Child Abuse and Maltreatment/Neglect:
Identification and Reporting
New York State Mandatory Training
Case Studies: Identifying Abuse
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 it.
- Corey has bilateral bruises
on his shoulders and arms. Accidental injuries tend
to occur on one side or another, not usually on
both shoulders or both arms.
explanation that he was "beaten up" by classmates
is not consistent with what EMS personnel describe
about the injury during physical education class.
is fearful when his father appears.
stops crying when his father appears.
father is angry and not concerned about his son's
father belittles Corey about his ability to play
- Corey's father uses shame
(ie. "acting like a baby") because Corey had been
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Juanita is withdrawn and has bruises on her face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?
- She has bruises on her face
has had a change in behavior, from outgoing and
engaging to withdrawn and tearful.
- Ms. Flores says Juanita
has been "bad".
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.
- Sam wears a short-sleeved
t-shirt even during cold weather; this is inappropriate
attire for the season.
family did not seek the medical attention that you,
as the teacher, suggested because of Sam's limping
and apparent injury to his left ankle.
seems nervous and is easily startled.
is preoccupied during class and doesn't pay much
attention to the class work.
doesn't make eye contact and is isolated at school;
he is often teased at school.
- Sam's ankle is injured and
Sam's family has not sought medical attention for
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.
has lost significant weight since birth. Although
some weight loss is not uncommon, by 10 weeks, she
should have gained more weight.
home is lacking formula for Alicia.
has circular burn marks on his arms and legs; the
nurse notes that they look like cigarette burns.
has a patterned bruise on his back which looks like
a wooden spoon.
is lethargic, cries frequently and seems fearful
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 has
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
has frequent complaints about abdominal pain; these
complaints often happen on Mondays, after spending
the weekend with her father.
year old Tisha has tested positive for a sexually
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, particularly Michael's
controlling nature. 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 used condom in
the trash. As the therapist, what should you do?
father is seen leaving Tisha's room and then throwing
a used condom in the trash.
has a controlling nature.
is uncomfortable with the closeness between Michael
and Tisha and his limitation of Tisha's playing
with other children and even Tisha's getting close
fears that Michael is sexually abusing Tisha.
Case #7: Marcus, Amber and
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?
children appear to be hungry when they come to school.
children often don't have any lunch, or if they
bring lunch it is not enough.
Shaw children, normally quiet and private, when
they speak with the nurse provide information about
their father's underemployment/unemployment.
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. 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.
of the boys at the residential treatment center
have reported that they have been sexually abused
by staff members.
showed his bloody underwear to the nurse, Jean.
felt uncomfortable with the way some male staff
interacted with the boys, either to rough or too
told Jean that an aide, Joe, was forcing him to
have sex and that Joe was making money since he
was taping the sexual activity and then selling
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