The Child Protection Team, from UVM Medical Center’s Child Safe Program conducts MDT evaluations of children who are suspected of being maltreated. Join host Cassie Gillespie from VT-CWTP as she talks with the Child Protection Team about the top 10 child abuse myths they encounter in their work.
The Child Safe Program identifies, treats and supports children who are suspected to have experienced or are at risk of experiencing abuse and neglect. This program is staffed by a board certified child abuse physician, pediatric forensic nurse and social worker. The Child Safe Program conducts multidisciplinary evaluations of children in the hospital and in the Child Safe Clinic on an urgent and routine basis. A core goal of our program is to ensure that all children who are suspected of being maltreated receive standardized, appropriate medical care and psychosocial support to address their medical and safety needs. The team is made up of: Mary-Ellen Rafuse, LMSW; Tracey Wagner, Forensic RN; & Dr. James Metz, Child Abuse Pediatrician.
Find out more about the Child Safe Program at their website:
And read more about them in this spotlight article:
Read more about these myths in the most recent issue of Voices at the Table. Voices at the Table is a forum for kinship, foster, and adoptive families to share with one another. It is also a place to learn about current resources, support, educational opportunities, and topics that are relevant to your experience. Voices at the Table was created by the Vermont Child Welfare Training Partnership (VT-CWTP), a collaboration between the University of Vermont and the Vermont Department for Children and Families.
Cassie Gillespie (00:02):
Hello, I’m Cassie Gillespie. And you’re listening to Welcome to the Field, a podcast for child welfare workers, caregivers, and community partners. Today, we are welcoming back the child protection team from UVMedical Centers, child safe program. And we’ll be talking about the top ten myths of child abuse that they encounter in their work. If you’re not familiar with the child protection team, they’re made up of Mary-Ellen Rafuse, LMSW Tracey Wagner, forensic RN, and Dr. James Metz, child abuse pediatrician. The child protection team conducts multidisciplinary team evaluations of children who are suspected of being maltreated so that they receive standardized and appropriate medical care. They’re also amazing to work with, and we’re so happy to welcome them back. Okay, here we go. So welcome to the child protection team. Thanks for coming in today. In the studio, we have Tracey Wagner forensic nurse.
Tracey Wagner (01:00):
Hello. Hey, how are you?
Cassie Gillespie (01:02):
I’m good. Thanks for coming Tracey. We also have Dr. James Metz.
Dr. James Metz (01:05):
Cassie Gillespie (01:06):
Thanks for coming. And Mary-Ellen Rafuse licensed MSW.
Mary-Ellen Rafuse (01:10):
Cassie Gillespie (01:11):
Okay. Today we’re going to do something different. We’re going to do the top ten myths about child abuse and the child protection team is going to walk us through them. So we’re going to count backwards from ten to one. And we’re going to start with the number ten myth and Tracey is going to let us know. That’s about the categories of abuse. Is that right?
Tracey Wagner (01:29):
That’s right. So the top ten, the number ten myth is physical abuse, neglect and sexual abuse are the three categories of childhood maltreatment. And actually there are two additional categories that include medical child abuse and intrafamilial child torture. So medical child abuse is a form of child abuse, defined as a child receiving unnecessary and harmful or potentially harmful medical care at the instigation of a caregiver. The diagnosis of medical child abuse focuses on the harm to the child and is not based on the motivation or mental health of the perpetrator.
Cassie Gillespie (02:13):
I have a different name historically that we used to go by.
Tracey Wagner (02:16):
Yes. We used to really focus on the parent and the mental health of the parent or the caregiver and not describe it as the, according to the mental health of the caregiver and not in terms of the harm being done to the child.
Dr. James Metz (02:35):
Some people might think of it as Munchausen by proxy, but the better term for it now is medical child abuse.
Cassie Gillespie (02:44):
Okay. I was thinking we used to call it something different. So that’s helpful for forgetting the straight there. Okay. Sorry, I’ll let you continue.
Tracey Wagner (02:51):
The second category is intrafamilial child torture, and this category is newly or fairly newly being defined and, refined. But at this time it’s defined as at least two physical assaults or a single extended incident and two or more elements of psychological maltreatment. So torture is an extreme form of child abuse and recognizing the early signs of it has the potential to reduce the significant morbidity and mortality associated with it.
Cassie Gillespie (03:30):
Wow. Every time you guys, every time I listened to you talk, I’m just blown away by, by the work you do. Okay. We’re going to go to number nine. So Mary Ellen is going to tell us this is about adolescents. And I think this one might be especially relevant, not just for family service workers, but probably also for caregivers and other folks in the system.
Mary-Ellen Rafuse (03:49):
All right, so number nine is the adolescents don’t need their injuries evaluated by a medical provider. So although what’s included in the standard workup may be more dependent on the disclosure from a youth, it is still important for adolescents to receive a medical evaluation. When they have injuries that are suspected to be from abuse, their medical workup might still include headed imaging or x-rays of specific body parts. Additionally, it’s still important to consider the possibility of the explanation regarding their injuries. And it can be really useful to have a medical opinion on that. Lastly, the medical evaluation can help ensure that injuries are being assessed independently from concerns regarding the youth’s behaviors.
Cassie Gillespie (04:33):
Is that some of the reasons that they don’t typically, or that they may get overlooked because people are attributing them to the behaviors.
Mary-Ellen Rafuse (04:40):
Yeah. I think there’s a common misperception that when adolescents get abused physically, it’s in a mutual altercation with the parents and then the adolescents injuries may be overlooked.
Cassie Gillespie (04:52):
Good point. Thank you. Okay, James, we’re coming to you for number eight. This one looks like it’s going to be about skill levels,
Dr. James Metz (04:59):
Right? So this one is particularly relevant for medical providers who may be thinking about getting a skeletal survey on a child. So the myth is that if there are no fractures seen on an initial skeletal survey, then that rules out abuse. And so let me just say, for those who aren’t up to date on what a skeletal survey is, a skeletal survey is a bunch of, x-rays actually 21 x-rays of a child to make sure that there are no injuries to the child that we can’t see with our eyes. So when a child comes in with a bruise or any sort of injury and they’re of the right age, and that’s usually under two years of age, we want to make sure that they don’t have additional injuries. So we get a skeletal survey on that child. And the myth is that often providers think that if it’s negative, then the child hasn’t been abused. But what we know is that the injury in and of itself that brought them to the care of a medical provider. So the bruise or the abrasion on their arm, or whatever other injury they might have, might be the only sign of abuse. And there might not be a fracture associated with that.
Cassie Gillespie (06:17):
So in that situation, how would you uncover abuse then?
Dr. James Metz (06:20):
It’s a great question. What you have to be aware of is that some injuries such as a bruise on a little child is highly specific and highly concerning for abuse. So just that bruise in and of itself needs to be explained and further investigation needs to be pursued to make sure that the child is safe.
Cassie Gillespie (06:43):
Okay. I have another question about this for you. Why is it that we typically do these on children two years old or younger?
Dr. James Metz (06:49):
Yeah. So a skeletal survey, the standard of care is for any child and their siblings with a suspicion of abuse, gets a skeletal survey. And the reason for that is that those children, under two years of age, can’t often tell us what happened and if they have additional injuries. And so we think that when you’re older, 3, 4, 5 years of age, you can start to localize your injury. You can start to talk and tell us something might’ve happened. And it’s more easy, or it’s easier to see a child who’s maybe in pain or having a limp or something else that might be indicative of abuse.
Cassie Gillespie (07:30):
That makes sense. As a parent, one of the things I was really surprised about is how old your kiddos are before they can tell you, like, if they have an earache or something, right, you just does their ear hurt and they really can’t connect it for you. Thank you, Tracey, coming back to you with number seven. So tell me about children who have been sexually abused and if there’s physical findings, that myth.
Tracey Wagner (07:52):
Okay. So we do know that less than 5% of children will have medical findings that substantiate sexual abuse. Abnormal genital findings are rare, even in cases where the abuse has been factually proven by other forms of evidence. And there’s a couple of reasons for that. Many of the acts are non-violent for example, fondling. Injuries that do result from sexual abuse tend to heal quickly. And I always use this example when I’m talking with families, think about biting the inside of your cheek and how quickly that heals. And in most instances, exams of child victims, don’t take place on the same day as the alleged, active abuse because kids have delayed disclosures and also kids tend to minimize the extent of the contact. So then they report and report weeks or months after the abuse event. I think what’s most important to share is that a normal exam, neither confirms nor rules out sexual abuse and an exam provides good reassurance to a child. So actually if you’ve turned those numbers upside down, we can say 95% of the time to the child that they’re body is healthy. And that’s a really powerful message.
Cassie Gillespie (09:14):
Okay, thank you, Mary Ellen, we have a myth here around what happens when the child safe team is involved with cases. And as you know, we have family service workers who listened to this podcast and other folks at family services, but also caregivers and community partners. So this one might be very relevant for everybody.
Mary-Ellen Rafuse (09:33):
So the myth would be that whenever child safe gets involved and sees a patient or our team makes a new report to DCF. But there are lots of times when we see patients either in the hospital or outpatient clinic where the information we learn through medical evaluation, psychosocial assessment, or a combination of the two indicates a plausible explanation for the child’s injuries exists or are concerned that abuse or neglect occurred is low. Just like we try to be transparent with families when we are reporting to DCF in the instance where our involvement has ruled out the concern for abuse or neglect from our institution, then we would share that assessment with the family as well.
Cassie Gillespie (10:13):
So I’m going to make up my own myth here, but this is one that I’ve heard is that everyone you work with came to you from DCF. And so there’s a flip side to this where you’re seeing plenty of patients in the clinic, right? Who the referral sources, not family services, is that right?
Mary-Ellen Rafuse (10:28):
That’s correct. We have referrals from outside primary care physicians. Families can refer if they have a concern. And many of the kids we see inpatient we’re alerted by the inpatient medical team. And there may or may not already be DCF involvement or a report about the incident that led to the consult
Cassie Gillespie (10:50):
Makes sense. So for those cases, especially is where folks should know that there won’t always be a report. James, I’m going to come over to you where it myth number five.
Dr. James Metz (11:00):
Okay, there’s a lot of misunderstanding about abusive head trauma or what we used to call shaken baby syndrome. And one of the things that we hear a lot is that a baby can have bleeding into their brain from simple coughing or choking episodes. And I think what we know from the literature and from years of studying it is that it takes something more than just a cough or an episode of vomiting to cause the kind of bleeding that we see in abusive head trauma. So we know that kids are pretty resilient. That’s why we all went into pediatrics. And we also know that children are pretty rough and tumble. And we see children being thrown up into the air by their parents and playing with their siblings. But we don’t see bleeding in the head or abusive head trauma from those situations are pretty innocuous or pretty safe.
Dr. James Metz (11:56):
And so we know from this experience that in order to get those findings of bleeding in the head or bleeding in the eyes or the skull fracture that we sometimes see in abusive head trauma, there has to be some significant injury that caused it. So if we get a child that comes into the emergency department or that comes into the hospital and has all of these findings associated, or that are concerning for abusive head trauma, and we don’t have a story like the child fell out of a window or was in a car accident or something significant, it makes us very concerned that there is something more going on and that there has to be further investigation to find out what that injury was that caused the bleeding in the head or other symptoms that we see in cases of abusive head trauma.
Cassie Gillespie (12:48):
Fascinating. So I have a follow-up question here, which is maybe a left-hand turn. So you let me know, but you know, we’re talking about healthy babies, right? Not having bleeding in their head from coughing or choking, is that different for adults?
Dr. James Metz (13:00):
Well, it’s a good question. I don’t think we, we probably don’t know the complete answer to that, but I think it’s pretty safe to say that adults also don’t have significant bleeding in their heads from coughing or choking. We do see bleeding on the whites of the eye in adults who have coughing or pertussis or who have had bouts of vomiting. We do see that and we know that kids, we just don’t see that in kids. So while there are some similarities between children and adults, there is some significant differences in the injury pattern with children and adults, especially when it comes to brain injuries.
Cassie Gillespie (13:43):
Okay. Thank you. Number four, back to you Tracey tell us about bruises and whether or not they can be dated. Wow.
Tracey Wagner (13:52):
I think first, sometimes we have to stop and I densify whether what we’re seeing is actually a bruise. There is a pretty common birthmark called the slate gray spot. That looks like a bruise. A bruise, however, is trauma. And it appears as an area of discolored skin because of the rupture of these teeny tiny blood vessels called capillaries. Bruises are usually painful because that blood that is leaking is taking up space in the tissues where it shouldn’t be and bruises don’t blanch. So if you take your fingertip right now and you press it on another fingertip, you’ll see that your skin turn white and quickly, I hope, returned to normal color. These are the minute capillaries that stopped their work for a minute when you applied pressure. And then they continued on when you let up. So bruises can be at the level of the skin they can be underneath to the subcutaneous tissue, muscle and bone. Most bruises aren’t a medical problem. You know, we, we do worry when there are bruises to the head or neck and because head injuries tend to bleed heavily, because there’s lots of blood vessels there taking care of your very important brain. And we worry about neck bruises because you have vessels that are nourishing the brain and the rest of the body. We all have personal experience of bruises and we think we know red and purple bruises are fresh. And there are some studies that talk about a yellow color of bruising doesn’t appear until 18 to 24 hours after the injury. But no matter what, we cannot accurately date a bruise at this time. I think someone will maybe win the Nobel prize, perhaps when they figure that out. There’s lots of interest in this topic. As you can guess, folks are researching right now as we speak, but we can’t date bruises. It’s just too in precise. And the reason for that there’s many variables, the type of tissue that gets injured, where on the body like looser tissue bruises earlier, sometimes. The mechanism of the injury, the health and nutritional status of a child. Medication they might be taking, the age of the child, and a simple one is color interpretation and perception. You might see blue and I’m seeing pink. So we can’t match them up to a date or time at this point in time.
Cassie Gillespie (16:22):
And this may be a silly question, but why would people want to date bruises in the first place? Like why does it matter?
Tracey Wagner (16:26):
I think when we’re trying to figure out when an injury occurred or sometimes pinpoint it down to an exact time.
Cassie Gillespie (16:36):
That’s obviously very important in all the ways our workers. Yeah. I just didn’t want to assume that there wasn’t another reason there, Mary Ellen, I think you’re up with myth. Number three.
Mary-Ellen Rafuse (16:46):
Sure this one’s about ingestions and whether all ingestions of Suboxone or methadone are a sign of supervisory, neglect, ingestions are a pretty common occurrence and hot topic that our team gets involved in a lot. But we are here to let everyone know that not every ingestion is the result of supervisory neglect. We all know that once children become mobile, they can get into things in a matter of seconds. And the accidents occur. The things, our team, who people will consider when thinking about ingestions and neglect are the context surrounding how the child got the medication, the child’s developmental level and length of time they may have been unsupervised and the possibility of a delay in accessing medical care. But most importantly, we believe that ingestion of Suboxone or methadone should be considered in the same way as any other prescribed medication that a child may get their hands on. And one of the reasons this is a myth that we like to debunk is that if it’s based on subjective factors or other concerns about the people who are Suboxone or methadone, it can lead to increased bias around reporting.
Cassie Gillespie (17:53):
And in your experience is there more of like a heightened awareness or worry when the ingestion is Suboxone or methadone, as opposed to a different type of prescription medication,
Mary-Ellen Rafuse (18:03):
There is a perception of a heightened sense of worry, but that’s not necessarily like in correlation with the actual harm that could come to the child. There are plenty of other prescription medications that could cause significant medical complications as well
Cassie Gillespie (18:18):
That makes sense. Thanks for making it visible. Those are the, those intersections between values and practice, right? So you can run right into. Okay James, back to you again with little babies and their brains. Tell me myth number two.
Dr. James Metz (18:34):
Great myth number two is about skull fractures and little babies. And I think the reason we spend so much time thinking about the brain and the skull and the head of little babies is because it’s, so the brain is such an important part of babies and it’s growing so rapidly that it’s really important to take note of and to really think about, especially in cases where there might be abuse. So the myth is that all skull fractures in little babies are a sign of abuse. Well, what we know is that the babies and children’s skulls are different than adults. For one thing, babies skulls have these sutures or these areas in them that are not fused together at birth. And so we know that it takes a few years for all of these bones to grow together. It’s kind of, I think of it like the tectonic plates that are moving around, and then at some point in a baby’s growth, they all joined together and are fused.
Dr. James Metz (19:36):
And so in adults, skulls, the bones are all fused together, but in, in babies, they’re not. Also, we know that the thickness of the bone in babies is still growing. And so the skull bone is not at the same density as an adult skull. And so if a baby falls off of a changing table or falls out of a parent’s arms, which we see fairly frequently and their head hits the ground, even if it’s on a carpet or something else that might be not so hard as like cement, they can still get a skull fracture. And those skull fractures can have very different appearances and be in different places on the skull and, and have different shapes. But there’s no one fracture pattern or even one fracture that is specific for abuse. So the example is a child is in the parent’s arms.
Dr. James Metz (20:34):
They’re trying the parents trying to get into the house with a bag of groceries in one hand and a baby in the other arm and the baby wriggles around and falls onto the floor and the parent takes the child into the emergency department because they have a big goose egg on their head and they get an x-ray or a CT scan, which shows a skull fracture and immediately some medical providers or DCF workers will think that that’s abuse regardless of the parent’s story. So we get involved hopefully sooner than later, and can look at the x-rays look at the CT scans, hear the story and hopefully make the medical provider and or DCF worker understand that this might be a very plausible story and not be something more devious or suggestive of abuse.
Cassie Gillespie (21:31):
I suppose that’s good news, right? That’s happy news.
Dr. James Metz (21:33):
Yes. I mean, I like Mary Ellen said we feel like heroes when we rule out abuse or when we can say, no, this is, this is an accidental and it’s not abuse.
Cassie Gillespie (21:44):
Okay, I hope everyone’s ready. We’re up to the number one myth about child abuse and I’m sending it to you, Tracey.
Tracey Wagner (21:52):
To be saved the best for last. The myth here is that children make up stories about child abuse, and it’s really a prevailing misconception that children lie and it’s not supported by the literature. I think children are much more likely to lie about it, not happening or to not talk about it at all than to make something up. And our culture sadly is still conditioned of disbelief children. Although I think it’s better, but children are still expected by some to be seen and not heard. We asked them to listen to adults. We ask them to be good to obey and the kids who are at risk, like those that have a lower level of supervision or might be needier for our attention and affection, or may have been abused or broken in before may be less willing to risk telling. And, also maybe less believed there are many factors that influence an outcry.
Tracey Wagner (22:56):
So age of a child, younger children are less likely to talk about things than older children. Gender differences. Girls for example, are more likely to, than boys to disclose sexual abuse. The relationship of the abuser. Children abuse by a family member are more likely to delay disclosure both closer to the relationship is actually the less likely the child will tell. If there are threats to a child, they fear the abuser may hurt them or one of their family members. If there is a lack of opportunity, if there isn’t that safe adult to talk to and also abuse, maybe harder to talk about over time, it’s harder to reveal if there is shame involved, fear of the consequences for others. Kids can have that developmental capacity to anticipate their parents’ reactions or worry about the impact of the disclosure. What that disclosure will have on their family.
Tracey Wagner (23:55):
Grooming is another factor that influences outcries. Kids might not know it’s wrong, or don’t recognize the experience as abuse. And then polyvictimization comes into play too. Kids with physical abuse histories may be more reluctant to disclose. So it’s a difficult and uncomfortable topic thinking about child abuse in general. It’s hard for anyone to talk about and kids need to know that we’re listening and will take action when they talk with us. I think it’s also important to understand that the care is a collaborative effort. So family law enforcement, DCF, child protection, medical, and mental health all work together to take care of kids.
Cassie Gillespie (24:40):
That’s great. I’d love to dig a little deeper there if we can, because I think at times there’s a prevailing narrative that, that’s true. And that there are these other times where there’s at least a worry. And so that, let me ask you about that. Like situations where a child is alleged to have been coached or situations where there’s concern that a child was victimized, but that for whatever reason there seems to be suspicion that the alleged perpetrator they’re naming is not the actual alleged perpetrator. And my guess is that your team comes up against those situations. And so what, how would you I guess talk back to those narratives in relation to that larger myth that you want to debunk about kids really telling the truth when they come forward,
Tracey Wagner (25:27):
That’s super hard to sort out sometimes. I think, well, kids can certainly be suggestible, so it is possible that kids can have a narrative displayed before them and they can repeat that to others. So I think it’s really just listening to all sides of the story, looking at the episode or the concern in context. Are there other behaviors going on, are there other worries? And then in the long run, if we can’t figure things out just building the walls of protection around kids as best we can. So cutting down the extraneous people in contexts and watching children and being alert and being ready to listen at any time, I’m sure my partners have other thoughts around this, but it’s a really difficult situation. We don’t always come out of an exam knowing exactly what happened and what to do about it.
Dr. James Metz (26:35):
I think just to add onto that, I think that the most powerful thing we can do for children is to give them a voice. And when they may not be able to express what’s going on, they may not know the words, but the more that we are able to empower them, to be able to speak about their experiences and to share those experiences with people they trust, the more protected they will eventually be. And I think that, you know, it’s unsettling to leave an exam room, not knowing what happened, or if a child is being abused or not. It’s really a very difficult part of our, our job that said, you know, what gives us hope and allows us to continue doing this is that over time in the right setting, that child will be able to tell their story and be able to tell what is happening to them. And hopefully we’ll be able to get the protection that they need.
Mary-Ellen Rafuse (27:31):
I think interestingly too, it’s easier for people to not believe children when the concern is around sexual abuse. And I think some of that might be just related to adults, comfort level and hearing those disclosures and how to support kids when that’s, what they’re talking about. So I would just echo that, offering kids the tools to feel empowered and talk about it. And hopefully the adults in their lives will catch up to speed as well and become comfortable addressing their concerns.
Cassie Gillespie (28:02):
Thank you. So thank you so much for coming in today. It is such a pleasure to have you here in the studio. And if folks want to ask you questions or follow up with you, what’s the best way for them to reach you?
Mary-Ellen Rafuse (28:16):
We have a shared email that people can reach out on. It’s email@example.com. And we monitor that every day. So people are welcome to get ahold of us with questions.
Cassie Gillespie (28:28):
Okay. Thank you so much. Have a wonderful day.
Cassie Gillespie (28:30):
Thank you for listening. Welcome to the Field is produced by the Vermont child welfare training partnership and the state of Vermont. Our music is composed and performed by local band Brick Drop and our sound production and engineering has been brought to you by Esmond Communications and Egan media productions for welcome to the field. I’m Cassie Gillespie, and we’ll see you next time.