Chapter 2 : Section 11.2

Investigations Involving Medical Child Abuse

Procedures

If during the course of an investigation or case Medical Child Abuse (MCA) is suspected, contact OCWI. Joint Investigation protocols shall be followed as suspected MCA is a criminal conduct allegation.

To determine if there is reason to suspect Medical Child Abuse (MCA), consider if one or more of the following indicators are true:

Related Indicators

• The child has a history of unexplained or unexpectedly difficult to treat medical, developmental or psychiatric symptoms or illnesses.

• The child has a history of very frequent visits to doctors, clinicians or therapists of any type, hospitalizations, medical procedures or surgeries.

• The child is more/less disabled or functional than one would expect for the reported diagnosis.

• The child’s healthcare providers have reported discrepancies with the history reported by the parent, guardian or custodian and clinical assessments.

Suspected Perpetrator Indicators

• The parent, guardian or custodian:

• has an intense desire to maintain close relationships with the clinical staff (physicians, clinicians or therapists of any type), or regularly engage in conflicts with staff regarding diagnostic and treatment decisions.

• request or demonstrate unusual acceptance of recommendations for invasive or painful procedures.

• fail to express relief when presented with negative (normal) test findings.

• appear to have more of an interest in the medical, developmental or psychiatric conditions than in the child’s well-being.

• insist on performing procedures or routine care in the hospital.

• demonstrate a strong resistance to having the child discharged from medical care.

• report numerous dramatic or life-threatening events.

• The parent, guardian or custodian confessed to exaggerating or inducing illness in the child.

• MCA has previously been suspected or confirmed.

• There is (direct or circumstantial) evidence that the parent, guardian or custodian falsified illness in the child.

Parent-Child Relationship Indicators

• The parent, guardian or custodian demonstrate excessive attention towards the child in the form of enmeshment, overprotection and, restriction of activities and relationships.

• Older child victims behave similarly to the suspected parent, guardian or custodian (reporting symptoms, wanting clinical interventions, etc.).

• Younger child victims appear to have a passive tolerance of painful procedures.

• A child reported illness fabrication, coaching by a parent, guardian or custodian, being given unknown medications or other concerning information.

• Video surveillance tapes revealed that the parent, guardian or custodian is neglectful or abusive of the child when others are not present.

• Symptoms occur only when the suspected parent, guardian or custodian is present or within a few hours after they leave.

• Separation of the child from the suspected parent, guardian or custodian result in a decrease of symptoms or disability in the child.

• The child’s illness responds to standard medical treatment when away from the suspected parent, guardian or custodian.

• Another family member has a history of unexplained or unexpected difficulty to treat medical, developmental or psychiatric symptoms or illnesses.

• Another family member has a history of frequent visits to the doctors, clinicians or therapists of any type, hospitalizations, medical procedures or surgeries.

• Another family member is more disabled or less functional than one would expect for the reported diagnosis.

• There has been a sibling death due to sudden infant death syndrome, unclear reasons or due to symptoms similar to the suspected victim.

• There is a reported history of physical or sexual abuse in suspected parent, guardian or custodian’s family of origin.

Review Medical Child Abuse Information for more information.

Investigation

Follow the procedures for investigating child abuse or neglect as described in Initial Contact and Conducting Interviews, Family Functioning Assessment-Investigations and Investigation Allegation Findings.

Convene a Medical Child Abuse Review Team(MCART). The MCART shall only include internal DCS employees and the AAG. Participants include the OCWI Investigator, DCS Specialist, DCS Program Supervisor, OCWI Manager, DCS Program Manager, the AAG and DCS CHP Chief Medical Officer, as available. The MCART shall meet at least monthly throughout the life of the case and for the reasons specified in the MCART Standard Work.

Immediate protective action must be taken to protect the child when the caregiver’s suspected behavior(s) places the child at risk for unnecessary invasive medical tests or interventions, potentially unneeded medications, physical or emotional abuse, harmful neglect or death.

A present danger assessment of all children in the household must be completed, as it may be necessary to take protective action to ensure their safety.

Interview family members and other persons with knowledge of the family, to obtain a detailed social history of all children, parents, guardians or custodians, and other significant family members. If possible, interview persons separately, but one right after the other, so that there is little or no time for family members to coordinate their answers.

Consult with the AAG to identify a mental health specialist who is familiar with medical child abuse (MCA).

Gather relevant information with guidance and direction from a mental health specialist who is familiar with MCA, if one is available, a qualified health professional(s) or reporting source, and provide the information to the Medical Child Abuse Review Team (MCART). Relevant information may include the following:

• The diagnoses of and treatment being provided to the parent, guardian or custodian if being treated by a clinician.

• Medical and other clinical records (from clinicians, hospitals, clinics, laboratories, emergency services, home health agencies and health insurance companies) including birth records for the suspected victim and all siblings who have been under the care of the suspected parent, guardian or custodian. Enlist the assistance of the DCS CHP Chief Medical Officer to obtain these records, especially from health insurance companies, if needed.

  • Medical facilities often keep separate records for clinic visits, emergency department visits, hospitalizations, and home visits. It is important to ask for all records.

  • In the requests for records, specifically request the inclusion of nursing notes and notes from mental health professionals.

  • If concerning behavior was recorded via video or audiotape, the record request should also include a copy of these recordings.

  • If falsification during pregnancy is suspected, it may also be necessary to request prenatal outpatient and inpatient records for the mother in addition to birth records.

• School records.

• Record of visits to the school nurse, telephone logs, attendance records, and Individual Education Plans (IEP) reports should be requested.

Review Medical Child Abuse Information for more information.

Responsible Adults and Out-of-Home Caregivers

The child’s living arrangement must be one in which the parent, guardian or custodian does not have unsupervised contact with the child and does not have the ability to influence daily care or medical treatment of the child.

If considering placing the child with a non-abusive parent, extended family member or other significant person as a Responsible Adult or caregiver, carefully assess the perspective caregiver’s ability and willingness to protect the child from the suspected parent, guardian or custodian, including their perception of whether the suspected abuse did or could have occurred. Also consult with the MCART and a mental health specialist who is familiar with medical child abuse when assessing the non-abusive parent, a relative or significant person as a Responsible Adult or caregiver.

Contact and Visitation

Assess the danger of the parent, guardian or custodian’s contact with the child. Ensure that visitation, including visitation in a hospital setting, is closely supervised by one or more persons who are familiar with Medical Child Abuse and have been instructed to observe all physical contact between the parent, guardian or custodian and the child and to monitor all communication. Contact the AAG if the parent’s behavior during visitation causes a concern for the child’s safety.

Refer for Clinically Supervised Parenting Time for supervision of parenting time by a qualified mental health clinician to ensure the safety and well-being of the child.

Strict guidelines are needed for visitation and contact. The frequency of visitation and contact depends on the nature of the case. It is imperative that the child feel safe during visitation and contact with the suspected parent, guardian or custodian. Use the following guidelines to develop a visitation and contact plan:

• All visitations should be closely monitored in a neutral location by one or more persons familiar with the safety concerns in the case.

• The parent, guardian or custodian cannot discuss the case or health-related issues, including diet, with the child.

• The parent, guardian or custodian should not give the child anything that the child can consume (such as food, drinks, candy, gum, or medicine) or anything the child can put in their mouth (pacifiers, etc.).

• Ointments or other topical agents cannot be applied to the child by the parent, guardian or custodian.

• All conversation must be audible to the monitor.

• All physical contact, activities and gifts must be developmentally and socially appropriate.

• Diaper changing should not be excessive.

• Clothing changes should be restricted when excessive or inappropriate.

• Telephone calls must be monitored.

• Letters and cards must be read by the monitor prior to being shared with the child.

• Audio and video recording and photographing the child are prohibited.

Case Management

Case planning includes obtaining an assessment and recommendations from a mental health professional regarding critical decisions including diagnosis, treatment, visitation guidelines and reunification.

Obtain an independent, non-treating expert to conduct the assessment for suspected Medical Child Abuse and the evaluation of associated psychopathology.

A Primary Care Physician who is familiar with MCA should be obtained to manage and coordinate the ongoing care of the child while in the care, custody and control of the Department. Request assistance from DCS CHP, if needed. This person may also participate in the Multi-Disciplinary Team(MDT) led by law enforcement.

In order to meet the acute and ongoing needs of the child and family, reasonable efforts should be made to ensure open and regular communication with the Medical Child Abuse Review Team (MCART). The MCART will meet at least once per month throughout the life of the case to review the case, any developments and make decisions regarding the safety of the child(ren). The MCART must be consulted when a change is considered related to the caregiver, visitation, service provision, ongoing assessment of safety, evaluation of progress in obtaining the permanency goal or change to the permanency goal.

MCART members should be provided with relevant information regarding any diagnosis, treatment recommendations and progress, outcome of visitation or contact and services provided and progress towards achieving the permanency goal.

The MCART may be convened to discuss unexpected increases in symptoms, visitation problems or other acute issues. An increase in concerning symptoms and other clinical issues should also be communicated to the assigned PCP or other clinicians.

On an ongoing basis, obtain relevant records to monitor the ongoing physical and emotional status of the child including medical, psychological or school records as appropriate.

As necessary, consult with the AAG regarding any court action required to expedite the gathering of medical records, to restrict or deny visitation, or to compel the suspected parent, guardian or custodian or other family members to participate in assessment or treatment services.

Depending on the nature of the case, a Multidisciplinary Team (MDT) may be used in conjunction with the MCART. The MCART and MDT participants will vary. The MDT is a meeting coordinated and led by law enforcement. The MDT may include the child's attorney or Guardian ad Litem, tribal representatives, mental health specialists, visitation supervisors and the child's caregiver.

Consider holding conference calls or meetings with the MDT as needed, depending on the needs of the case.

Review Medical Child Abuse Information for more information.

Documentation

Document contacts, including collaboration and consultation with the members of the MDT, in Notes.

Document the MCART using the Medical Child Abuse Review Team Staffing Agreement/Signature, DCS-2526 and store in an envelope clearly marked Attorney/Client Privilege in the hard file.

Document the action plan developed by the MCART in Notes under AAG Contact as the meeting is subject to attorney client privilege.

If the child is removed update the Legal tab in Guardian.

Document the search efforts for relatives in Notes.

Upload records received as documents in Guardian.

Effective Date: November 11, 2022

Revision History: November 30, 2012, February 1, 2021