Assessing Allegations of Physical Abuse

0070-529.10 | Revision Date: 10/24/22

Overview

This policy provides an overview for assessing allegations of physical abuse and provides instructions on observing, gathering, and assessing evidence.

TABLE OF CONTENTS

Policy

Physical Abuse

Documentation

Forensic Evaluation

Medical Hub Referral

Forensic Evaluation Results

Medical Hub Referral Follow Up

Consent

Procedure

Investigating a Referral Alleging Physical Abuse

CSW Responsibilities

SCSW Responsibilities

Obtaining a Forensic Evaluation

CSW Responsibilities

SCSW Responsibilities

Reviewing the Results of a Forensic Evaluation

CSW Responsibilities

SCSW Responsibilities

Approvals

Helpful Links

Attachments

Forms

Referenced Policy Guides

Statutes

Version Summary

This policy was updated from the 07/01/14 version, to align with current policy and practice for assessing suspected or known physical abuse during an emergency response (ER) investigation or throughout the life of an open case.  Additionally, clarification on when to refer to a Medical Hub for consultation and obtaining forensic evaluations have been included.

POLICY

Physical Abuse

Physical abuse, which refers to non-accidental bodily injury inflicted on a child, can include a single incident ranging from “over-discipline” (e.g. the caregiver loses control and inflicts a mark or bruise on a child) to the extreme case of child death.  The longer the physical abuse continues, the more serious the consequences.  Early identification of child physical abuse and effective intervention is critical.

Regardless if a child has already been treated for an accidental injury, CSWs shall not assume all injuries are accidental.

Indicators of physical abuse include, but are not limited to:

• Bruises/welts in unusual configurations, patterns or reflecting the shape of the object used to inflict the injury

• Lacerations/abrasions to the head, face, mouth and other body parts

• Cluster bruises of various colors or stages of healing that may indicate repeated abuse

• Burns/scalds that may show the shapes of the item used to inflict them, such as a cigar; or that are found on different parts of the body (e.g., soles, palms, back or buttocks)

Physical abuse is a criminal offense.  A child may be removed from the custody of a parent/legal guardian due to physical abuse.  As a result, law enforcement must be involved in all investigations when there are allegations of physical abuse. As mandated reporters, CSWs must cross-report all allegations of physical abuse. In many cases, a child may be referred to DCFS after law enforcement has already detained the child and/or the child’s siblings. 

CSWs must be familiar with the physical and emotional indicators of physical abuse by being observant and conducting interviews that address issues of discipline, punishment and physical abuse during all contacts with DCFS- supervised children.

• Consultations with supervisors, County Counsel, and any other staff that
  
  may provide guidance are strongly encouraged.

For every instance in which there are allegations or concerns of physical abuse, CSWs shall submit a referral for consultation with a medical hub (Hub) to determine the need for a forensic evaluation.

• The CSW is to call 9-1-1 for life-threatening injuries or in instances when
  
  they are uncertain about the extent of the child's condition.
  
  
• The child may be taken to an emergency room if it seems that immediate
  
  medical services are needed and there do not appear to benon-life-
  
  threatening injuries, etc.
  
  
• A parent/legal guardian consent or there must be exigency or a court order
  
  for medical services. The parent/legal guardian has a right to be present and
  
  may not be excluded absent parent/legal guardian consent, a legitimate basis
  
  for exclusion, or an emergency requiring immediate medical attention (see
  
  the "Parent/Legal Guardian Rights in a Medical Examination” section of the “
  
  Medical Hubs” policy for more information
  
  
• Consent also is needed for the CSW to take the child (and the family) to a
  
  medical facility (e.g., urgent care or emergency room) if the parent/legal
  
  guardian is unable to and/or unwilling to take the child to a medical facility. If
  
  consent is denied, the CSW should call 9-11 for medical transport (e.g., an
  
  ambulance).
  

Documentation

Any time marks or bruises are observed and/or when investigating physical abuse allegations, the CSW must complete the DCFS 550 Body Chart form, in its entirety, according to the instructions on the form. The completed Body Chart form must be placed in the child’s physical case file. CSWs are encouraged to upload a legible DCFS 550 Body Chart Form in CWS/CMS (green folder). Uploading the DCFS 550, Body Chart form in CWS/CMS is not a substitute for documenting written details in the CWS/CMS Delivered Services Log. Additionally, a consult or conversation with the SCSW will assist in assessing physical abuse indicators, even in situations where physical abuse was not initially suspected, not part of an allegation, or not the reason for an open case.

Forensic Evaluation

A forensic evaluation is comprised of a physical examination and clinical assessment to determine the presence and extent of injuries and/or signs of abuse and/or neglect (e.g. If there are marks, such as bites; fractures; burns; and/or bruises); and/or sexual abuse, and/or Commercial Sexual ExploitationConduct involving matter depicting a minor engaged in obscene acts in violation of Section 311.2 (preparing, selling, or distributing obscene matter) or subdivision (a) of Section 311.4 (employment of minor to perform obscene acts). Any person who knowingly promotes, aids or assists, employs, uses, persuades, induces or coerces a child, or any person responsible for a child's welfare who knowingly permits or encourages a child to engage in, or assist others to engage in, prostitution or a live performance involving obscene sexual conduct or to either pose or model alone or with others for the purpose of preparing a film, photograph, negative, slide, drawing, painting or other pictorial depiction involving obscene sexual conduct. 'Person responsible for a child's welfare' means a parent, guardian, foster parent, or a licensed administrator, or employee of a public or private residential home, residential school, or other residential institution. Any person who depicts a child in, or who knowingly develops, duplicates, prints, or exchanges, any film, photograph, video tape, negative, or slide in which a child is engaged in an act of obscene, sexual conduct, except for those activities by law enforcement and prosecution agencies and other persons described in subdivisions (c) and (e) of Section 311.3.' (CSE). It includes the provision of clinical care for all injuries and effects of abuse and/or neglect. This may include old injuries that may not be clinically obvious and the initiation of treatment.

Forensic evaluations interpret the physical findings regarding the likelihood that they are the result of abuse and/or neglect and may involve evidence collection, including evidence of sexual assault and STIs; and, may include photo documentation of injuries, including but not limited to, sexual assault injuries.

Forensic evaluations may include diagnostic imaging such as a skeletal survey or full body radiograph, Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). Diagnostic imaging is critical in detecting previous or hidden injuries and in obtaining accurate diagnosis and treatment for children. It is an essential element in documenting the evidence needed in both Juvenile and Criminal Court to protect a child from further injury and death.

• Certain fractures and injuries, such as those found in the abusive head trauma (AHT) formerly Shaken Infant Syndrome, can only be evaluated with diagnostic imaging.
  
  
  

Medical Hub Referral

Medical Hub referrals are required in all cases of suspected physical abuse.

• CSWs are reminded that abuse, neglect and CSE may occur either during an ER investigation or throughout the life of an open case.

Whenever allegations of physical abuse or sexual abuse or CSE of a child comes to the attention of a CSW, as soon as practically possible, the CSW shall submit a Medical Hub referral. The referral will initiate a consult with a Hub medical provider (aka, Specialist) who has specialized training in the detection and treatment of child abuse and neglect. It is the responsibility of the Specialist to determine if a forensic evaluation is appropriate. If it is determined that a forensic evaluation is necessary, an additional referral to the Hub is not needed.

• Out-stationed CSWs are available to facilitate consultations with the Hub medical providers.
  
  
• If a forensic evaluation, or equivalent medical examination, was completed by a medical
  
  provider other than the Hub, the CSW must still submit a medical hub referral.

The need for a forensic evaluation is determined by the Hub medical provider on a case-by-case basis; some children may not require one. If it is determined that a forensic evaluation is necessary, the hub will determine the timing of the evaluation.

For siblings or other children who live in the same home and/or have contact with the alleged perpetrator (companion referrals or cases), the Hubs will request the CSW to provide complete information at intake from the CSW’s interview of each child.

In circumstances where the alleged victim is under the age of five (5) or is non-verbal, the Hub may request that older siblings or children/youth identified in companion referrals/cases accompany the alleged victim to the Hub to assist in providing history. In some instances, the alleged victim may be examined first and the other child(ren) may not require a (complete) forensic evaluation.

Forensic Evaluation Results

The results of the Hub forensic evaluation are documented in E-mHub and sent to the currently assigned DCFS regional CSW within ten (10) business days of the appointment, or ten (10) business days after the receipt of all requested medical records needed to complete the forensic evaluation.

• If the medical records are not received by the Hub forensic medical provider within ten (10) business days, the Hub forensic medical provider will communicate with the currently assigned DCFS regional CSW regarding what is needed to complete the forensic evaluation.

Medical Hub Referral Follow Up

Any child/youth with serious acute medical concerns may be referred to the Emergency Department or hospitalized, if needed, to address these conditions. The Hub medical provider will attempt to contact the DCFS CSW who submitted the Medical Hub referral by phone if urgent forensic concerns are identified, or in case of hospitalization. Hub clinics may provide follow-up care for identified forensic medical concerns if a child does not have a primary care physician that is able to adequately address these issues.

Consent

Forensic evaluations require:

1. Parental consent ; or,
   
   
2. Exigent circumstances which demonstrate either a medical emergency, or for preservation of
   
   physical evidence of a crime that is likely to dissipate before a court order can be obtained.
   
   
3. In some circumstances, youth may consent to a sexual abuse exam, if deemed sufficiently mature to consent.

Absent the above requirements, a request for an investigative / evidentiary medical examination, such as a forensic evaluation, should be made via:

1. A warrant , or
2. A court order

When completing a warrant consultation, specify the need for a forensic evaluation.

Back to Policy

PROCEDURE

Investigating a Referral Alleging Physical Abuse

CSW Responsibilities

1. Enter the home and assess all children in the household for signs or symptoms of physical abuse.

• Consent, exigent circumstances or a court order is required to enter a home.

2. Without removing the child’s clothing, look for immediately observable marks, bruises, or burns on the exposed areas of the child’s body.

• Examine all indicators in context with other family characteristics.
  
  
• Complete the DCFS 550, Body Chart as reflected in the Visual Inspection on Children policy

3. Observe whether the child wears clothing that is inappropriate for the weather, (e.g. long sleeves in very hot temperatures), which may hide possible injuries.

4. Interview each child separately and privately. Consider the child’s age and developmental stage, physical and mental health, and intellectual, verbal and cognitive capacity.

1. Approach the child in a non-threatening manner to establish rapport and build trust, keeping in mind that the child may:

• Be wary of all adults

• Be fearful of the parent/caregiver

• Accommodate a high level of family violence with the belief that physically abusive behavior is normal

• Be protective towards a parent/caregiver who is also a victim in a domestic violence situation

• Blame themselves and/or think the abuse was deserved

2. Assess the child’s emotional affect, including whether the child presents as:

• Compliant, withdrawn, uncommunicative, depressed

• Aggressive, agitated

• Fearful, vigilant

3. Assess for behavioral indicators, including, but not limited to :

• Destructive behaviors towards self/others

• Regression (e.g. bedwetting, soiling)

• Poor school attendance/performance

• Substance abuse, running away, or criminal violations

4. Ask the child how they are punished and/or disciplined in the home.

5. Follow-up on all disclosures of physical abuse even when it may be indirect (e.g. a child describing abuse as happening to a friend or someone else).

6. For each interview, document in the CWS/CMS Delivered Service Log if it occurred separately and privately, and if not, state the reasons
7. Be especially alert to the possibility of physical abuse when:

• The nature or extent of the injury does not fit with the explanation given.

• The child’s age or developmental stage is inconsistent with the type of injury.

• There is a high incidence of accidents or frequent injuries.

• The explanations given by the child, their sibling(s), and parent/caregiver(s) do not match.

• The severity or type of injury itself is of concern.

5. Interview each parent/caregiver separately and privately.

1. Consider whether the parent/caregiver who is alleged to be the perpetrator of physical abuse possesses any of the following:

• A current or past history involving domestic violence

• Substance abuse or mental health issues

• Low impulse control

• Unrealistic expectations of children

• Limited or incorrect knowledge of child development

• Negative view of a child or a fear of spoiling them

2. Consider that a child is often targeted for abuse when:

• Bonding and attachment have been disrupted (e.g. in an unwanted or difficult pregnancy, a lengthy hospitalization of a child with severe medical problems,etc.).

• The child’s appearance is perceived as ‘different’ (e.g. as the ‘wrong’ genderRefers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women. These influence the ways that people act, interact, and feel about themselves. Gender is different from Sex in that Sex is assigned at birth., having a darker skin tone, resembling the father/mother with whom the parent/caregiver has difficulty, etc.).

• The child presents behaviors or possesses characteristics, such as disabilities, that require special attention or care.

• Difficulties occur at developmental stages (e.g. toilet training, adolescence, etc.).

3. Consider the possibility of physical abuse when:

• The nature or the extent of the child’s injury is inconsistent with the explanation given by the parent/caregivers.
  
  
• There are multiple injuries, particularly within a short period of time, especially
  
  for children ages 0 to 5.

• The explanations are unbelievable, inadequate, and/or illogical, or changes over time and do not match those of the child, the child’s siblings or the other parent/caregiver.

• The alleged victim is accused of lying about the abuse.

• The parent/caregiver appears unconcerned about the child(ren)’s condition.

• The parent/caregiver appears to have concealed the physical abuse by delaying medical assistance or failing to attend regular health care appointments.

• The child has had unexplained fractures to the skull, nose, or facial structure and/or multiple or spiral fractures.

6. To evaluate physical abuse, consider differences in how cultures, ethnicities, races and/or religions view children, parental authority, and discipline.

• Be aware that physical discipline is permitted if the parent acted with a genuinely
  
  disciplinary motive, the discipline was warranted by the circumstances and the
  
  punishment was “reasonable.” Reasonableness depends on the age of the child, the
  
  part of the body that was struck, the instrument used to strike the child and the amount
  
  of damage inflicted.

7. If there is reasonable cause to believe that physical harm has occurred, and there is no other way to verify the allegation, consider whether removal or adjustment of the child’s clothing is necessary. 

• Follow all guidelines set forth in the policy on Visual Inspection of Children

8. Complete the steps below under Obtaining a Forensic Evaluation.
   
   
9. If the child has physical injuries or symptoms which may be indicative of physical abuse, consider detention if any of the following apply:

1. These physical injuries/symptoms are verified through a forensic evaluation to be the result of physical abuse, or

2. A verbal child:

• Discloses being physically abused

• Describes the perpetrator as being a parent/caregiver or other person who has access to them

• Is fearful of going home or remaining in the home

• Has observable marks, bruises and/or other symptoms of physical abuse

3. There is evidence that the child has been physically abused and the alleged perpetrator is the parent/caregiver and

• Has access to the child

• Discloses that they abused the child

• Displays symptoms of mental illness, and/or substance abuse

• Denies, excuses and/or justifies the abuse by not taking responsibility or blaming the child

• Is involved in a domestic violence situation

10. Complete the DCFS 550
    

1. If any marks or bruises or any other injuries are observed on the child, in addition to completing the body chart, document the dates it was completed in the CWS/CMS Contact Notebook
2. If not marks or bruises or any other injuries are observed, make a notation on the DCFS 550
   
   and document this information, including the date it was completed in the CWS/CMS Contact
   
   Notebook.

11. Absent exigent circumstances or voluntary parental consent to remove the child, a removal order is required for the detention. 

• If it is determined that a child is at immediate risk of serious bodily harm, detain the child immediately. 

• Consult with the SCSW, ARA, County Counsel or other DCFS staff that may provide guidance, as necessary. 

12. Complete the SDM Safety and Risk Assessments.

13. Document all information, including observations and findings in the CWS/CMS Contact and Health Notebooks.
14. On an open case, notify the child's attorney of the new allegations and the detention via the
    
    DCFS 5402, Notice to Child's/NMDs Attorney Re: Case Status.

SCSW Responsibilities

1. Approve all applicable SDM tools.
   
   
2. Ensure that a Medical Hub referral was submitted by the CSW.
   
   
3. Consult with the CSW and include the ARA in discussions, as needed.

Back to Procedure

Obtaining a Forensic Evaluation

CSW Responsibilities

1. If the child is in need of emergent medical care, call 9-1-1.
   
   

2. Submit a Medical Hub referral for a forensic evaluation.
   
   

3. Consult with a Hub medical provider (aka, Specialist) who has specialized training in the detection and treatment of child abuse injuries and child neglect. Out-stationed CSWs are available to facilitate consultations with the Hub medical providers.

• It is the responsibility of the Specialist to determine if a forensic evaluation is appropriate and if so, the timing of the evaluation.

2. Ensure parental consent is obtained for a forensic evaluation when there is no exigency. In
   
   situations where parental consent and/or exigent circumstances do not exist, consult with
   
   your SCSW and County Counsel regarding next steps, including possibly securing a court
   
   order for an investigative/evidentiary medical examination and/or investigative/evidentiary
   
   sexual abuse examination.

• Conversely, if the parent/caregiver refuses to cooperate, and it is an exigent
  
  circumstance, a CSW may enlist the assistance of law enforcement in securing a
  
  forensic evaluation. CSWs are to consult with their SCSWs and County Counsel for
  
  such circumstances.
  
  
• A court order must be obtained prior to the forensic evaluation for non-exigent
  
  circumstances or when consent is not given.
  
  
• Consult with County Counsel, as needed.

3. Complete the SDM Safety Assessment, SDM Risk Assessment.

4. Document all observations and findings inCWS/CMS the Contact and Health Notebooks.

• Consult with the Public Health Nurse (PHN) regarding documenting information in the
  
  CWS/CMS Health Notebook, as needed.
  
  

5. On an open case, notify the minor’s attorney of notify the minor’s attorney of the forensic exam
   
   and the results if/when available via the DCFS 5402.
   

SCSW Responsibilities

1. Approve all applicable SDM tools.
   
   
2. Ensure a Medical Hub referral was submitted, and that a consultation with the Medical
   
   Hub provider and/or forensic Evaluation occurred.

Back to Procedure

Reviewing the Results of a Forensic Evaluation

Staff are reminded that when reviewing any medical reports, such as the forensic evaluation results, to consider the totality of the information received and observed through interviews, etc. and not just the forensic evaluation results. Forensic evaluations are only one tool amongst many that CSWs are to consider when assessing the safety and risk of a child as the absence of physical injuries does not necessarily indicate that abuse and/or neglect has not occurred.

CSW Responsibilities

1. Review the forensic evaluation results.

1. Consult with the Hub for any clarification needed.
   
   

2. Determine next steps (e.g., removal, obtain a warrant, develop a safety plan, etc.).

1. Consult with the SCSW, County Counsel or any other staff for guidance as to next steps, as needed

SCSW Responsibilities

1. Review the forensic evaluation results.

1. Ensure that the CSW consulted with the Hub for any clarification, as needed, or consult
   
   directly with the Hub for such clarification
   .

2. Assist the CSW in determining next steps (e.g., removal, obtain a warrant, develop a safety
   
   plan, etc.).
   
   

1. Consult with the CSW, SCSW, ARA County Counsel or any other staff for guidance as to next steps, as needed.

Back to Procedure

APPROVALS

SCSW Approval

• SDM Safety Assessment

• SDM Risk Assessment

HELPFUL LINKS

Attachments

LA County Medical Hub Core Services - Escalation Decision Tree for CSWs

Forms

CWS/CMS

SS 8572, Suspected Child AbuseThe non-accidental commission of injuries against a person. In the case of a child, the term refers specifically to the non-accidental commission of injuries against the child by or allowed by a parent(s)/guardian(s) or other person(s). The term also includes emotional, physical, severe physical, and sexual abuse as defined in CDSS MPP Section 31-002(c)(9)(D). Report (SCAR)

SS 8583, Child Abuse Investigation Report

LA Kids

DCFS 550, Body Chart

DCFS 5402, Notice to Child's/NMDs Attorney Re: Case Status

Referenced Policy Guides

0050-502.10, Child Protection Hotline

0070-525.10, Assessment of Shaken Infant Syndrome

0070-531.10, Visual Inspection of Children

0070-548.10, Disposition of Allegations and Closure of Emergency Response Referrals

0070-548.24, Structural Decision Making (SDM)

0070-548.25, Completing the Structured Decision Making (SDM) Safety Plan

0070-560.05, Joint Response Referral: Consulting with PHN

0070-570.10, Obtaining Warrants and/or Removal Orders

0400-503.10, Contact Requirements and Exceptions

0600-500.00, Medical Hubs

Statutes

Penal Code Sections 11165.3 – Refers to a situation in which any person willfully causes or permits any child to suffer, or inflicts thereon, including unjustifiable physical pain or mental suffering.

Penal Code Sections 11165.4 – States, in part, that "unlawful corporal punishment or injury" means a situation where any person willfully inflicts upon any child any cruel or inhuman corporal punishment or injury resulting in a traumatic condition.

Penal Code Sections 11171 (a), (1) & (2) – States, in part, that adequate protection of victims of child physical abuse or neglect has been hampered by the lack of consistent and comprehensive medical examinations. Enhancing examination procedures, documentation, and evidence collection relating to child abuse or neglect will improve the investigation and prosecution of child abuse or neglect as well as other child protection efforts.

Welfare and Institutions Code Section 300 (a) – States, in part, that a juvenile court may adjudge that a child to be a dependent of the court should the child have suffered, be at risk of suffering physical harm inflicted non-accidentally, by the child's parent or guardian.

Welfare and Institutions Code Section 324.5 (a) – States that whenever allegations of physical or sexual abuse of a child come to the attention of a local law enforcement agency or DCFS and the child is taken into protective custody, that agency may, as soon as possible, consult with a medical practitioner to determine whether a physical examination of the child is appropriate. The examination shall be performed within 72 hours of the time the child was taken into protective custody or within 72 hours of the time the allegations were made, if the child is already in custody at the time of the allegations.

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