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UPDATE ON MICHELLE
 
A few weeks ago, her mother’s boyfriend attempted to rape Michelle.  She fought back and, in the struggle, he broke her wrist.  Her mother’s boyfriend waited until her mother came home to take Michelle to the hospital. While they were waiting for her mother, the boyfriend threatened Michelle that if she told anyone what he did he would hurt her worse next time.  Michelle told the hospital nurses that she had been clumsy and tripped on her brother’s toy on her way to the bathroom.  The hospital staff became suspicious because her wrist injury was not consistent with a typical fall and made a report with Child Protective Services.  CPS has opened an investigation but is having trouble gathering information because Michelle’s mother refuses to cooperate.  What should CPS do?
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What do I think?

 

1. I think it would actually be very difficult to tell if the 14 year old's fracture was not consistent with the mechanism of injury at this age.  We can tell in infants with posterior rib fractures, metaphyseal fractures, or multiple fractures, fractures at varying ages of healing and certain long bone fractures in toddlers that these do or very likely do represent cases of non-accidental injury.  In a 14 yr old girl, to determine if this fracture was non-accidental would generally be difficult unless it looked like a crush injury or something very serious. Most wrist fractures in a teen won't scream, "I am the result of abuse" and would more likely prompt an order for a vitamin D level. I don't even believe in most ED departments that with the history as written above, a CPS case report would even be initiated.

2. So a more important question might be, what could the ED do? Well first you want a good physical exam. In a 14 yr old with this hx, it would generally be inappropriate to completely undress and look at this child's entire body, but certainly she could take her shirt off (especially if in long sleeves or a turtle neck) so her shoulder and upper arm could be viewed for range of motion and other external indicators of other trauma such as bruising.  Looking at her neck for signs of strangulation marks would be important and easy to do. Also looking at her arms for evidence of cutting would be important and would suggest something more serious is going on in this family.

3. Also some type of questionnaire for the patient (not just intake information for the family may be helpful).  A simple questionnaire given to the teen about safety -- with just 4 yes/no questions could be useful. Along with a statement such as, in our ED we give this questionnaire to all teens who come in. 

  • Do you feel safe at home?
  • Do you feel safe at school?
  • Do you feel safe with friends?
  • Do you feel safe in your community?

Having a means of asking these simple yes/no questions to the teen  on a form that she can fill out without being required to verbally answer such questions in front of potentially punitive parents might just allow her to answer no to feeling safe at home and then the doctor could speak to her alone and ask why.  This happened to me when I was 14. My dad punched me in the face and it cut my eyebrow (about 1 inch gash) and blackened my eye. My school teacher for the first time asked me what happened and guess what I said? "I fell".  But if she had given me something to write on asking if I felt safe, I don't know for sure but I am certain there would have been a greater likely hood of my answering no to "Do you feel safe at home?" 

 

So.....

I think this case, unless obvious non-accidental trauma occurred --- likely with multiple injuries or a significant complicated wrist fracture requiring surgery, wouldn't even prompt CPS referral and if it did would likely be "screened" out.  75 - 80 percent of CPS reports are screened out... meaning that they do not fit a definition where the state would believe an investigation is required. This occurs at least in Michigan. 

 

Now the doctors could hospitalize her especially if she needed surgery on the wrist and not just casting and then they could get the hospital social worker involved and an astute and compassionate doctor could very likely get this girl to open up.  

 

So what should CPS do? They most likely wouldn't be involved.  What is more important is this. How can the doctors caring for this injured child have a greater "index of suspicion for abuse." 

 

Actually there is one thing that CPS should do.  That is accurately document a report.  If in the future there were further reports, this makes it more likely that eventually an investigation would occur.

 

Thanks. 

Last edited by Former Member

Okay so I will add a little more hx: 

 

In the ED, the attending physician when doing the initial physical finds bruise marks on Michelle's arms that are in the shape of a human handprint. After this discovery - a CPS referral is made. What should CPS do?

 

In this case they should take Michelle and her brother to the closest Children's Advocacy Center - assuming one is close. 

 

There they would also contact the police and a trained interviewer from the CAC would interview Michelle in a teen friendly atmosphere.  These interviewers (our Kellie for example --- kudos to you Kellie -- I know that work is hard to do) can be very good at getting children to open up and to actually tell what is happening to them.  CAC interviewers aren't always successful but the more interviews they have done, the better they become.

 

Let's first assume Michelle opens up and tells all.  Then Michelle would be asked to have a forensic exam after the interview by a physician trained in this area.  Michelle however could refuse the exam and at 14, that is her choice.  Her 10 year old brother would also have an interview and an exam.  No matter how you slice this one, it will be traumatic but doing it at a CAC will give better results. In the past some of these interviews might begin in the police station (not very child friendly - and not very conducive to opening up or it may be done by a social worker a little better but still difficult).   If Michelle refuses to discuss how she got the bruises and the broken wrist, it is possible that her 10 year old brother who would also be interviewed may reveal detail he knows, for example did he hear the argument? Did he hear arguments in the past?  Any information he provided could be shared with Michelle and then she may decide that it is time to tell what happened to her.  So assuming she does tell.  

 

Then comes the hard part.  Likely both children will be taken into CPS custody.  The mother may be allowed to get her children back in time after she gets rid of the boyfriend.   But in the immediate circumstance a determination of safe placement for both children would have to be made.  Hopefully there is a trusted relative such as an aunt or uncle who could take both children.  I am not sure if the state would let the children go to NY with the father but he may be able to come back to California for a while.  If no safe relative placement could be found and if foster placement is the only option, the best option would be a home that can keep both siblings together and in the same school district so as not to further exacerbate trauma anymore than it has to be. If this isn't possible then I am really sad for both children. 

 

Siblings in Foster Care Maintaining the Ties that Bind (University of Minnesota)

 http://cascw.umn.edu/wp-conten...ractice-Notes-09.pdf

Last edited by Former Member

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