 Thank you. Good morning. My name is Dr. Natalie. I'm one of the child abuse pediatricians in San Antonio, Texas And today I'm going to be talking to you about recognizing child abuse on my slides up Yes okay So we're going to talk a little bit first about how common child abuse is so these statistics are from 2018 nationally in the United States 1.3 million reports were made to child protective services of those 678,000 children were thought to be victims of child maltreatment The most common form of child maltreatment is neglect Followed by physical abuse sexual abuse and then other types such as being threatened abused by a parent or caregiver Parents drug and alcohol abuse or safer linkishment of a newborn When we look at the kinds of child maltreatment each child suffers most commonly again because neglect is the most common form of child maltreatment That one type of child maltreatment and most of that is neglect others Physical abuse and then sexual abuse neglect and physical abuse is the most common combination When we think about which children are most likely to have to be abused You think it's the data reflects that it's the younger age group So it's the kids who are at home with parents most dependent on adults to do things for them They're the young nonverbal children. So for most of my talk, I'm going to be focusing on how to recognize child abuse in these young children When we look at who is most likely to perpetrate abuse Parents and again because we're talking about these young nonverbal children who are the people who have most access to them They are their parents who the ones most responsible for them. They are their parents So they're the ones who are most likely to be determined as the Reason that this child has been abused or neglected Then we have a non-parent relatives. So those living in the household who aren't related to them Who are related to them like a grandma auntie uncles things like that and then other which are non relatives babysitters foster siblings foster parents things like that Nationally in America about four children die every day as a result of child abuse that adds up to 1,700 children per year and again not surprisingly most of those Fatalities are those young nonverbal children So next I'm going to tell you a little bit about myself and what I do to try to explain why I'm able to give you this information So I'm a child abuse pediatrician a child abuse pediatrician is a subspecialty of general pediatrics So what that means is I went to college So undergrad then I did four years of medical school at the end of medical school Everyone comes out and it's a doctor, but they're not a certain kind of doctor yet Then I did three years of a pediatric residency. That's where I learned how to become a pediatrician After you finish residency anyone can go out and practice being a pediatrician So that's where you take your children for well child checks or for sick care visits But I didn't want to do that. So I decided to focus on child abuse So after my residency I did additional three years of training called fellowship Where every day all day for three years the only children that I evaluated Were those kids where there was a concern for abuse or neglect So during those three years I did complete medical evaluations for any child when there was a concern for abuse That means looking at taking a full history just like they do at the regular doctor's office Doing a full physical exam head to toe looking at all of the skin all of the body parts Just like they do at the regular doctor's office looking at lab work Ordering lab work looking at x-rays and then at the end of all of that looking at all of that information And trying to determine whether the situation or the injury that this child has is due to child abuse or a medical problem Or an accident or something else that we need to find out I work really closely with child protective services and law enforcement And when I write my note, I realize that what I write down is most likely going to be read by other non medical professionals Such as lawyers such as social workers child protective services law enforcement attorneys, right? So I write it in such a way where there's uh, it's people are able to understand it if you're not in the medical field I also go to court and testify as an expert witness in civil and criminal cases And so that's in general what a child abuse pediatrician does So now we're going to move on and we're going to talk a little bit about the different kinds Of abuse so the first thing I'm sorry first thing we're going to talk about is mandated reporting and what that means now every state in the us has mandated reporting The laws regarding it is a little different Every country also has some form of mandated reporting Most countries in the world do i'm not sure. I don't know the rules for those So i'm just going to talk about mandated reporting in general in the united states and a little bit more specifically for texas So the reason the united states has mandated reporting is because of something called the child abuse prevention and treatment act or CAPTA So this was originally passed in 1974 and basically what it says is that all of the states need to come up with some way To gather reports and investigate any concerns for child maltreatment And this was passed first in 1974 and subsequently every time it's come up to say Do we still want to do this the government had said yes, we're going to continue to do this because we know it's in the best interest of children So in general all of the states have language that says something like this Any person who's engaged in the examination care and treatment of persons So notice they don't say just children. They say persons So adults and children Are mandated reporters and some states have actual lists of who are mandated reporters But if you work in some some capacity where you're taking care of and Seeing social work teaching Law enforcement Medical fields all of those you're going to be a mandated reporter in every single state not just here in texas Now in texas every citizen is a mandated reporter and again, that's not the same for everywhere Some states have just specific specific things, but in texas every person is a mandated reporter And it's important to know that even if you live in a state where you're not listed as being a mandated reporter You can still report child abuse So you don't have to be a mandated report or in order to report child abuse The mandated part basically just says if you don't report it then you can actually get in trouble And we'll talk a little bit more about that So when should you report every state has language that says something like this Whenever you suspect a child is being physically abused sexually abused and neglected So the point is Suspect you don't actually have to know that the abuse is happening before you report it Because we are not investigators We only know very little about a family what they want to show us when they come into contact with us We're not in their home. So you don't actually know what's happening So we will most often will not actually have definitive evidence that something is happening We just have a suspicion and a suspicion is absolutely enough to make a report to child protective services When you call them you want to give them as much information as possible because You're calling them and telling them go out and find this person who lives somewhere in my state In my city in my, you know, we're in my county And so you want to give them as much information as possible who the child is who the parents are Who else is living in the home contact information a good address if you have it So all of these things because they're not going to be able to go out and investigate and find out what's going on If they don't know how to find this family And as I said, you only have to have a suspicion So it's okay if you don't know because every state has laws that protect you from from Liability from these parents if they're angry because a report was made to child protective services that if you make a report in good faith then You're not you can't get in trouble because you were trying to protect the child and that's more important But if you if you make a report and you're trying to get someone in trouble Well, that's a little different So the focus for reporting to child protective services is keeping a child safe Not really what's going to happen to the parent and who you're getting in trouble Because again, you don't actually know what's happening in the home because you're not in the home And so you want to be sure that you're thinking about how to protect that child the best way that you can And again, I talked about this mandated people being mandated so that only means that if you don't report it and you're a mandated reporter you can actually get in trouble because The government feels that if you come in such close contact with children and adults who have children That you are obligated if you have a suspicion to report and if you don't then that's not living up to your civic duty And so you can get in trouble here in the state of texas It's a class a misdemeanor, which means a fine and jail time So it just every state is a little different, but there is some version of this in most states in this country Now every state also has laws that says that cps can't tell the family who calls The reason that is is because again, they don't it's not a punitive thing They don't want anybody to get in trouble because they're making a report because they're concerned About the safety of a child and so by law they can't tell a family who calls However, some families can figure it out based on what the allegations are and who they've talked to and who they've interacted with recently If you're a professional or anyone really when you give your name and position and how you know this family and how you come in contact with them It can add credibility to your concern and also it gives the investigator the opportunity to come back and check in with you And make sure they understand what your concerns are and potentially follow up with you once they have discussed with the families Whether you still have concerns based on the information that they have gathered through their investigation You can make the decision whether or not to tell the family and it really depends on your relationship with the family As a physician and a pediatrician if i'm making a report to child predictive services I always tell my families what what's going on and I explain it to them is this Something has happened to your child and i'm worried that someone has hurt them I don't know who did it and it's not my job to figure out who or how That job is what child protective services. That's what their investigation does And the reason you want to tell the person who you're talking with the caregiver You're talking to is so that they're not blindsided and it shows that you're in partnership with them And I just think about what it would be like if i'm sitting in my house and child protective services knocked on my door And I have no idea what i've done or what the concern is or where is this coming from That someone is now asking me what's going on with my child You don't know if the person you're talking to is the person who has caused this Injury or the situation to this child the things they may be telling you may be the truth as they know it And so our job is not to try to hide something from them It's to be full disclosure. Here's what's going on. Here's what i'm worried about My job by law is to keep this child safe and here's what I have to do in order to do that So really the bottom line is our job is to protect children Making a report to child protective services is not a punishment for anyone It is our way to make sure that children are safe and if you keep that in mind I think it would it helps you sort of get over that well someone's going to get in trouble or What if they take that child away? So from my experience working with child protective services in now three different states Removing children is not the first thing that they do. It's actually the very last thing that they choose to do Um if they've exhausted all other options and so it's definitely not a punishment for families You don't know what other services cps can offer lots of services to families And so they can help them in ways that we might not be able to And they're not going to know that they need that help unless they're able to get in and see that family so Make a report to child protective services if you have a suspicion now if you go online You can just google child abuse and neglect report and in your state will come up There's usually a hotline most states also now have an online way to do that And so that's how you find out how you make that report and where you need it to Typically the online reports are used for things that are not urgent So you're not afraid that a child is imminently in danger And so you can do an online report because it just takes time for someone to get to it But then make a report in person by phone If it's something that you're worried about imminently and you can immediate response for child safety And at the end of this we're going to I will take all of your questions So just make sure that you know write your questions in the chat and we can talk about those at the end So next we're going to talk about the different kinds of child abuse and how to recognize those So first just a general definition of what child abuse is and this is the federal definition Every state has their own version of this but it all includes something like this Any recent act or failure to act on the part of a parent or caretaker Which results in death serious physical or emotional harm Sexual abuse or exploitation or an act or failure to act which presents an imminent risk of serious harm So notice in this definition It's a harm actually happen or a serious risk of imminent harm So in many cases you don't have to have injury or actual harm being done before It can determine child abuse if you put a child at significant risk of harm For example, allowing a two-year-old to wander the street Even if the two-year-old did not wasn't injured during that incident The risk of harm was so high that that is still considered neglect and will still be substantiated by child protective services So first we're going to talk about physical abuse So physical abuse is any non accidental or inflicted injury. So this includes cutaneous So things on the skin like bruises burns bites lacerations. So cuts those things It also includes broken bones like fractures. It also includes things like head injuries or abdominal injuries So any physical injuries that can happen to a child and when we think of physical abuse from the medical standpoint We don't think about whether someone intended to hurt their child and And I think from the standpoint of someone who's suspicious of physical abuse Our job is not to think of whether someone intended to that's something that cps and law enforcement Investigative services that's their job is to figure out and then they can look at the laws the family code And the criminal code and determine whether Intend and and what needs to happen there our job again is to think about what's best for this child and the safety of this child So if an adult caused an injury to a child that could be concerning for physical abuse And then once the investigation happens Then they can determine whether that's something that reaches the level that they can say yep definitively This is physical abuse or not so When should you have a suspicion of physical abuse? So here are some things that we're going to talk about we're going to talk about where the injury is and That there are parts of the body that kids don't typically get injured during accidental things We're going to talk about patterned injuries and the fact that kids don't typically get injured in a pattern during accidents We're going to talk about the age and development of a child So thinking about what kids can and cannot do and what kinds of injuries that leads to And then we're going to talk about the history. So what do we know about the injury that this child has So first I told you that there are certain locations on the body That lots of kids get injured So those places aren't concerning for physical abuse and then there are places on the bodies where kids don't typically get injured So the way that we know this is by Experience of course of seeing lots and lots of children and seeing where they typically get injured But we've actually done research looking at this. So looking at thousands of children going to their pediatricians office Just for a checkup. So no reason they're not coming in because they have an injury And then we wrote down researchers wrote down where on their bodies they have injuries And the places that we consider to be very concerning are the places where less than two percent of children Just all children all ages coming to the pediatricians office get injured or had injuries And so these are places that we know are less likely to happen during accidental ways So These are the places that kids when we see them we don't we're not concerned for abuse because kids get injured here all The time so when we think about children You think about how they explore their world, right? They're full force going hard when they fall they fall forward The places that i'm taught that I have listed up here are the places where the skin and the bone are really close together And so the way that you get an injury is when you crush your skin against a bony surface And so we have the forehead right lots of kids get goose eggs from falling all the time Their nose that gets hit their chin their elbows forearms their hip bones there their knees and their shins So those are places when kids are running around a plane on a playground having a good time They get bruises there all the time and when I see those it doesn't make me concerned that abuse is happening However These places on this list when I see these I'm really concerned about abuse because these aren't places that typically children will Hurt themselves when they're when they're just having normal routine playing activity So we think about their chest So kids at about 15 months of age start putting their hands out to protect themselves when they're fall So they're less likely to impact their chest when they fall down They're back so kids tend to if they fall backwards they sit on their bottom Again, they put their hands out to protect themselves So they're less likely to impact their back their belly or their abdomen. So again, this is a very protected area They put their hands out. It's also very soft. And so because it's very soft We don't have that bone for the skin to crush against to cause that bruise It takes a lot more force and energy to cause a bruise there and a lot more force than you typically see from Normal routine accidents that happen with kids who are just playing The genitals and the buttocks again very well protected now when we think about those young nonverbal kids who are wearing diapers Their genitals or buttocks even more well protected. And so They're less likely to get injured there because that's just not where they impact I talked about kids when they fall down backwards. They fall on their buttocks a lot Again, those young nonverbal kids. They have clothing on they have diapers on not going to get injured The buttocks is a soft cushy place. Again, it takes a lot of force to cause that We see lots and lots of kids who fall down all the time on their butt on the playgrounds jumping from swings landing on their butt No bruises at all. So it takes a lot of force to cause an injury there Now i'm just going to step out a little bit from this very concerning location to talk about buttock bruising So in the united states corporal punishment is legal And that is you know hitting a child as a form of discipline However, in most states if you leave an injury that's considered physical abuse The reason is we know that the amount of force it causes to take to cause a bruise Is excessive physical discipline and is outside the realm of what can be considered normal corporal punishment Now as a pediatrician, I have to say that pediatricians have recommended no corporal punishment at all The reason that we do that is because we know that corporal punishment does not actually change behaviors And it actually causes more harm than good. So we have done over 700 studies looking at corporal punishment Trying to find whether or not this is this can be helpful for children Not one study has found a positive impact on children as a result of corporal punishment Every single study has found negative effects. What it does is it causes fear in children It damages the parent-child relationship And so parents children are afraid to tell their parents things even things that they should tell their parents Because they're worried that they're going to get hit and hurt It causes aggression in children because of modeling. So children who See that the way that you solve a problem if someone does something inappropriate that you hit them That's how they will Engage with their world also because children learn by watching us and seeing what we do and so It also causes anxiety. It also causes depression when we look at adults Correlation with corporal punishment with substance and alcohol abuse And so corporal punishment in general is not recommended by a pediatrician And even though it is legal here in the united states Again, if it is something that is used and leaves an injury Then that is concerning for physical abuse because that's excessive corporal punishment So the next part of the body that we're concerned if you see a bruise It's concerning is the ears because again the ears are well protected when you fall on your side You hit the top of your head. You hit your shoulder You rarely ever hit your ear your neck again a well protected area in your mouth So kids don't typically get injuries in their mouth Especially the young non-mobile babies who aren't moving very much They can't put their finger in their mouth to cause an injury And so this is from forceful insertion of an object a pacifier a bottle a spoon a toy Kids don't do that themselves. They're not strong enough to do that themselves now Do weird accidents happen? Absolutely But again as the person who's starting at the very beginning of the process who doesn't know everything about that family Our job is not to say well, this must be a weird accident because this is a very nice family I don't want to get them in trouble. Our job is to think well, this is a concerning place for a kiddo to have an injury I have to keep make sure this kid is safe. I need to make a report to child protective services Other places the angle of the jaw so right along the side your cheeks are soft and cushy There's not a lot of bone right there in the middle of your cheeks So it takes a lot more force to cause an injury there They're also a well protected area your eyelids and subconjunctival hemorrhages So your eyes in general i'm talking about bleeding on the white parts of your eyes That's what subconjunctival hemorrhages mean and so your eyes are well protected because it's sunk in Into your face and so when you fall down you don't typically directly impact your eyes And so when you have injuries to your eyes You make a concern that you have some sort of direct blow and we need to figure out how that direct blow happened Now i've mentioned a couple times weird accidents can happen and that is absolutely true But we don't start with this was a weird accident. We always start with well, this is concerning Let's get some more information through a good investigation and maybe at the end we'll make a determination that this is a weird accident So now patterned injuries so most every patterned injury is suggestive of impact with an object Most accidents when you impact an object the reason that it's not usually pattern Is because of the chaos theory when you when you're having an accident lots of things are moving and going at the same time So you don't typically impact something just so to get a pattern And so when we see a pattern it makes us worried that they had very good contact Um with a lot of force with an object my job Even when I see a pattern as a child abuse pediatrician who makes assessments about abuse and neglect I don't ever try to figure out or give cps It was definitely this thing that caused the injury unless a child tells me That something caused the injury on them and it looks like that thing caused the injury on them that i'm gonna say okay Yeah, this caused this injury But I look at the pattern and I I can give them information about it So if it's uh injury that wraps around the child's body I think okay, it must be a flexible object because I had to wrap around Or if I see a texture on it. I think oh that's sort that's a textured thing We should look for a textured thing that sort of looks like the bottom of my shoe or a shoe that I've seen before So things like that so I can talk about it, but I never give I definitively this caused this injury unless someone tells me that this is what caused that injury and I say Oh, yeah, that looks like that now Do I have cases where someone said this caused that injury and then I look at the injury and I'm like I don't see that this caused that injury Definitely I can see that does it mean that either thing is untrue that this child was impacted with an object and that this object caused An in that this object was used No, it just means the pattern doesn't match the thing that they're telling me and I'm able to say that because again I'm not trying to find abuse. I'm trying to make sense of what I'm seeing in this child The next thing is the age and development So again researchers have looked at lots and lots of kids and what we find is the younger a child is The less likely they are to have an injury and that totally makes sense because kids when they're really young and they're not moving around They're not interacting with the world unless the world interacts with them And so routine care and handling of an infant should never result in an injury Right. There's nothing about an infant's skin that makes them more susceptible to bruising than an adult or an older child And so nothing about routine care and handling should result in an injury So if you have a young child who is not mobile when I say not mobile I think about not yet crawling and they have an injury any injury no matter how small it is no matter what it looks like That is concerning for physical abuse because they should have zero injuries because they're not interacting with the world Now when they start to be mobile so crawling pulling to a stand cruising Then you start thinking about again how the kids fall down and those very concerning locations that when it comes That's when it comes into play about where you want to be concerned about where an injury is And then we talk about the history. So of course if a child tells you that they're being hit And it left a physical injury. That's physical abuse If a child is disclosing that they've been hit you should make a report to child protective services A physical injury that results during a domestic violence episode is physical abuse here in the state of texas And in many states they look at it like that. And so that is something that needs to be reported to child protective services And of course we know that there are lots of reasons that kids don't tell about what's going on with them at home And we're going to talk a little bit more about what those reasons are and so it's okay if you ask the child What happened and they tell you something or they don't tell you that doesn't necessarily mean that it's abuse It just means that they're not ready to tell you or that they're afraid to tell you something If it's in a concerning location if it's an immobile child if it's a patterned injury Those are reasons that you should make a report to child protective services so that we can get more information And try to figure out what's going on and make sure that that child is actually safe So Getting the history it's okay to ask a kid about it If you can don't ask what the parents present in case they're the person who the people who caused the injury You don't want to ask leading questions. So what I mean by leading questions is don't say well your mom hit you, right? Right, you don't want to ask them what happened just ask things like What happened? How'd you get that boo boo buddy? What's going on? So very open-ended questions give the child the opportunity to let you know what's going on And if they tell you something and it doesn't seem to make sense with you, that's fine You don't need to interrogate that child and say like you're lying You're not telling you the truth If you continue to have a suspicion after you've asked the question Make the report to child protective services so they can investigate and figure out more what's going on So be concerned if the child discloses physical abuse if they have injuries on the On those locations that we talked about the chest the ears the neck the back the the genitals the buttocks in the mouth Any infant with a bruise is concerning for abuse if they have a patterned injury that's concerning And of course if they tell you that something bad is happening to them So we talked about neglect being the most common form of child maltreatment And it's really hard to define and so there's actually no definition So you want to think about neglect as something that parents didn't do versus child abuse is something that they did do So the way I think about it. It's something that's minimally necessary for the safety growth and development of a child Now there are different kinds of neglect right we can think about it in different ways So active neglect is intentionally not doing something so they're not taking full responsibility Versus passive neglect. So that's unintentional failure And so that can be because of lots of different reasons again, whether it's active or passive our job is not to determine that Our job is to make sure that the kids are safe and child protective services will do a further investigation and make Make adjudications based on that Lots of different forms of neglect such as lack of supervision Inadequate food clothing or shelter educational neglect Medical neglect and then other forms of neglect that the state may have to Now I want to take a moment to talk about domestic violence quickly domestic violence is a form of neglect the reason That we know that is because that we think that way is because children who live in homes with domestic violence Are physically abused and neglected at a rate 15 times higher than the national average For a young child witnessing assault against their mothers is associated with more symptoms than any other type of trauma including assault sustained by themselves 12 of children present during a violent episode or injury And so exposure to domestic violence is very concerning for neglect And what child protective services looks at is the different kinds of exposures the way they've been exposed And so our job again is not to make determinations about this If we're concerned that domestic violence is going on and there are children in the home Then that's that's a home that should be reported to child protective services So they can investigate and make sure that those kids are safe So lastly, I want to talk to you about sexual abuse and your next session is going to be about sexual abuse So i'm going to go a little bit fast on this one So this is the uh federal definition of sexual abuse and again Every state has their version of this It's the employment use persuasion inducement enticement or coercion of any child to engage in Or assist any other person to engage in any sexually explicit conduct A simulation of such conduct for the purpose of producing a visual depiction Uh, the rape and in cases of caretaker interfirmative relationship statutory rape molestation prostitution or other forms of sexual expectation of children or incest with children So lifetime prevalence of unwanted sexual experience for girls is about 25 percent for boys. It's about 10 percent Girls are more likely to abuse than boys But we think that that number is a little bit skewed because girls are more likely to report sexual abuse than boys are And girls are more likely to be sexually assaulted during their teen years than any other time Risk factors for sexual abuse Sexual abuse sexual abuse is not like physical abuse where we think it happens in lower socioeconomic status more commonly or neglect Sexual abuse can really happen in all socioeconomic classes and ethnic groups some things that increase the risk Are disabilities in the children children who are pre-verbal and of course having a very chaotic household with multiple caregivers present So some things about sexual abuse That people think but aren't true that the perpetrators are strangers In reality most perpetrators of sexual abuse are known to the child and known to the family Perpetrators who sexual abuse boys don't sexually abuse girls Most perpetrators are not specific to anything. They're situational So if a situation arises that they can do something then they do it. So it doesn't matter whether it's a boy or a girl Children will tell you what's going on immediately. That's not true and we're going to talk about why not Children tell fantasies So we know that children don't typically make up fantasies about sexual abuse And that's done based on years of research looking at how kids fantasize and when kids fantasize They fantasize about things that are good for them that make them the hero and sexual abuse does not make children the hero So they don't fantasize about sexual abuse Also, children can't fantasize about something that they haven't had experience with And so they've either been exposed to something inappropriate or something inappropriate has happened to them as a result for them to give you a disclosure of sexual abuse And then any child victim with penetration will have an abnormal exam and that's not true. We're going to talk about that too So every child has sexual behaviors. It's along the spectrum of normal behaviors There are some sexual behaviors that are normal and some that are abnormal So this researcher looked at sexual behaviors and described them in normal children And this is a graph that he made looking at boys and girls and the amount the frequency of sexual behaviors they have and what he found was both boys and girls have the same frequency same amount of sexual behaviors And that at about between somewhere three to five There's this big peak and then it starts to go down and he stopped looking at 12 But we know in adolescence those sexual behaviors increases because of going through puberty So the key to get from this is that both boys and girls have sexual behaviors And that it is very common and we have a big peak in that three to five year range Now normal sexual behaviors and kids can be influenced by their surroundings So how old they are who do they live with what happens? How do they talk about sexuality in their homes? Do people walk around naked and it isn't a big deal in their house? All of this will influence what's a normal sexual behavior for a child The most frequent normal sexual behaviors are self-simulation Exhibition Exhibitionism and behaviors related to personal boundaries So those are the kids who get too close they're close talkers or they touch people in You know touch breasts or buttocks when they when it seems inappropriate Again, they just have problems with boundaries and those can be very normal Especially in those young kids because they haven't learned what those are yet Self-simulation so masturbation very common behavior not abnormal does not mean sexual abuse It means it feels good and the kids are self-stimulating We tend to see it a lot when kids are falling asleep when they're tired when they're stressed out The best way to handle it is to ask them To go if they need to do that they can go to a private space do that wash their hands when they're finished Or you can ask them to stop usually most kids are can be distracted from normal sexual behaviors because they're transient They respond to redirection and if it's between children, it's not cohesive. It's very cooperative. They each want to do it I'll show you yours, you know Not coercive or aggressive So there's not any single sexual behavior that indicates sexual abuse We have to look at all of things in context Abnormal sexually risk can also be just a part of other behavioral problems So it makes you concerned if it's a represents a sudden change in behavior if it's persistent if it's aggressive And if it's imitative of adult sexual behaviors So the way we find out about sexual abuse in my field most of the time is that the child tells however It takes about two years for a child to tell Someone witnesses the abuse is very rare the perpetrator confesses again very rare and then the kids actually have symptoms or injuries Those again are very very rare So a kid telling is the most important thing So of course if a kid tells you or if they're having abnormal sexual behaviors, you should suspect sexual abuse Now when someone tells you about sexual abuse You may feel completely overwhelmed and so Couple things I want to tell you about most cases the physical exam findings is completely normal Reason is that most abuse may not involve something that causes an injury Also that part of the body is made to stretch and accommodate so it might not get injured It also heals really quickly. So even if it gets injured It healed before I can see them because again kids take on average two years to tell what's going on So it looks completely normal And so the reason that I do a medical evaluation is not so much so that I can find evidence that this happened Is because I can find out what's really going on with that child My job is to be a trusted and neutral party I look for injuries. I look for sexually transmitted infections. I look for pregnancy I make referrals to other medical professionals Psychological referrals and I reassure them that even though this bad thing happened to them Their body is healthy and normal and nobody would know something happens to them without By looking at them because I can't tell by looking and I and I'm looking to see if something happened to you So reassuring the child and their family that their bodies are healthy and normal So the absence of physical findings does not rule out the possibilities of sexual abuse So what do you do if a child discloses to you believe them listen to them Tell them they did the right thing by telling you do not interview them Don't ask all the questions You're so you want to find out because we all want to find out so that we can do the best and help You can't don't do that. That's what style protective services and law enforcement is for Document what they're saying document the context of their disclosure Did you ask them a question or did they just come up and tell you report it to child protective services to law enforcement? Reasons kids don't tell is because when they're really young they might not know what's happening to them is bad They might have been threatened. They might have been said told. This is a secret They feel trapped and helpless. They don't they fear that people aren't going to believe them They feel responsible children at that at a young age Everything is their fault and so they feel like it's their fault. They want to protect their family Even the offending person they want to protect because they love them because they're their family So sexual behaviors do not necessarily mean child abuse, but they can so you have to look at the context of it Disclosure is the most important part of a sexual abuse evaluations And if a child discloses to you control your emotions and make the necessary reports The last thing I want to leave you with and this is something you're going to talk about a lot in your next session Is how to protect children from sexual abuse? One thing we can do as a general is use appropriate language So use the right names for all the body parts to make sure that kids know how to talk to you about their bodies Don't tell them. They're not allowed to say those words. Don't make it bathroom words Give them the opportunity to talk to you about anything they want to talk to you about about their own bodies In this time and space they feel comfortable telling you about it Don't force affection. So hugs and kisses especially here in south texas. That's just part of our culture However, when you force them one to hug someone that makes them uncomfortable or kiss them one that makes them uncomfortable You take away their autonomy and you let children know that it's okay sometimes to let people do uncomfortable things to their bodies So suggest instead that they can give high fives or handshakes or waves from afar Give them that autonomy for their body so that they don't feel like they have to do something uncomfortable It doesn't give them the idea that adults can do things that they don't want them to do explain what safe and unsafe touches are And make sure you control their media exposure children today have lots of things they can see in here And if they're exposed to sexually explicit material, they will play in a sexually explicit way And so we want to make sure we don't do that All right, that's the end. I know I went a little bit over. I'm sorry Um, let me see what questions there are Um a question my sister was told that she will get a visit from cps Because my niece is not eating well. She's 16. My sister is all scared Why the doctor is telling her that she has pancreatitis and she eats just That sometimes she won't want to so again, um It I don't know the aspects of the case and so it just depends on If child protective services visits and they talk to the physician and they find a medical reason for the reason that you're That your niece is not eating then that's they just find the medical reason if there's something else going on Then they they would find they would do they have interventions that they can take so again I know your sister is worried, but they will do a full investigation and it won't be just come in and say Oh, she's not eating and there you go at the end of it. It will be a full investigation Well, they'll talk to the physicians. They'll ask you what's going on with the medical health. So it won't be It won't be like that Should pictures be taken of physical injuries noticed on a child? so From a medical standpoint, we definitely take photographs child protective services take photographs law law in person take photographs If you're able to take photographs, you can definitely do so. I want to caution you photographs that are on sensitive areas of the body That it might not be the best thing for you to do if you're making a report for child protective services because you're worried about an injury They are going to be taking photographs. So that would be something As long as they're responding to it in a timely manner and the injuries are going to be gone There but if you're worried the injuries are going to be gone, then you can certainly take photographs What if a caseworker quickly says well children that age don't really know anything When the kids do talk very well and understand things So again, you need to when you express your concern. That is all you can do is to express your concern make a report Unfortunately, we can't control what cps does with the information And so if they choose To not investigate or they choose to not do a good investigation because these are human beings doing Investigations and I like to think all of them do a really great job But as we all know, there are some people who don't we can't control that So if you continue to have a concern I would make another report and another report and continues giving your Reporting your concerns Because that's the only way we have to keep that child safe and we can't control what cps does So don't let what you think the response is going to be affect whether or not you make a report There's there's a question up at the top. What happens? Yes, I see it What happens if cps tells the family who called is there a consequence for them? So Cps legally cannot tell the family who called now a family may come back and say cps told me you called That may be them trying to find out who called so it's not necessarily that cps told them It's that the family is trying to fish and find out who called. That's what I've found most often Is that they don't know They didn't they did the cps didn't tell them they're just trying to figure out so they come and they say I know you called cps and that's like And sometimes it is you and because you know that you called you feel like okay Yes, cps told them but a lot of times it's the parents and sometimes again They can figure it out because of the circumstances of it Again, that should not prevent you from calling If you think cps caseworker did Tell the family who called you should call their supervisor if the supervisor isn't responsive call the person above them And keep calling the person above them until you get the response But I will caution you that some families say that but they don't actually know it They say that as a way to try to find out And see if they can find out who made the phone call because they're at at some points They're trying to you know find someone to blame for what's happening in their lives Next question how Would someone figure out emotional or mental abuse from a parent? I understand physical abuse, but that the child is still with the parent while asking questions How is that figured out as far as mental and emotional abuse? Right? So mental and emotional abuse are much harder Determinations to make so the way that that is determined is if this child is having Psychological effects. So are they having behavioral problems as a result? Are they having depression? Are they having anxiety? And so again at the very beginning It's very difficult for Like me. I'm not a psychologist to a psychiatrist to figure that out And so I would say that if the child is telling me things that it's concerning for the way that a parent is talking with them And they they they tell me that they feel like their parents don't love them Or they feel worthless or things like that I would report to cps and say i'm concerned about emotional abuse and then as part of their investigation Cps is going to cps talks to the child alone to the parent alone They talk to other people in the child's sphere to see how the behaviors are They might get a psychological evaluation for the child. So those are ways that they determine that So if you are concerned about it, absolutely make a report with the reasons that you're concerned about it Um knowing that it's definitely harder to show But if you're concerned about emotional abuse chances are there's lots of other things going on in the home and cps investigation is probably Would be helpful to that family How does cps justify using testimony of a three-year-old against an adult even open-ended may want to tell you what you want to hear and keep changing stories So I'm guessing that means in relation to sexual abuse. So we know that Children don't tell fantasies about sexual abuse. So if a three-year-old is making a disclosure that is concerning for sexual abuse That warrants further investigation now depending on the development of a three-year-old We the the investigative process There's something called a forensic interview The forensic interview is conducted by someone who's specifically trained to talk with children in a non-leading manner using open-ended questions To discuss everything that's to discuss everything that's going on So Again, because we know children don't lie about sexual abuse We know that if a three-year-old is using language and saying things that are inappropriate Um sexually inappropriate the likelihood is they've been exposed to something inappropriate And that could be pornographic material or it could be that they've experienced something and that's where the investigation comes in Further and trying to decide so it's not It's I don't want you to think about it as a the three-year-old is against an adult Because the three-year-old is a person Who can give you information? It's just how you get that information and we definitely try to be We use the forensic interview as a way to try to tease that out So if a child in a child care is engaging in self stimulation We are to allow it and it's okay between one and another child I'm certain child care license will not see it that way It is a normal behavior And you don't want to you can ask them to stop you can talk so children can understand What behaviors they can do in certain spaces at a very young age? So children know the different ways the rules they're at home the rules There are child at daycare and so you can tell them that we don't do that Here that is something you can do at home in privacy in your in your bedroom It's not something it's not appropriate to do that here. So in addition to teaching them And you want to make sure when you tell them you're not telling them because it's a wrong thing to do It's just inappropriate to do in the space that they're in So you don't want to make them feel bad So someone answered your question and said they've had a three-year-old who did it every day at nap time And our rep said that we were doing the right thing by just asking her to stop It's normal and you're not supposed to shame them on it not between two children That's not what she said so You need to make sure exactly you don't want to shame them You want to make sure that you're letting them know because again, it's their body They're allowed to touch their body in any way that they want to Um, you just talk about what's appropriate and what's not appropriate for the space that they're in And that's the same thing I tell parents like you don't masturbate in the living room You can go to your bedroom when you're done wash your hands and come back and join the family So you talk to them about that that and when I talk about Normal sexual behaviors normal exploratory behaviors between children of the same age That again can certainly happen and can be normal. It doesn't mean one of them has been sexually abused But if you see that happening again in the space that it's happening You redirect the children and if it's a normal behavior, they will be redirectable Just tell them to stop. So i'm not saying let it all happen in inappropriate spaces It's recognizing whether something is normal or abnormal and raises your suspicion for concerns of sexual abuse We have just a couple more minutes before the next session starts, okay Should I ask a few questions to complete the report to cps? It depends on the situation and the questions that you're asking If how what you need so for the report to cps You just have to report what your concerns are and then they ask you like other Ancillary questions. So if a child is saying i'm being hit With by my mom that is enough information for you to make a report to cps You don't need to find out when how why that sort of thing um The sexual abuse the things the most important thing there is to find out when the next time they have Contact with the potential perpetrator because you don't want to send a kid home in a terrible situation So it really depends on the situation whether or not you ask a few more questions And again the way that you ask it it needs to be very open-ended and depending on the age of the child That's how you ask those different questions. So it's difficult to answer that one sort of like that Some children will not trust a new person when then they clam up Yep, absolutely and we know that we definitely know that and we take that into account So some cases so, you know Some kids tell me things that they don't say during their forensic interview or they go to their forensic interview And they say things and they come and see me and they don't tell me anything And that is totally fine. We understand that and we understand the um The uh development of children and what they will and will not do And so when you know, this process is not something that happens in isolation So when a child when a report is made to child protective services The cps is involved medical personnel could be involved law enforcement can be involved The children's advocacy center where we do forensic interviews can be involved their counseling can be involved Attorneys can the da's office can be involved. So we all meet regularly to discuss cases that we Are uh stuck or have concerns about and so it's not just one case worker making a decision You have the potential for all of these community partners who work in child maltreatment to look at all these cases and Give and add all of their expertise because we're all trying to do the same thing We're all trying to protect kids in our community. And so there's lots of things that happen once that investigation starts It's not just a One Process, it's a very complicated process. And so we recognize all the different aspects of kids and try to do that Okay, given I think we're gonna have to end um, okay Because the next session is about to start but you can answer in the comment if you want you can type out a comment Yeah All right, thank you all so much for attending and we're gonna end this session and Give you a minute to get over to the next session