This is a guest post by Bruna Dessena, with edits by Justin Morgenstern. Bruna is an ALS paramedic from South Africa, with 26 years of clinical experience. She has worked for 17 years preparing children for court as a volunteer at the Teddy Bear clinic in Johannesburg. She has also published a book that acts as a guide to interacting with children after abuse.
You are seeing a 3 year old child with a femur fracture. You perform a rapid primary and secondary survey, confirming that there are no other life threatening injuries. The vital signs are stable. You provide rapid analgesia, starting with an intranasal dose of fentanyl as you set up for an IV. As you finish ticking off the clinical boxes in your head, a question pops into your mind: how exactly did this injury happen? Was this truly an accidental injury? And what should I say to this child?
As emergency medical personnel, we are usually the first responders in cases involving accidents or injuries to children. Heartbreakingly, it occasionally becomes clear that these injuries were non-accidental; in other words, the result of child abuse.
As emergency medical personnel, we are incredibly well trained in the medical management of trauma. On the other hand, we often feel ill prepared for cases of child abuse. For my master’s thesis, I performed a questionnaire that included 30 basic ambulance attendants, 30 intermediate life support medics, 30 advanced life support medics, and 30 emergency medicine registrars. In this group, only 41.7% of respondents stated that they felt that they had been adequately trained about what to say and what not to say to a child if abuse is suspected. This was true across the groups, with 63% of the registrars and 40% of BLS providers feeling confidence in their training. There were also significant gaps in understanding with regards to the requirement to report suspected child abuse.
The initial response to a disclosure of abuse is essential. Bear in mind that disclosure of abuse could happen either prehospital or in hospital. Medical professionals often leave the “touchy feely” stuff for the social workers, police, or councillors, but this could (and probably should) be taught to everyone who has contact with children. Training first responders is especially important, as the child may still be in a heightened state of trauma, injuries are raw, and the child’s immediate environment can be assessed for mechanism of injury and whether the caregivers’ version of events match the injuries at hand. These details could become critical later, should the case ever get to court, and should be noted by the medic on duty.
But what do you actually do in the moment? How do you manage your anger? What do you say when you are at a loss for words?
Physical interaction during disclosure
- Take a deep breath and remain calm.
- Come down to the child’s level, maintain eye contact, and give the child your undivided attention (ignore external distractions, including your cell phone).
- Maintain an open posture towards the child.
- Keep your tone friendly
- Use short sentences and easy to understand words.
- Make sure that the child understands you; get an interpreter, if needed.
- Do not overreact with anger, judgement or disgust. Children find it very difficult to separate the person abusing them from the deed (most children are abused by someone they know).
Important sentences to say when the disclosure occurs
- Thank you for telling me, I know it was not easy.
- I want you to know how brave you are.
- You have done the right thing to tell me.
- I want you to know that I believe you.
- I want you to know that whatever has happened to you is not your fault.
- I want you to know that it is not because of who you are that this bad thing has happened to you.
- If you want me to help you to tell another adult your story, I will be with you. You will not be alone.
- I know that what you are going through is hard and you are very brave to tell me your story.
- Your story is very important and I don’t want to miss anything – would you mind if I write it down?
Sometimes it may appear that the child wants to disclose but is afraid or hesitant to do so; creating a safe space for the child may help the process of disclosure.
Do not try to pry information from a child as to who was the perpetrator. It is not for the medical staff to know this unless the information is voluntarily offered by the child. This is important because, if the case goes to court, the defence team might be able to use the fact that you have pointed a finger at a specific person to cast doubt about the story. (Justin edit: I think it is a good idea to talk to local experts about this. I know nothing about the law, but medically speaking, there are times that I think it could be essential to inquire about the perpetrator to ensure the child is returning to a safe environment.)
Sentences that are safe to use from a legal standpoint
- Some secrets are bad and they make us feel sad and angry.
- When we share bad secrets we can get help. It can make us feel better.
- If you are being hurt we must tell your story to another adult because the law says we must protect children from people who hurt them. You can decide which member or friend you want to tell, but we must also tell the police and a social worker. They will be the people who will be able to help us.
- Telling others may be hard but it is to try and help you. You telling me your story is one of the hardest things you have done. You are so brave.
Although these sentences may seem simple, they are an invaluable point of reference as this type of interaction is very difficult. It is of utmost importance that children feel safe when they are disclosing and that they feel believed – this was reflected in the research.
If you would like to take a deeper dive into this subject, you can find a full copy of Bruna’s master’s thesis here.