Ken Hammond, USDA
Case #1: Corey
Corey is an 8 year old
boy who was brought into the emergency department
where you work, by EMS personnel after he was hit
by a softball during physical education class at school.
Corey lost consciousness for several minutes. During
the physical exam, you note that he has bilateral
bruises to his shoulders, arms and abdomen. Crying,
Corey reports that he was "beaten up" by classmates.
When his father arrives at the ED, Corey becomes visibly
fearful and stops crying. The father is clearly angry;
he begins to shout at Corey about having to leave
work early during an important business meeting; he
was shouting at Corey about not paying attention to
the game, about being a lousy ball player and acting
like a baby. As the physician in the ED, you note
the dad's behavior and how Corey is responding to
Case #2: Juanita
You are a family nurse practitioner working in a primary
care office. Juanita's mother comes to the office
in follow-up to the hypertension noted at the last
visit. She brings 9-year old Juanita with her to the
appointment, as she usually does. Today you note that
Juanita is withdrawn and has bruises on her face and
arms. She looks like she's been crying. Juanita is
typically a chatty girl who usually engages you in
talking about her love of dancing, often showing off
her latest moves for the staff. Her mother appears
irritable and distracted. You ask her what's wrong
and she says she's fine. You mention that Juanita
is so quiet and looks upset today, to which she replies
that Juanita has been "bad". What would you do if
you were the nurse practitioner this situation?
Case #3: Sam
Twelve year old Sam comes to school wearing only a
short sleeved t-shirt and jeans on days when the temperature
is in the 30s. Sam is a quiet, slender young man.
He often seems nervous; he is easily startled. Sam
is a C student. He never seems to be paying much attention
during class; he looks preoccupied. Sam doesn't make
much eye contact. He spends most of his time alone;
he doesn't really have any friends at school. Indeed,
often Sam is the focus of harassment and teasing from
his classmates. About 2 weeks ago Sam came to class
limping. He said he sprained his left ankle. The ankle
didn't get better after a week, so you sent a note
home to have Sam's family get medical attention for
Sam. That was last week and there has been no change.
As the teacher in this 7th grade classroom you wonder
if Sam might be really injured.
Case #4: Alicia and Martin
The visiting nurse comes to the home to follow-up
on 10 week old Alicia. The baby was born to a 19 year
old mother with a history of cocaine addiction. Alicia
weighed 6 lbs. 2 oz. at birth and was not drug addicted.
Today, the first day you have been able to get into
the home since the referral was made 6 weeks ago,
you note that Alicia weighs 4 lbs. 6 oz. The mom tells
the nurse that she ran out of formula yesterday and
hasn't had a chance to get to the store yet today.
Alicia is fretful, but does not cry. Also, during
the home visits the nurse notes that 3 year old Martin
has circular burn marks on his arms and legs. He is
a lethargic child who cries frequently and is very
shy and fearful of adults. The nurse examines Martin
and finds that he also has a patterned bruise on his
back which looks much like a wooden spoon.
Case #5: Tisha
5 year old Tisha has been to see her primary care
provider almost weekly for the past month. Each week
Tisha has complained to her mother that her stomach
hurts, so her mother brings her in to be examined.
Tisha's only symptom is abdominal pain. She has no
nausea, vomiting or diarrhea. She is well nourished
and developmentally appropriate for her age; she clearly
has been well cared for. Multiple diagnostic tests
have been run over the past month. As the family nurse
practitioner in this practice, you must inform Tisha's
mother that Tisha has tested positive for syphilis.
Case #6: Leah and Tisha
As a clinical social worker, you are Leah's therapist.
Leah is step-mother to 5 year old Tisha, having been
married to Tisha's father, Michael, for the last 6
months. The whirlwind relationship has been the frequent
topic of your sessions. Leah has also talked about
her role as a step-mother and her discomfort with
it. She thinks that Michael and Tisha are too close;
it makes her uncomfortable. Leah reports that she
thinks Michael is too protective of Tisha, not really
allowing her to play with other children when she
is staying at their house, even limiting her contact
and relationship with Tisha. In the last session with
Leah, she told you that she fears that Michael is
sexually abusing Tisha: she saw him leave Tisha's
room early in the morning, when he thought she was
sleeping; she saw him toss a condom in the trash.
As the therapist, what should you do?
Case #7: Marcus,
Amber and Isaiah
Sometimes, the Shaw children come to school appearing
to be hungry. You are the school nurse who comes to
this school most afternoons, usually getting to the
school at lunchtime. You note that the Shaw children
often don't have any lunch. When they do bring a lunch,
it is often not enough food. Other than this, the
children seem well-groomed and well-behaved. The children
are generally quiet, rather private. As the nurse,
you begin talking to them and learn that their father
does seasonal work and is often between jobs. How
would you handle this if you were the school nurse?
Case #8: Tim
At a residential treatment center for boys age 13-16,
recently some of the boys have alleged that they were
sexually abused by staff. The internal investigations
at the facility have never supported these claims.
One of the registered nurses, Jean, suspects that
what she is being told by the boys is correct; she
has noted how some of the aides, mostly males, treat
the boys so roughly on the one hand and then at other
times are often way too familiar. She has often felt
uncomfortable with their behavior. 15 year old Tim
showed Jean his bloody underwear. He also told Jean
that one of the aides, Joe, was forcing him to have
sexual relations with some of the other aides and
that Joe was making money on it. Jean complains to
the facility administration about these allegations,
but was told that an internal investigation has occurred
and there is no evidence that these allegations are
based in fact.
These situations are real, or at least they
could be real; several are based on real situations. If you
were faced with these situations, what would you do? Do you
know what child abuse looks like? Would you recognize child
abuse if signs and symptoms were presented to you? Would you
know what to do ethically if you suspect child abuse? Do you
know what you must do legally if you suspect child abuse?
What if you are not sure? Do you know what you might face
legally if you did not report your suspicions? Would you face
repercussions if you did report? How should you proceed?
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