect


Materials: • Trainee Content: Poverty and Child Neglect (page 28 in the Trainee’s Guide) • PowerPoint Slides: 24 & 25 Training Activity:

Step #1. The trainer discusses the research regarding the relationship between poverty and neglect: • 3rd National Incidence Study which states that the rate of neglect is 44 times

higher for families earning less than $15,000 per year (Sedlack & Broadhurst, 1996)

• Emphasize that poverty is a contributing factor to neglect (Besharov, 1990) – see trainee content for actual statistics.

• Emphasize that poverty is stressful and that such stress may increase one’s propensity to anger, hopelessness/indifference, violence, and substance abuse (Danziger & Danziger, 1993).

• It should be stressed, however, that poverty itself does not constitute neglect. The following may also be present in families where neglect occurs: Chaos, Lack of interpersonal and job skills, Disorganization, Apathy, and Drug addiction (also in trainee content).

• Remind trainees of the child maltreatment statistic re: neglect and to consider/think about the percentage of this number that is connected to poverty: Between Jan 1, 2005 and Dec 31, 2005, the percentage of children who entered child welfare-supervised foster care with neglect as the removal reason was 80% (Needell, et al., 2006).

End of Activity

PowerPoint Slide, Activity 4B: Slides 24-26


Poverty & Poverty &

ChildChild

NeglectNeglect


Poverty & neglectPoverty & neglect

▪▪ 3rd National Incidence Study3rd National Incidence Study

▪▪ Rate of neglect Rate of neglect 44 x44 x higher in higher in

▪▪ Families earning < $15,000/ yrFamilies earning < $15,000/ yr

Sedlack & Broadhurst, 1996


Elements of NeglectElements of Neglect

▪▪ Poverty as an issuePoverty as an issue

▪▪ BIASBIAS

▪▪ Poverty itself does not constitute neglectPoverty itself does not constitute neglect

▪▪ Other factors: chaos, lack of interpersonal or Other factors: chaos, lack of interpersonal or

job skills, disorganization, apathy, drug job skills, disorganization, apathy, drug

addictionaddiction

▪▪ Others?Others?





Trainee Content

Page 28





15

TRAINING ACTIVITY 4C

ACTIVITY: Indicators of Child Neglect


Materials: • Trainee Content: Further Elements of Neglect: Possible Behavioral Indicators (page

29 in the Trainee’s Guide) • Trainee Content: Possible Indicators of Child Neglect (page 30 in the Trainee’s Guide) • Trainee Content: Possible Manifestations of Neglect (pages 31-34 in the Trainee’s

Guide) • Trainee Content: Failure to Thrive (pages 35-36 in the Trainee’s Guide) • Trainee Content: Positive Toxicology (page 37 in the Trainee’s Guide) • PowerPoint Slides: 26-30 • Flip chart paper • Markers • Masking tape Training Activity:

Step #1. Activity • Trainer divides trainees into four groups. • Trainer distributes flip chart paper between the four groups of trainees. • Trainee groups should identify all INDICATORS OF CHILD NEGLECT by listing them

on the paper. • Trainer asks trainee groups to be ready to discuss how they are indicators of

neglect.

Step #2. Processing/Debriefing the Training Activity: • When each group is done writing on their flip chart paper, ask each group to

appoint a spokesperson. • Ask each spokesperson to report out one at a time (and the other groups cross

them out if they have the same). Ensure that a given spokesperson reports out only a couple answers at a time (not their group’s entire list), and rotate answer-giving from group to group.

• Have each reporter or group describe how what they have written is an indicator of child neglect.

• Trainer goes into depth on each indicator, offering case examples to illustrate the point.

• Refer trainees at the end of this exercise to content in their manuals labeled: “Further Elements of Neglect: Possible Behavioral Indicators”; “Possible Indicators of Child Neglect”; “Possible Manifestations of Neglect”; “Failure to Thrive”; and, “Positive Toxicology”.



16

Tips: Many of the items the trainees list may or may not be an indicator of child

neglect, but could be a possible indicator. (Some will be a question of degree.) When discussing various issues, weave in scenarios and case examples. Ask class what they think to keep it as interactive as possible. Pay careful attention to fairness & equity issues as they arise. Many issues of

perceived neglect may relate to culturally specific practices. Example: leaving children “unsupervised.” In many cultures, young children are given more responsibility and left alone at a younger age than in Western culture. The child welfare worker should be aware of their bias in this area when investigating these situations. They need to look at safety and risk while respecting the cultural context of the presenting situation.

Trainer discusses: Discuss with trainees that neglect is a culturally constructed phenomenon. Discuss with trainees that parental/caregiver mental illness/substance abuse is a

factor to consider in neglect cases (refer trainees to Critical Thinking in Child Welfare: Safety, Risk & Protective Capacity module)

End of Activity

PowerPoint Slide, Activity 4C: Slides 27-31


BEHAVIORAL BEHAVIORAL

INDICATORS OF INDICATORS OF

NEGLECTNEGLECT


▪▪ Large percentage of neglected children Large percentage of neglected children

are developmentally delayedare developmentally delayed

▪▪ May present as unresponsive, placid, May present as unresponsive, placid,

dull, uninterested in their surroundingsdull, uninterested in their surroundings

▪▪ May appear hungry or tiredMay appear hungry or tired

▪▪ May be out of controlMay be out of control

▪▪ May have school/learning issuesMay have school/learning issues


What does neglect look What does neglect look

like?like?

▪▪ AbsenceAbsence

▪▪ Lack of supervisionLack of supervision

▪▪ ““dirtydirty”” homehome

▪▪ Dental or medicalDental or medical

▪▪ PsychologicalPsychological

▪▪ Chronic lice/scabiesChronic lice/scabies

▪▪ FTTFTT

▪▪ Drug exposure (in Drug exposure (in uteroutero and beyond)and beyond)

CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- Draft Draft

V1.1: October 2006 V1.1: October 2006

3030



3131

What can neglect look What can neglect look

like?like?



Trainee Content

Page 29–37





17

DAY 1, SEGMENT 5

Challenges and Dilemmas of Neglect Total Segment Time: 15 min


ACTIVITY: Challenges and Dilemmas of Neglect


Materials: • Trainee Content: Perceptions and Dilemmas in Identifying and Intervening in Neglect

(pages 38-39 in the Trainee’s Guide) • PowerPoint Slide: 32-34 Training Activity: • Review Trainee Content noted above. • Highlight information from Rose & Meezan study. Processing/Debriefing the Training Activity: Trainer should point out the difference between perceptions and the findings in

the study. Trainer should also point out the challenges of neglect investigations for the child

welfare worker.

End of Activity



Challenges & dilemmas Challenges & dilemmas

of neglectof neglect

▪▪ Different Different standards, values standards, values and norms re: and norms re: child rearing in child rearing in different cultural different cultural groupsgroups

▪▪ Marginal child Marginal child rearing issuesrearing issues

▪▪ Ross & Ross & MeezanMeezanstudystudy


Intervention/ Treatment Intervention/ Treatment

Can Work!Can Work!


Severe Neglect & ResilienceSevere Neglect & Resilience

▪▪ At age 4At age 4, , excellentexcellent catch up in growth & catch up in growth & dev. for children who arrived < 6 mos.dev. for children who arrived < 6 mos.

▪▪ For those who arrived > 6 mos., For those who arrived > 6 mos., goodgoodcatch up in development catch up in development

▪▪ McCarthy General Cognitive Index = 92 McCarthy General Cognitive Index = 92 (vs. 109 for UK (vs. 109 for UK adopteesadoptees))





Trainee Content

Pages 38–39





19

DAY 1, SEGMENT 6

Challenges in Identifying Emotional Abuse Total Segment Time: 25 min


ACTIVITY: What is Child Emotional Abuse?


Materials: • Trainee Content: Child Emotional Abuse (page 40 in the Trainee’s Guide) • Trainee Content: Indicators of Emotional Abuse (page 41-43 in the Trainee’s Guide) • PowerPoint Slides: 35-39 Training Activity:

Step #1. Trainer elicits responses from trainees regarding the following questions: What are the elements of the definition of child emotional abuse? Does there need to be intent? How does the trainees’ own definition of emotional abuse compare to the

legal definitions? Include discussion on thresholds for emotional abuse (discuss different

standards/consult with supervisor and county counsel) Include discussion re: the need for mental health evaluation Include discussion re: need of documentation of all 3, as evidenced by severe

anxiety, depression, or aggressive behavior in child/adolescent as a result of parents’ behavior

Step #2. Trainer reviews and discusses: Trainee Content: Child Emotional Abuse Trainee Content: Indicators of Emotional Abuse

End of Activity



EMOTIONALEMOTIONAL

ABUSEABUSE


DEFINITIONS OF DEFINITIONS OF

EMOTIONAL ABUSEEMOTIONAL ABUSE

▪▪ PENAL CODEPENAL CODE

▪▪ W & I CODEW & I CODE


Challenges with Emotional Challenges with Emotional

Abuse InvestigationsAbuse Investigations

▪▪ Difficult to define and evaluateDifficult to define and evaluate

▪▪ Difficult in the Court processDifficult in the Court process

▪▪ Often combined with other factors of Often combined with other factors of

abuseabuse

▪▪ Often requires great effort to get Often requires great effort to get

documentationdocumentation


What does it look like?What does it look like?

▪▪ RejectionRejection

▪▪ IsolationIsolation

▪▪ TerrorizingTerrorizing

▪▪ Ignoring/deprivingIgnoring/depriving

▪▪ CorruptingCorrupting

▪▪ HumiliatingHumiliating

▪▪ ConfusingConfusing

▪▪ scapegoatingscapegoating

•Setting unrealistic

expectations

•Verbally assaulting

•Putting child in

“double binds

•Parental

unpredictability

•Exposure to DV



20


Impact of Emotional Impact of Emotional

Abuse on DevelopmentAbuse on Development

▪▪ Research findings!Research findings!



Trainee Content

Pages 40–43





21

DAY 1, SEGMENT 7

Introduction to Physical Abuse Total Segment Time: 40 min


ACTIVITY: Defining Physical Abuse


Materials: • Trainee Content: Child Maltreatment Statistics (page 5 in the Trainee’s Guide) • Trainee Content: CA W&I Code, Section 300 (page 6-9 in the Trainee’s Guide)Trainee

Content: CA Penal Code, Sections 11164 and 11165 (page 10 in the Trainee’s Guide) • Trainee Content: Child Physical Abuse (page 44 in the Trainee’s Guide) • PowerPoint Slide: 40-42 Training Activity:

Step #1. As an introduction, cite data on physical abuse in California (from Day 1, Segment 1, Activity 1B). Compare to numbers throughout the USA. Point out trends and factors that are present in these statistics. Refer trainees back to:

California W&I Code, Section 300, subsections (a), (e), (f), (i), and (j). California Penal Code, Sections: 11165.3, 11165.4, 11165.5, and 11165.6

Step #2. Processing this Activity:

Discuss: Elements of the definition of physical abuse Culturally specific examples that could be misinterpreted as abusive Cultural context (will be discussed further in next activity)

End of Activity



PHYSICAL PHYSICAL

ABUSEABUSE


Physical Abuse:Physical Abuse:

▪▪ NonNon--accidental, inflicted injury/traumaaccidental, inflicted injury/trauma

▪▪ 300 (a) W I 300 (a) W I –– physical abusephysical abuse

▪▪ 300 (e) W I 300 (e) W I –– severe physical abusesevere physical abuse

▪▪ Injuries causing death, permanent disfigurement, Injuries causing death, permanent disfigurement,

significant bleeding, deep bruising, significant significant bleeding, deep bruising, significant

internal or external swelling, fractures, internal or external swelling, fractures,

unconsciousness, prolonged withholding of food.unconsciousness, prolonged withholding of food.

SUBSTANTIAL RISK of physical harmSUBSTANTIAL RISK of physical harm


Physical Abuse in a Physical Abuse in a

Cultural ContextCultural Context

▪▪ Do our personal Do our personal

values, experiences values, experiences

and biases influence and biases influence

our decisions?our decisions?





Trainee Content

Pages 5–10, 44



23


ACTIVITY: Values Clarification Activity


Materials: • Trainee Content: Values Clarification: Personal Definitions of Abuse and Neglect

(page 45 in the Trainee’s Guide) • Trainee Content: Values Clarification Exercise, Groups 1-6 (page 46-51 in the Trainee’s

Guide) (Trainer should make 1 additional copy of each of 1-6 to distribute to group tables.)

• Paper at tables to record trainee responses • Markers • PowerPoint Slides: none Training Activity:

Step #1. Brief Lecture Discuss how our personal values and biases can influence our decisions. Point trainees to the following “values clarification” box in their manuals. Have a trainee read this aloud.

Step #2. Small group exercise Then have groups respond to the information on the prepared cards. Ask trainees to record their various responses on the chart paper at their tables. Processing this activity: Discuss: Cognitive versus impulsive responses Volatility Stress factors Parent’s history Cultural aspects around these issues, etc. Poverty and abuse Ask trainees, if they are comfortable doing so: Share how they were raised and how this may influence their evaluating abuse? How do we guard against our own bias based on our personal history or

experience? Add examples of cultural practices that may present as abusive by Western standards but that fit in specific cultural contexts.



24

Ask trainees: How to intervene in a respectful manner? Trainees can suggest those areas that may evoke an emotional or value laden

reaction. Possible areas may include: discipline, LGBTQ, age, religion, gender, sexual abuse,

and severe injuries.)

End of Activity



Trainee Content

Pages 45–51



25

DAY 1, SEGMENT 8

Information Gathering and Physical Abuse Total Segment Time: 30 min


ACTIVITY: Age and Injury


Materials: Trainee Content: Elements to Consider in Identifying Physical Abuse, Short Version

(page 52 in the Trainee’s Guide) Trainee Content: Elements to Consider in Identifying Physical Abuse, Extended

Version (pages 53-58 in the Trainee’s Guide) Trainee Content: Information Gathering and the Identification of Physical Abuse:

Explanation of Injuries (pages 59-64 in the Trainee’s Guide) Trainee Content: Information Gathering and the Identification of Physical Abuse:

Obtaining Medical Opinions (pages 65-66 in the Trainee’s Guide) Trainer Content: Supplemental Scenarios for Age/Injury Activity (pages 67-68 in the

Trainee’s Guide) 3 x 5 cards PowerPoint Slides: 43-48 Trainer notes: Introduce the following exercise by discussing how we all have experienced,

directly or indirectly, physical injuries. Physical injuries may be a personal experience, that of a friend or family member, or it may be through a previous job experience.

Introduce the concept of self-care, that is, no one has to put down an example of an injury that is too personal to discuss openly or that may bring back very unpleasant memories.

Also, mention that the discussion of physical abuse, in and of itself, may provoke strong feelings.

Suggest “reasonable alternative hypotheses” to injuries, and note use of this language.

If class does not come up with an adequate variety of examples, go to Trainer Supplement.

Training Activity: Pass out blank index cards.



26

Ask trainees to think of a child (can be a child of theirs, themselves as a child, or a real case situation they know about) and write the age of the child and an injury the child sustained, but don’t write how it happened.

Trainer collects the cards and uses them as scenarios child welfare workers may receive from the hotline to investigate.

Trainer gives the following setup for reading the cards: “You are the worker who is new on the job. You will be gathering the referral information for your new case, which may be scanty, from the hotline, as well as your clipboard of forms and your new plastic ID card. After driving directly to Starbucks for a cup of energy, then you are on your way to investigate this referral. Read the first card, and elicit from group: what kinds of things are you thinking about as you prepare to investigate this report? After reading each card and discussing, ask the author of the card to identify themselves and tell what really happened in that situation.” Processing/Debriefing the Training Activity: Trainer should refer trainees to content for this activity labeled “Elements to Consider in Identifying Physical Abuse, Short Version,” “Elements to Consider in Identifying Physical Abuse, Extended Version,” “Information Gathering and the Identification of Physical Abuse: Explanation of Injuries (Extended Version),” and “Information Gathering and the Identification of Physical Abuse: Obtaining Medical Opinions (Extended Version).” Trainer should train to and emphasize the 13 elements listed in the handout “Elements to Consider in Identifying Physical Abuse, Extended Version,” and should explain the definition of each of the 13 elements listed, in order to ensure that the trainees are better prepared for the embedded evaluation on Day 2. Trainer should also weave the following discussion points into the following exercise, while referring to content noted above: Accidental versus non-accidental Abuse versus discipline Cognitive versus impulsive Factors contributing to abuse Child welfare worker bias (refer back to values exercise and discussion) Self-care Critical thinking: elements of? Brief discussion, refer to discussion in Safety, Risk,

& Protective Capacity class where subject to be discussed fully. Weave into the discussion some of the ensuing information about “Elements to Consider in Evaluating Abuse” as well ensuing information about “Types of Injuries.”



27

Mention and reinforce when people bring up how they think an injury might have happened, i.e., “what is the mechanism that caused the injury” and that, for example, injuries to the back of the torso are more suspicious than to the front and why, and considering elements of age, developmental abilities of the child, description of injury, location of injury, etc.

Ask the same question with each example. Use several cards in the same scenario

for at least one week or more (each card a new day to go out and investigate), until class understands the concepts—is this abuse, or an accident? Class will come up with the fact that more information is needed before the determination can be made that it is either accidental or abuse. Class will reach the understanding that certain themes are important—such as location of injury, getting a good description of the injury, and thinking about the mechanism that causes the injury.

Generally there will be a mix of accidental, more personal stories of themselves or

their children, and client situations of non-accidental injury. Weave in appropriate commentary on those situations and respond to questions/comments as they arise.

Weave in humor as well—this exercise gets people involved; ask people, for

example, if they are okay now? Some may share stories of non-accidental issues that are personal; be very respectful with those, and thank them for disclosing that information.

Reinforce that this is a difficult job and we are going to practice and talk about

these issues today in training so that they can reflect back on these discussions when in the field—(secures buy-in for the class and acknowledges the anxiety often felt by new staff in tackling this job).

Weave in elements: location of injury, explanation, location of incident/scene; age

of child; severity of injury; frequency; history of abuse/CWS priors; child’s overall appearance; developmental abilities of child; parental history of child maltreatment; parental substance abuse.

TRAINER NOTE: It is important for the trainer to emphasize that the trainees should

always check their county’s protocol to see if the “Location/Scene of Incident” element (taking measurements, making photographs, checking water temperature, etc.), is a function of the law enforcement investigator working the case or for the CWS child welfare worker. The trainer should emphasize that a complete viewing of the location where the injury allegedly occurred is essential for the CWS worker.



28

End of Activity



Elements to consider in Elements to consider in

evaluating abuse:evaluating abuse:

▪▪ Location of injury on childLocation of injury on child’’s bodys body

▪▪ Location/scene of the incidentLocation/scene of the incident

▪▪ Type(s) of injuryType(s) of injury

▪▪ Severity/extent of current injury/injuriesSeverity/extent of current injury/injuries

▪▪ Frequency of injuries over timeFrequency of injuries over time

▪▪ Explanation of injury/injuriesExplanation of injury/injuries

▪▪ ChildChild’’s overall appearances overall appearance


Elements, Elements, concon’’tt

▪▪ Chronological age of childChronological age of child

▪▪ Developmental abilities of childDevelopmental abilities of child

▪▪ History of unreported maltreatment of these History of unreported maltreatment of these children by anyone children by anyone oror by these adults of any by these adults of any other childrenother children

▪▪ History of CWS involvementHistory of CWS involvement

▪▪ Parent/caregiverParent/caregiver’’s own history of s own history of abuse/neglectabuse/neglect

▪▪ Parent/caregiver substance abuseParent/caregiver substance abuse


Characteristics of ChildCharacteristics of Child

Typical TriggersTypical Triggers

▪▪ Colic; incessant cryingColic; incessant crying

▪▪ Awakening at nightAwakening at night

▪▪ Separation anxietySeparation anxiety

▪▪ Normal exploratory behaviorNormal exploratory behavior

▪▪ Normal negativismNormal negativism

▪▪ Poor appetitePoor appetite

▪▪ Toilet training resistance or accidentsToilet training resistance or accidents


Information Gathering Information Gathering ––

Parent/CaretakerParent/Caretaker

▪▪ People do liePeople do lie

▪▪ People do take children to ER after People do take children to ER after abuse abuse butbut there may be a delay in there may be a delay in seeking careseeking care

▪▪ People can love their kids & abuse themPeople can love their kids & abuse them

▪▪ May take truth, change it a littleMay take truth, change it a little

▪▪ Changing/contradictory stories very Changing/contradictory stories very suspicioussuspicious

▪▪ Absence of explanation suspiciousAbsence of explanation suspicious


Information Gathering, Information Gathering,

concon’’tt

▪▪ Blaming sibs suspiciousBlaming sibs suspicious

▪▪ Incident described not consistent Incident described not consistent with the developmental abilities of with the developmental abilities of the childthe child

▪▪ No witnesses to incidentNo witnesses to incident

▪▪ ““Trigger EventTrigger Event”” describeddescribed

▪▪ ““UnknownUnknown”” perpetrator high riskperpetrator high risk


Information GatheringInformation Gathering--

Medical PersonnelMedical Personnel

▪▪ What is the nature of the injury?What is the nature of the injury?

▪▪ Is injury consistent with explanation?Is injury consistent with explanation?

▪▪ What mechanism would cause this injury?What mechanism would cause this injury?

▪▪ Spell it Spell it –– what does it mean?what does it mean?

▪▪ Put it in writing.Put it in writing.

▪▪ How old is the injury?How old is the injury?

▪▪ Would child be in pain?Would child be in pain?

▪▪ Cry out when injured/reaction?Cry out when injured/reaction?



29

Supplemental Scenarios to Use in Age/Injury Activity

The following scenarios should be used if the class does not come up with enough scenarios or scenarios of a broad enough range to elicit discussion on child maltreatment indicators/investigation. Instructions:

• Read description of injury aloud,

• Elicit input from class on possible causes, and

• Provide real outcome after discussion. Example 1: Possible Physical Abuse Female, 4 years old. Child was brought to the emergency department at 8:00 pm with a large bump on head above right eye. Cause: Child was bouncing on living room couch, slipped, and hit her head on the edge of the coffee table. Parents verified and the child told doctor what had happened outside the presence of her parents. Example 2: Possible Supervisory Neglect Female, 1 year old. Drowning, EMT called to the home. Cause: Father was asleep. The 1-year-old got out through sliding glass door and fell into the pool. The 13-year-old sibling was at home at the time as well. Example 3: Possible Supervisory Neglect Male, 7 years old. Died in an apartment fire

Cause: Mother left child alone in apartment for 5 hours while she went to work. Blaze started in child’s bedroom, possibly by cigarette lighter. Example 4: Physical Injury Male, 3 months old. Presenting in Emergency Room, with seizures. Grandmother states her son, Terry, 43 years old, brought the baby to her saying the baby had spit up after taking a bottle and was shaking like he was cold.

Cause: Baby had old and new subdural hematomas and a fractured skull. Father finally admitted to shaking the baby twice. He was charged with criminal attempted homicide, simple assault, aggravated assault.



30

Example 5: Physical Injury Female, age 9 years. Fractured elbow, presenting at the Emergency Room at 8:30 pm. Cause: Went down metal slide standing up in socks. At bottom of slide, child’s feet went out from under her and her right elbow slammed against the edge of slide. Child did not disclose injury to parent for 9 hours because she had disobeyed mother’s injunction to “play safely” on the swing set. Example 6: Possible Medical Neglect Female, 18 months. Infant diagnosed with meningitis. Infant died.

Cause: Parents said they believed child only had a cold or the flu and did not seek medical attention because they believe strongly in faith healing and chose to pray for the child. Parents charged for manslaughter and willful cruelty to a child.



Trainee Content

Pages 52–68





31

DAY 1, SEGMENT 9

Introduction to Types of Injuries- Part 1 Total Segment Time: 30 min


ACTIVITY: Bruises, Bites and Cultural

Practices that may be Construed as Abuse


Materials: Trainee Content: Types of Injuries: Accidental and Non-Accidental, Part 1- Bruises,

Bites and Cultural Practices that may be Construed as Abuse (pages 69-71 in the Trainee’s Guide)

Trainee Content: Folk Medicine Practices (pages 72-76 in the Trainee’s Guide) PowerPoint Slides: 49-63 Processing/Debriefing the Training Activity: Trainer should attempt to weave in examples from their case practice experience. Training Activity: Introduction and self-awareness alert for trainees: Emphasize the need for viewing these photographs, acknowledging that many

are difficult to look at because some of the pictures are more graphic and display examples of abuse of a more severe nature along the continuum of child abuse cases.

Reinforce that these may rarely be seen out in the field and so it is very important

to be exposed to them in training so that they don’t miss something when they are in the field working with clients and children who may be at risk.

At this point or some time during the class, participants may ask how to manage

their own feelings about some of the very difficult issues, trauma, and emotions they are exposed to in this role. (This may already have come up in the Feelings/Behaviors Exercise.) It is advisable to acknowledge the challenges but support that it is good for the profession to have caring, empathetic people in these roles.



32

Again this leads to reinforcing the need to be well prepared for the job through education, training, consultation, and supervision as well as maintaining balance and obtaining support both professionally and personally.

Trainer begins going through slides: Explain that you will now be going through a number of power point pictures depicting the variety of ways that children are maltreated: “This afternoon, we will be looking at slides of bruises, welts, pettichiae, abrasions, bites, fractures, burns, and cultural practices that may be construed as abusive. Abusive head trauma, chest and internal injuries will be covered in the next segment in the morning.” Inform trainees that these are medical slides, from the American Academy of

Pediatrics (AAP) as well as from the presentations of Dr. Seth Asser at the APSAC (American Professional Society for the Abuse of Children) Colloquium of June 2006. Every effort will be made to be explicit and brief in this presentation so as not to affect anyone adversely.

When possible, during the slide presentation, elicit input from the class as to how they think the injury may have occurred (the mechanism of the injury). While doing so, note that there may be a variety of possibilities, some abusive, some not, and reinforcing the importance of having a medical professional make the determination rather than a child welfare worker guess or make an assumption.

Lecture on the importance of documentation when working with families (throughout the life of a case).

Emphasize that documentation is especially important during the phase of identifying child maltreatment. The courts will be reviewing this information with a high level of scrutiny to determine if the evidence (information that trainees will be gathering) meets the threshold for continued involvement by the child welfare system.

For two slides of your choosing, ask the class how to document the injury. Emphasize neutral, descriptive language. Provide language for them if the trainees cannot come up with it.

End of Activity



TYPES OF INJURIESTYPES OF INJURIES


▪▪ Bruises/ Pattern BruisingBruises/ Pattern Bruising

▪▪ Broken Bones/FracturesBroken Bones/Fractures

▪▪ BitesBites

▪▪ BurnsBurns

▪▪ ContactContact

▪▪ LiquidLiquid

▪▪ ImmersionImmersion

▪▪ FlameFlame

▪▪ Internal InjuriesInternal Injuries

▪▪ Head InjuryHead Injury


BruisesBruises



5252



33

CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 5353 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 5454 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 5555 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- Draft Draft

V1.1: October 2006 V1.1: October 2006 5656


V1.1: October 2006 V1.1: October 2006 5757 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- Draft Draft


5858 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 5959 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- Draft Draft


6060

CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 6161 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 6262 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- Draft Draft


6363





Trainee Content

Pages 69–76





35

DAY 1, SEGMENT 10

Empathy Total Segment Time: 30 min


ACTIVITY: Empathy Exercise


Materials: Large cards or labels (one set for each table)

▪ PARENT (2) ▪ CHILD ▪ MEDICAL PERSONNEL ▪ CHILD WELFARE WORKER

Chart paper for brainstorming activity-optional PowerPoint Slides: 64 Trainer Note: It is important to reduce the tension and stress which may be present in the classroom as a result of the graphic nature of the slides and discussion before concluding class. There may also be a feeling of hostility towards parent(s)/ caregiver(s) who may be perpetrators of child maltreatment. One way to encourage a distancing of the trainees from the slides, as well as a reminder of the importance of strength-based engagement with the parent(s)/caregiver(s), is to conduct the following training activity: Training Activity: Trainer will present the situation of a verbal-aged child brought to the Emergency

Room by the police with an injury that raises suspicion for child abuse. Ask trainees to visualize a child coming into the emergency room with a broken

arm with his/her parents. Break class into four small groups with the roles of: parents, child, hospital

personnel, and child welfare worker or have each table select 4 of their tablemates to respond in the roles listed above. The person selected as the “child” can choose to portray the injury as inflicted or accidental.

Have small groups brainstorm or act out the various reactions each of these individuals could have to the investigation including cultural, socio-economic, education, and other possible factors. Ask groups to consider how perceptions may affect how the situation is handled based on socioeconomic status (high- and low-income), race, English as a second language, age of the parents, etc.



36

Refer to supplemental handouts and wall posters on strength-based practice. Processing/Debriefing: Have each group report out the major points of their brainstorming experience. If

the trainees have role-played the perspectives, the trainer can have all trainees who assumed the role of the “child” come to the front of the room and describe their feelings. The same can then be done for the parents, medical personnel, and child welfare worker. The trainer can wrap up the exercise by reinforcing learning points as they relate to information gathering, collaboration, and identification of risk factors for maltreatment. It is also appropriate to discuss the emotions of the child as he/she is asked to disclose the cause of the injury.

End of Activity PowerPoint Slide, Activity 10A: Slide 64


Empathy ExerciseEmpathy Exercise

▪▪How would you feelHow would you feel……

▪▪ChildChild

▪▪ParentParent

▪▪Social WorkerSocial Worker

▪▪Medical ProfessionalMedical Professional



37

DAY 1, SEGMENT 11

Introduction to Types of Injuries- Part 2 & 3 Total Segment Time: 35 min


ACTIVITY: Part 2- Fractures and Burns


Approximate time: 35 minutes during Day 1. Trainers should attempt to get through as many parts as possible prior to the end of Day 1. During Day 2, pick up where you left off.

Materials: Trainee Content: Types of Injuries: Accidental & Non-Accidental, Part 2- Fractures &

Burns (pages 77-83 in the Trainee’s Guide) Trainee Content: Folk Medicine Practices (pages 72-76 in the Trainee’s Guide) Optional Handout: The Skeletal System (not included in curriculum) PowerPoint Slides: Fractures 65-75; Burns 76-103 Training Activity: Introduction and self-awareness alert for trainees: Emphasize the need for viewing these photographs, acknowledging that many

are difficult to look at because some of the pictures are more graphic and display examples of abuse of a more severe nature along the continuum of child abuse cases.

Reinforce that these may rarely be seen out in the field and so it is very important to be exposed to them in training so that they don’t miss something when they are in the field working with clients and children who may be at risk. Again, this leads to reinforcing the need to be well prepared for the job through education, training, consultation, and supervision, as well as maintaining balance and obtaining support both professionally and personally.

Trainer begins going through slides: This morning, we will be looking at slides of fractures and burns. As before, when possible, elicit input from the class as to how they think the

injury may have occurred (the mechanism of the injury). The Trainer can refer the trainees to the Skeletal System Handout to acquaint the

trainee with bones being discussed. This allows the trainee to see not only the bone being discussed but its relative length and relation to other bones. These



38

drawings may be ordered from Bruce Algra’s Anatomy Series at www.algra.com. Please note there is a cost.

Repeat self-care warning about the nature of slides about to be shown. Pictures of burns are often the most difficult to look at.

During discussion of burns, acknowledge that they are very painful, even when accidental, and difficult to view and talk about. However, it is important to understand about burns enough to sort out some of the ways we can tell if burns are accidental or non-accidental.

Remind trainees of the natural reaction to getting burned is to get away from the heat as quickly as possible, whether you were being burned by a hot object or hot liquid. Emphasize that this is a significant factor when listening to caregiver’s explanation of how the burn occurred and the child’s reaction.

Review PowerPoint slides and explain each slide using the notes accompanying each slide. (Give possible scenarios and explanations of mechanism of injury for each slide.)

End of Activity PowerPoint Slide, Activity 11A: Slide 65-103 65-75 Fractures


FracturesFractures


▪▪ The most common nonaccidental The most common nonaccidental

fractures in children of all ages involve fractures in children of all ages involve

the skull, the long bones, and the ribs.the skull, the long bones, and the ribs.

▪▪ In infants, the most common fractures In infants, the most common fractures

are in the skull, ribs, and are in the skull, ribs, and metaphysesmetaphyses..

CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 6767 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 6868


▪▪ Twenty per cent of fractures in abused Twenty per cent of fractures in abused children involve the femur.children involve the femur.

▪▪ 20% of femoral fractures seen in children 20% of femoral fractures seen in children ages 2 to 3 are due to abuseages 2 to 3 are due to abuse

▪▪ 60 % of femoral fractures seen in 60 % of femoral fractures seen in children under 1 are due to abuse.children under 1 are due to abuse.


▪▪ There may be a delay in seeking medical There may be a delay in seeking medical

treatment in cases of abuse. treatment in cases of abuse.

▪▪ In many abuse cases, minor falls are In many abuse cases, minor falls are

blamed for fractures and other serious blamed for fractures and other serious

injury.injury.


▪▪ Many studies have documented that Many studies have documented that minor falls do not usually produce serious minor falls do not usually produce serious injury.injury.

▪▪ In one study of 246 children, only 3% In one study of 246 children, only 3% suffered suffered fracturessfracturess, and none involved , and none involved the femur.the femur.


Pediatric Trauma Center DataPediatric Trauma Center Data

01/0001/00--03/0603/06

All Falls by Major EAll Falls by Major E--codescodes

N=2417 N=2417 By major mechanism By major mechanism

subgroupssubgroups

Steps/stairs

Ladders

Building/oth.Struct.

One level to another

Into Hole

Playground

Cliff

Chair/couch

Bed

Oth. Furniture

Slip/Trip/Stumble

Wheels

Sports


Pediatric Trauma Center DataPediatric Trauma Center Data

01/0001/00--03/0603/06

All Falls All Falls

N=2417 N=2417 By Mortality Rate (.008% to By Mortality Rate (.008% to

.016%***).016%***)

Lived

Died

***Note: Of the four deaths, two were clearly a result of a fall from height—one from

a 3rd story and one from a 2nd story. The other two deaths were complex cases and

the etiology was not clear. CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 7474 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 7575

http://www.algra.com/



39

76-103 Burns


Self careSelf care

▪▪ Be prepared, burns are difficult to Be prepared, burns are difficult to

look at.look at.

▪▪ Likewise, this is parallel to your need Likewise, this is parallel to your need

to take care of yourself as a child to take care of yourself as a child

welfare workerwelfare worker

▪▪ High burnout if you donHigh burnout if you don’’t!t!


Burn TypesBurn Types

▪▪ Thermal :Thermal :

▪▪ ScaldsScalds

❖❖Flowing/splashing/splattering liquidFlowing/splashing/splattering liquid

❖❖ImmersionImmersion

▪▪ContactContact

❖❖Smoldering sourceSmoldering source

❖❖Hot solidHot solid

▪▪FlameFlame

▪▪Radiant Radiant


▪▪ Burns represent 10% of all physical Burns represent 10% of all physical

abuse cases.abuse cases.

▪▪ The peak age of burn victims is 13 to 24 The peak age of burn victims is 13 to 24

months.months.


Severity FactorsSeverity Factors

•• Exposure timeExposure time

•• Temperature of heat sourceTemperature of heat source

•• Thickness of skinThickness of skin

•• Type of ExposureType of Exposure

▪▪ Heat content/specific heat of sourceHeat content/specific heat of source

▪▪ Heat conductivity within sourceHeat conductivity within source

▪▪ Heat emission from surface of sourceHeat emission from surface of source

▪▪ Coupling media between heat source Coupling media between heat source & skin& skin


Burn Profile ChecklistBurn Profile Checklist

▪▪ Attributed to siblingAttributed to sibling

▪▪ Unrelated adult Unrelated adult

seeking medical seeking medical

attentionattention

▪▪ Differing historiesDiffering histories

▪▪ Treatment delay >24 Treatment delay >24

hrhr

▪▪ History of injuriesHistory of injuries

▪▪ Inappropriate affectInappropriate affect--

parent or childparent or child

▪▪ History incompatible History incompatible

with injury or with injury or

developmental developmental

abilitiesabilities

▪▪ Mirror image burnsMirror image burns

▪▪ Localized to Localized to

perineum, genitalia, perineum, genitalia,

buttocksbuttocks

▪▪ Older than historyOlder than history

▪▪ Other injuriesOther injuries

CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 8181 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 8282 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 8383

Multiple similar Multiple similar

burnsburns

CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 8484 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 8585 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 8686 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 8787


asphaltasphalt


▪▪ Tap water scald burns account for 87% Tap water scald burns account for 87%

of inflicted burns.of inflicted burns.

▪▪ They are often associated with toilet They are often associated with toilet

training accidents.training accidents.


Reference Temperatures, degrees FReference Temperatures, degrees F

((pain precedes burning!)

▪▪ 101 Comfortable Infant Bathing101 Comfortable Infant Bathing

▪▪ 104104--106 Hot tub106 Hot tub

▪▪ 109109--113 Painful for adults113 Painful for adults

▪▪ 113 2113 2ndnd degree burn; 6 hoursdegree burn; 6 hours

▪▪ 120 2120 2ndnd degree burn; 10 minutesdegree burn; 10 minutes

▪▪ 127 127 22ndnd degree burn; 1 minutedegree burn; 1 minute

▪▪ 130 130 22ndnd deg; 10 sec (child), 30 sec deg; 10 sec (child), 30 sec

(adult)(adult)

▪▪ 140 140 22ndnd deg; 1 sec (child), 3 sec deg; 1 sec (child), 3 sec

(adult)(adult)

▪▪ 156 156 33rdrd degree burn; 1 second childdegree burn; 1 second child CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 9191

Calvin and HobbesCalvin and Hobbes


Stocking & glove injury:Stocking & glove injury:

Foot immersionFoot immersion


DonutDonut

diagram diagram


Pull down

scalds

Flowing water runs downhill


170170ooF faucet F faucet

water.water.

Toddler left in tub.Toddler left in tub.

Parents find Parents find

standing, holding standing, holding

open hot water open hot water

handle.handle.

Injury fits history,Injury fits history,

but neglect?but neglect?


Clues to Abuse: Clues to Abuse:

Explanation of injury Explanation of injury --▪▪ HistoryHistory

▪▪Not consistent with age, Not consistent with age,

ability of childability of child

1 of 11 10-month-olds

& 36 of 121 10 to 18-

mo-olds tested,

could climb into

bathtub.

(Allasio & Fischer)


Explanation of Explanation of

injury: Does it Fit?injury: Does it Fit?

▪▪ Heights/depths/volumeHeights/depths/volume

▪▪ Types handles/ease of Types handles/ease of turningturning

▪▪ Does water accumulate Does water accumulate with open drain?with open drain?

▪▪ How fast/hot as tub How fast/hot as tub fills?fills?

▪▪ Bathroom layoutBathroom layout

▪▪ Other basinsOther basins


Other hot fluids: Oil splatterOther hot fluids: Oil splatter(Heat content greater than water;(Heat content greater than water;

fluid more viscous)fluid more viscous)



Cultural Folk TreatmentsCultural Folk Treatments

▪▪ MoxibustionMoxibustion –– Asian medicine practice of Asian medicine practice of burning herbs to the abdomenburning herbs to the abdomen

▪▪ Cao Cao GioGio –– SE Asian practice of rubbing hot SE Asian practice of rubbing hot coins over the back of chest to cure fever, pain, coins over the back of chest to cure fever, pain, congestioncongestion

▪▪ Cupping Cupping –– Mexican/S. American practice of Mexican/S. American practice of placing warm cup over the chest to draw out placing warm cup over the chest to draw out illnessillness






Trainee Content

Pages 72–83





41


ACTIVITY: Part 3- Injuries to Face,

Ears, Mouth and Neck


Approximate time: 35 minutes during Day 1. Trainers should attempt to get through as many parts as possible prior to the end of Day 1. During Day 2, pick up where you left off.

Materials: Trainee Content: Types of Injuries: Accidental and Non-Accidental, Part 3- Injuries to

the Face, Ears, Mouth and Neck (pages 84 in the Trainee’s Guide) PowerPoint Slides: 104-109 Training Activity: Slideshow

End of Activity PowerPoint Slide, Activity 11B: Slide 104-109


Injuries to the Face, Injuries to the Face,

Ears, Mouth and NeckEars, Mouth and Neck







Trainee Content

Page 84





43

DAY 1, SEGMENT 12

Review of the Day Total Segment Time: 15 min


ACTIVITY: End of Day 1


Materials: PowerPoint Slides: none Training Activity: Process questions and comments Remind trainees re: self-care tonight Brief preparation for tomorrow’s material

End of Activity




Common Core | Child Maltreatment Identification, Part 1: Trainer's Guide | Version 1.25, January 2009 45

DAY 2, SEGMENT 13

Welcome Back Total Segment Time: 15 min


ACTIVITY: Review of Day 1 and Agenda for Today


Materials: • PowerPoint Slide: 110 Training Activity: Review learning from Day 1 Process questions Review today’s agenda Remind trainees re: self-care

End of Activity

PowerPoint Slide, Activity 13A: Slide 110


Day 2: WELCOME BACKDay 2: WELCOME BACK

▪▪REVIEW OF PREVIOUS REVIEW OF PREVIOUS

DAYDAY

▪▪AGENDA FOR TODAYAGENDA FOR TODAY





DAY 2, SEGMENT 14

Continued Introduction to Types of Injuries- Parts 4 & 5 Total Segment Time: 45 min


ACTIVITY: Part 4: Abusive Head Trauma


Materials: Trainee Content: Types of Injuries: Accidental and Non-Accidental, Part 4 -Abusive

Head Trauma (pages 85-86 in the Trainee’s Guide) PowerPoint Slides: 111-118 Training Activity: Slideshow

End of Activity

PowerPoint Slide, Activity 14B: Slide 111-118


Abusive Head Trauma Abusive Head Trauma


▪▪ Head injuries are the primary cause of Head injuries are the primary cause of

death in infants in child abuse cases.death in infants in child abuse cases.

▪▪ Head injury is the leading cause of death Head injury is the leading cause of death

in child abuse cases.in child abuse cases.


Abusive Head TraumaAbusive Head Trauma

▪▪ Head trauma means injury to the face, Head trauma means injury to the face,

scalp, skull, scalp, skull, meningesmeninges and/or brain as a and/or brain as a

result of mechanical forceresult of mechanical force

May be a result of direct impact, May be a result of direct impact,

ashyxiationashyxiation, or shaking, or shaking


▪▪ ConcussionConcussion is the most common brain injury is the most common brain injury

and usually has a brief period of loss of and usually has a brief period of loss of

consciousness with memory loss for the event.consciousness with memory loss for the event.

▪▪ Diffuse axonal injury Diffuse axonal injury is the term for a more is the term for a more

severe brain injury. Unconsciousness is severe brain injury. Unconsciousness is

immediate and lasts more than 6 hours.immediate and lasts more than 6 hours.


▪▪ The skull of the small child is thinner than The skull of the small child is thinner than that of an adult. The larger head size that of an adult. The larger head size and lesser muscle strength results in and lesser muscle strength results in more accelerationmore acceleration--declerationdecleration injury.injury.

▪▪ Skull fractures Skull fractures do not predict the amount do not predict the amount of brain injury of brain injury –– large fractures can be large fractures can be associated with minor brain injury and associated with minor brain injury and severe brain injury can occur without a severe brain injury can occur without a fracture.fracture.


▪▪ Skull fractures may be simple or Skull fractures may be simple or

complex. complex.

▪▪ Approximately 1/3 of skull fractures in Approximately 1/3 of skull fractures in

children under 3 are nonaccidental.children under 3 are nonaccidental.





Trainee Content

Page 85–86






ACTIVITY: Part 5: Chest Injuries & Abusive Abdominal Trauma


Materials: Trainee Content: Types of Injuries: Accidental and Non-Accidental, Part 5 –Chest

Injuries & Abusive Abdominal Trauma (pages 87-88 in the Trainee’s Guide) Optional: Medical Drawing on Internal Organs and the Circulatory System entitled

“How Food is Digested & the Heart & Blood Circulation”, The Health & Anatomy Series, Bruce Algra, www.algra.com

PowerPoint Slides: 119-125 Training Activity: Slideshow

End of Activity

PowerPoint Slide, Activity 14C: Slide 119-125


Chest InjuriesChest Injuries


Abusive Abdominal Abusive Abdominal

TraumaTrauma▪▪ Abdominal injuries are the second Abdominal injuries are the second

leading cause of mortality in child abuse leading cause of mortality in child abuse cases.cases.

▪▪ Average age is older, approximately 2 Average age is older, approximately 2 years.years.

▪▪ Boys outnumber girls 2:1Boys outnumber girls 2:1

▪▪ Approximately 50% mortality rate, mostly Approximately 50% mortality rate, mostly due to delay in seeking care or due to delay in seeking care or misleading histories at presentation misleading histories at presentation delaying appropriate diagnosis.delaying appropriate diagnosis.

▪▪ Kaplan, 2006Kaplan, 2006 CMI 1 CMI 1 -- Core Curriculum Core Curriculum -- V1.2V1.2 122122

Internal Organs include:Internal Organs include:

▪▪ LiverLiver

▪▪ StomachStomach

▪▪ PancreasPancreas

▪▪ SpleenSpleen

▪▪ KidneyKidney

▪▪ Spinal columnSpinal column

▪▪ DuodenumDuodenum


EpidemiologyEpidemiology

▪▪ 3 most common mechanisms (n=927):3 most common mechanisms (n=927):

▪▪ Motor vehicle accidentsMotor vehicle accidents 61%61%

▪▪ AbuseAbuse 16%16%

▪▪ FallsFalls 13.5%13.5%

▪▪ Mortality 6X greater in abuse than fallsMortality 6X greater in abuse than falls

▪▪ TrokelTrokel et al, 2004et al, 2004


General Features of General Features of

Abusive Abdominal InjuryAbusive Abdominal Injury

▪▪ Result from punch, kick, or decelerationResult from punch, kick, or deceleration

▪▪ Toddlers and young children at particular Toddlers and young children at particular

riskrisk

▪▪ Victims often unable to verbalize Victims often unable to verbalize

complaintscomplaints

▪▪ Children donChildren don’’t expect and dont expect and don’’t protectt protect

▪▪ Often no external signsOften no external signs


▪▪ ParentParent’’s dons don’’t provide an accurate historyt provide an accurate history

▪▪ May not have immediate symptomsMay not have immediate symptoms

▪▪ Where there is an abusive head trauma, Where there is an abusive head trauma,

abdominal injury may be overlookedabdominal injury may be overlooked

▪▪ MORE FATAL THAN ACCIDENTAL MORE FATAL THAN ACCIDENTAL

INJURY!INJURY!

▪▪ 53% to 24% in Ledbetter et al (1988) study53% to 24% in Ledbetter et al (1988) study

▪▪ N=156 patients <13 years old with blunt N=156 patients <13 years old with blunt

abdominal injuryabdominal injury

▪▪ Kaplan, 2006Kaplan, 2006

http://www.algra.com/





Trainee Content

Pages 87-88





DAY 2, SEGMENT 15

Skill Practice/Embedded Evaluation Total Segment Time: 90 min


ACTIVITY: Embedded Evaluation


General Tips: Trainers should read the content contained within the Evaluation Protocols Tab of the Trainer’s Guide prior to proceeding with any type of evaluation. More specifically, trainers should be very familiar with the sections of content labeled “Coding & Confidentiality” and “Maintaining Security of the Knowledge and Skill Evaluations.” In addition, trainers should review this activity in its entirety well before attempting to facilitate the embedded evaluation process. This evaluation process consists of many steps and details; some trainers may be unfamiliar with this type of evaluation as it is fairly new to California child welfare training. When facilitated well, this activity is an invaluable learning tool for trainees and provides critical information about the fidelity of the curriculum. Materials: Pen/pencils for filling out assessment forms (Please use ballpoint blue or black ink

pens or other types of dark-ink pens that will not bleed through to the back of the answer sheet. Please avoid the use of felt-tip pens for the answer sheets.)

• Evaluation Protocols Tab: Letter to Participants, Informed Consent, ID Code Assignment instructions, Demographic Survey

• Evaluation Protocols Tab: Ramon Sample Case Scenario

• Evaluation Protocols Tab: Embedded Evaluation Answer Sheet (for Ramon scenario)

• Evaluation Protocols Tab: Four Test Scenarios

• Evaluation Protocols Tab: Embedded Evaluation Answer Sheets for test scenarios

• Evaluation Protocols Tab: Answer Key for sample and test scenarios

• PowerPoint Slides: 126 Training Activity: Note to Trainers: As new versions of curricula are edited and released, CalSWEC will remove the following evaluation-related documents from within the curriculum sections of a given Trainer’s or Trainee’s Guide:



▪ Trainer Content/Tips: remove instructions for facilitating the embedded evaluation process (both for the sample scenario and for the test scenarios) and instructions for facilitating the knowledge test process for applicable curricula and place such instructions solely in the Evaluation Protocols Tab (and/or on the secure section of the CalSWEC website).

▪ Trainee Content: Remove any sample scenarios and/or test answer sheets from within the Trainee’s Guide and place them solely in the Evaluation Protocols Tab within the Trainer’s Guide (and/or on the secure section of the CalSWEC website).

The rationale for removing evaluation-related content from the respective sections of the Trainers’ and Trainees’ Guides is that when changes are made to the sample scenario, or to instructions for the evaluations, or to the sample/test answer sheets, then we can avoid re-numbering the entire curriculum and just re-number the evaluation documents. Please refer to the Evaluation Protocols Tab in your Trainer’s Guide for a full copy of the instructions for facilitating the sample embedded evaluation process.

End of Activity

PowerPoint Slide, Activity 15A: Slide 126


EMBEDDED EMBEDDED

EVALUATIONEVALUATION

Time to see what you have learned so far!


53

For security purposes, the embedded evaluation scenarios and answer keys are not posted in the

same area as the curriculum on the CalSWEC website.

Scenarios and test answer sheets (and answer keys, including for Ramon) for Toby, Miko, Crystal

and D’Shan can be found in the Evaluation Protocols Tab of the Trainer’s Binder. If you don’t

have these documents in your binder, please contact:

1. California-based trainers: Please contact your RTA/IUC training evaluation personnel for copies

of the scenarios and answer keys.

2. Outside of California: Please contact Leslie Zeitler [email protected] at CalSWEC for

copies of the scenarios and answer keys.

Please do not distribute any of the answer keys once you receive them.

mailto:[email protected]





DAY 2, SEGMENT 16

Wrap-Up and Closure Total Segment Time: 15 min


ACTIVITY: Wrap-up and Closure


Materials: PowerPoint Slides: 127-128 Training Activity: Field any last questions trainees may have about the content. Review/revisit competencies and learning objectives chosen from Day 1, Segment

1. Thanks and good wishes.

End of Activity



Life and DeathLife and Death Union Tribune July 26, 1998Union Tribune July 26, 1998

▪▪ ““We rarely hear about county social workers until they We rarely hear about county social workers until they

make a mistakemake a mistake……

Unfortunately we canUnfortunately we can’’t pass laws demanding they t pass laws demanding they

make no mistakes. All we can do is demand the make no mistakes. All we can do is demand the

highest training, and impress upon child protection highest training, and impress upon child protection

officials that the decisions they make are among the officials that the decisions they make are among the

most critically important in our society.most critically important in our society.””


CLOSURECLOSURE

THANK YOU AND GOOD LUCK TO THANK YOU AND GOOD LUCK TO

YOU IN YOUR CHILD WELFARE WORK YOU IN YOUR CHILD WELFARE WORK

WITH CHILDREN AND THEIR WITH CHILDREN AND THEIR

FAMILIESFAMILIES

Child Maltreatment Identification Part 1: Neglect, Emotional ......Common Core | Child Maltreatment Identification, Part 1 Trainer's Guide | Version 1.25, January 2009 1 Child Maltreatment

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