Full text of DOI:10.1080/10903120290938283

SPECIAL CONTRIBUTIONS
KNOWLEDGE AND ATTITUDE ASSESSMENT AND EDUCATION
OF PREHOSPITAL PERSONNEL IN CHILD ABUSE AND NEGLECT:
REPORT OF A NATIONAL BLUE RIBBON PANEL*
David Markenson, MD, EMT-P, George Foltin, MD, Michael Tunik, MD, Arthur Cooper,
MD, Hedda Matza-Haughton, MSW, CSW, Lenora Olson, MA, Marsha Treiber, MPS
address this issue. With expertise in EMS education,
Violence against children, specifically in the area of
pediatric emergency medicine, pediatric surgery, psy-
chiatry and psychology, social work, legal practice,
law enforcement, and fire and rescue services, the par-
ticipants represented the entire continuum of care for
at-risk children. When all available services are used
and integrated, children are kept from falling through
the cracks, and the highest quality of care possible is
provided for them.
child maltreatment, is a public health concern that has
reached epidemic proportions. Prehospital providers,
who often witness scenes of child abuse and neglect,
can fill an essential role in identifying neglect and
abuse in the home, at school, and in other locations.
In October 2001, a blue ribbon panel of national
experts in emergency medical services (EMS), emer-
gency medical services for children (EMSC), and child
protection services (CPS) convened to discuss the pre-
hospital provider’s role in identifying and reporting
suspected child abuse and neglect. Significantly, this
marked the first time national experts from the worlds
of child protection and EMSC met face-to-face to
Guided by research findings from a national survey
conducted by the Center for Pediatric Emergency
Medicine (CPEM), the panel’s goals were to:
• Recommend content areas in child protection that
will form the basis for future educational resources
for prehospital providers
Received February 24, 2002, from the National Child Protection
Project (DM, GF, HM, MT, MT, AC), Center for Pediatric
Emergency Medicine, Division of Pediatric Emergency Medicine,
Department of Pediatrics and Department of Emergency
Medicine/Surgery, NYU School of Medicine/Bellevue Hospital,
New York, New York; Division of Pediatric Critical Care and Child
Protection (DM), Department of Pediatrics, Columbia College of
Physicians and Surgeons/Harlem Hospital Center, New York, New
York; Division of Pediatric Surgery (AC), Department of Surgery,
Columbia College of Physicians and Surgeons/Harlem Hospital
Center, New York, New York; National Emergency Medical
Services for Children Data Analysis Resource Center (LO),
Intermountain Injury Control Research Center, Salt Lake City,
Utah; and Department of Pediatrics (LO), University of Utah, Salt
Lake City, Utah. Accepted for publication March 1, 2002.
• Develop recommendations regarding advocacy and
policy issues important to EMS and CPS
• Discuss plans for continued collaboration between
the EMS and CPS worlds
This article presents a summary of their findings.
BACKGROUND
In 2000, CPEM received federal funding from the
EMSC Program to launch a National Child Protection
Education Project. To begin the project, CPEM estab-
lished an advisory board representing major national
organizations in EMS, EMSC, and child protection, as
well as a review panel composed of individuals with
expertise in these areas. Working with the advisory
board and review experts, the National EMSC Data
Resource Center (NEDARC), and the National Regis-
try of Emergency Medical Technicians (NREMT),
CPEM staff developed a questionnaire targeting EMTs
and paramedics nationwide. The survey instrument
queried prehospital providers regarding 1) knowl-
Supported by HRSA Grant No. 6 H34 MC 00077.
Address for correspondence and reprints: David Markenson, MD,
Director of Pediatric Critical Care and Child Protection, Harlem
Hospital Center, Columbia University College of Physicians and
Surgeons, 506 Lenox Avenue, MLK 17, New York, NY 10037. e-
mail: <dsm2002@columbia.edu>.
*Blue Ribbon Panel participants, Center for Pediatric Emergency
Medicine staff, and local conference staff are listed in the appendix.
This article is being co-published in Pediatric Emergency Care and the
Annals of Emergency Medicine.
261

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PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
edge of signs and symptoms associated with child
abuse or neglect, 2) self-efficacy and attitudes toward
recognition and management of child abuse or neg-
lect, and 3) knowledge of identification, documenta-
tion, and reporting procedures for suspected child
abuse and neglect.
on child protection issues is provided. The EMT-para-
medic program provides for expanded pediatric infor-
mation and skills. Child abuse is a required compo-
nent in this curriculum, but there is no set time for the
didactic material and no opportunity for applied edu-
cation using scenarios or role-playing; typically, it is
no more than 15 to 20 minutes.
Each of these curricula includes practical compo-
nents that could be applied to child abuse, such as the
scene survey, during which EMS providers could gain
valuable information for CPS. However, the compo-
nents are not taught within the framework of child
abuse, so this opportunity is missed. Other topic areas
that could include child abuse information are patient
assessment, mechanism of injury, focused history,
documentation, and communication with other health
care professionals.
The questionnaire was pilot-tested and revised, and
then 10,000 copies were distributed to a representative
cross-section of prehospital providers throughout the
United States. Two mechanisms were used for distri-
bution: one was a sampling system previously devel-
oped for the NREMT’s Longitudinal EMT Attributes
and Demographic Study (LEADS) project, and the
other involved direct distribution to EMS offices in 15
states and territories, where the surveys were subse-
quently administered at regional training sites during
certification courses and continuing medical educa-
tion conferences. The overall return rate, independent
of method, averaged 44%. The results were tabulated
and analyzed in collaboration with the NREMT and
NEDARC. Following data analysis, the blue ribbon
panel convened to review and discuss the results.
Because EMS providers are often called to the home
of the child, they can have an important role in identi-
fying and recording information that many medical
and child protection professionals do not have an
opportunity to see.
It is imperative that prehospital providers and their
leadership, as well as child protection advocates,
understand each other’s roles. For example, without
an understanding of the variety of child protection
interventions possible, prehospital providers who
report their suspicions may see that the child was not
removed from the home and conclude that nothing
came of their report. However, CPS professionals are
encouraged to keep families together when the child’s
safety and well-being are not compromised. CPS is a
complex system; prehospital personnel would benefit
by understanding how it is designed to work and how
cases move through it.
THE CONTINUUM OF CARE FOR
THE ABUSED OR NEGLECTED CHILD
Prehospital Phase
Emergency medical services providers are trained and
either certified or licensed. Levels are defined by the
state and region and are based partially on the
Department of Transportation’s National Standard
Curricula. In their original forms, these curricula pro-
vided limited information on pediatric care and even
less on child protection. In addition to the time con-
straints in these curricula, a review of their outlines
indicates that material focuses on recognition of
severe physical abuse, with little discussion of docu-
mentation and almost no discussion of other manifes-
tations of child maltreatment, interaction with fami-
lies, and issues of cultural diversity. Representatives
from EMS and EMSC discussed the roles and respon-
sibilities of prehospital providers as well as training
for the different certification levels.
Child Protection Phase
The child protection phase begins after a prehospital
provider has reported a suspicion of abuse or neglect.
This phase encompasses interventions performed by
hospital personnel and the local child protection
agency. CPS professionals presented key issues in
child protection as they relate to EMS.
The Certified First Responder curriculum touches
only briefly on pediatrics in a description of resuscita-
tion techniques. No information on child abuse is
given at this level. The EMT-basic program provides
for 6 hours of pediatric education, half of which is
didactic material. This level of training accounts for
the education of the majority of EMS providers. Child
abuse is a required component of the didactic materi-
al without specifying the exact time for this topic; tra-
ditionally, however, only 5 to 10 minutes is spent on
this subject. The EMT-intermediate learns additional
skills in adult care together with a brief mention of
pediatric airway issues, but no additional information
All states have laws, policies, and guidelines for
child protection, which are based on federal statutes.
The CPS agency in each state or region provides sup-
port services to families. CPS workers may remove
children from unsafe homes; try to reunite children
with their parents or other primary caregivers when
appropriate; and develop alternative permanency
plans, including adoption, when the latter is not pos-
sible. They also help children develop independent
living skills as they near the age of emancipation.
Depending on local statutes, the family court may be
involved alongside CPS.
Regional variations in child protection practices

Markenson et al. KNOWLEDGE/ATTITUDES ABOUT CHILD ABUSE
263
indicate that more uniform guidelines are needed. For
example, states do not universally consider prehospi-
tal personnel mandated reporters of suspected child
abuse or neglect. Mandated reporters are generally
defined as individuals who, in the course of their
employment, their occupation, the practice of their
profession, or any capacity as required by state juris-
diction, come into contact with children and report or
cause a report to be made to CPS when they have rea-
son to believe, on the basis of their medical or profes-
sional capacity, that the child they observe is a mal-
treated or abused child. The definition of an abuser
also varies by state. It could be the parent or paramour
of the parent, other relatives, other caregivers (e.g.,
foster parents, facility staff, and child care providers),
or any other person with ongoing responsibility for
the care of a child.
diately, because federal law mandates that a perma-
nent plan for a child’s living arrangements be made
within 18 months from the time the child enters the
child welfare system.
A ruling of “unfounded” or “ruled out” means that
there is insufficient evidence to indicate abuse or neg-
lect. The case is closed unless additional information
supports a finding of abuse or neglect. Some states
may elect to enter a finding of “unsubstantiated.” This
means that the court believes that abuse or neglect
occurred, but evidence to support such a finding is
lacking.
Multidisciplinary child protection teams in local
hospitals and in some communities review all cases
reported from their hospital or geographic areas.
These teams often include a representative from CPS
to help facilitate the flow of information, but the EMS
community is rarely represented. This lack of repre-
sentation hinders the efforts of EMS providers and
child protection workers to develop a mutual under-
standing of each other’s roles; as a result, child protec-
tion workers often have little knowledge of the infor-
mation prehospital providers can furnish regarding
the cases they examine.
Reporting is necessary so that further injury can be
prevented and the safety of the child ensured. For an
incident to be considered child maltreatment, the fol-
lowing must be true:
• The alleged victim is younger than 18 years.
• The alleged perpetrator has temporary or ongoing
responsibility for the child.
Legal Issues Affecting the Continuum
• There is harm or substantial risk of harm to the
child.
A final presentation and discussion focused on legal
issues of concern to EMS and CPS professionals.
• A specific incident or set of circumstances is evident
or manifest (as defined by individual state law).
Mandatory Reporting
All of the states and the District of Columbia have
enacted a mandatory reporting statute. These statutes
vary greatly from jurisdiction to jurisdiction, but all
include a list of persons who qualify as mandated
reporters. Typically, all persons who are employed in
occupations in which they deal with children or who
come into contact with children are mandatory
reporters. This may include school personnel, doctors,
medical examiners, daycare providers, social workers,
mental health professionals, law enforcement officials,
EMTs, and others in similar professions. Some juris-
dictions even include photo developers who may dis-
cover photographs depicting pornographic images of
underage children. In approximately 18 states, anyone
who suspects child abuse is required to report it,
regardless of profession. It is vital for prehospital
providers to be familiar with their jurisdiction’s defi-
nition of a mandated reporter.
The first step in reporting suspected abuse and neg-
lect is to communicate with a hotline or another
reporting mechanism.
The child protection worker who initially responds
to the complaint will determine whether the informa-
tion meets the state’s criteria for abuse or neglect and
whether an investigation is warranted. If so, the Child
Protection Agency will initiate an investigation. This
often begins with interviews of the child, the caregiv-
er, the alleged perpetrator, and, in some instances, the
person who reported the information. The investiga-
tion will determine whether there is sufficient evi-
dence to substantiate a finding of abuse or neglect.
Possible investigative outcomes include “founded” or
“indicated,” “unfounded” or “ruled out,” and
“unsubstantiated.”
An outcome of “founded” or “indicated” means that
enough evidence is present to indicate that physical
abuse or neglect occurred. Depending on the circum-
stances, the child may be allowed to remain in the
home while various interventions are provided, such
as home visits by a social worker, counseling, parent-
ing classes, or drug testing. Alternatively, if there is a
high risk for further abuse or neglect, the child may be
removed from the home. Planning must begin imme-
Standard of Proof for Reporting
The standard to determine whether a mandated
reporter must notify authorities of suspected child
abuse varies from state to state. Typically, a report is
required whenever the reporter suspects or has reason
to suspect child abuse or neglect. Suspicion can be
based on physical observation, statements made by

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PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
TABLE 1. List of Words and Phrases to Be Defined
dence in these areas tended to exceed their knowl-
edge. There were significant knowledge gaps in the
respondents’ understanding of pediatric developmen-
tal stages and abilities, interaction with families, and
the type of evidence that is needed in order to report
suspicions of abuse or neglect. Prehospital providers
perceived a need for additional training in a multitude
of areas; the most frequent requests involved cultural
competency, interaction with families, and documen-
tation.
Maltreatment
Abuse
Neglect (e.g., optimal care vs adequate care vs minimal care)
Reasonable cause to believe/suspect
Suspicion
High-risk behavior
Assessment/history (physical vs psychosocial)
Caretaker and caregiver (legal, local definitions)
Treatment
Documentation
Report
Mandated reporter
Consent
Sudden infant death syndrome (SIDS)
Differences in overall trends were noted according
to sex, type of provider, and years of service. The
detailed results have been submitted for publication.
GENERAL RECOMMENDATIONS
The panel participants defined several overall issues
of importance for EMS and child protection and made
the following recommendations.
the child, statements overheard, or transfer of knowl-
edge from another person.
Liability Issues
For a state to receive funding under the Child Abuse
Prevention and Treatment Act, it must provide immu-
nity from prosecution to all good faith reports of sus-
pected or known child abuse or neglect. Most states
extend this immunity protection to include all crimi-
nal and civil actions as well as all judicial proceedings
arising from the report.
In 45 jurisdictions and the District of Columbia,
penalties are imposed if a mandated reporter fails to
make a report. Most states impose one of the follow-
ing standards: “knowingly,” “knows or should have
known,” or “willfully.” A minority of states imposes
the standard of “intentionally or purposefully.”
Penalties may include forfeiture of license or certifica-
tion, fines, or criminal prosecution.
Mandated Reporters
In many states, EMS providers are not mandated
providers, and in places where they are mandated
reporters, EMS providers, physicians, and child pro-
tection workers may be unaware of this fact.
Prehospital providers, as health care professionals
responsible for the care of children, should be consid-
ered mandated reporters in all states and territories.
Prehospital providers and child protection personnel
should be educated on this point.
Cross-disciplinary Cooperation
Emergency medical services providers and CPS
experts, albeit knowledgeable in their own disciplines,
do not possess comprehensive knowledge of each
other’s areas of expertise and function, and coordina-
tion and collaboration between EMS and CPS are vir-
tually nonexistent. As such, further cooperation, coor-
dination, and collaboration between EMS and CPS are
needed.
Confidentiality
To receive grant funding under the Child Abuse
Prevention and Treatment Act, records must be kept
confidential to protect the identity of the parent or
guardian. Mandatory reporters do not have a legal
right to know the results of their report. They may be
entitled to information, however, if they have subse-
quent involvement with the child.
Education
Prehospital providers should be better educated in the
following areas: their role in the child protection sys-
tem, assessment of children in different developmen-
tal stages, documentation, and reporting. Further-
more, child protection workers and physicians should
receive training on the role of prehospital providers,
the assessments they perform, and how they may
identify abuse and neglect.
RESEARCH FINDINGS
The research findings of the CPEM National Child
Protection Education Project were presented. The
assessment instrument previously described included
demographic information; case scenarios; and ques-
tions covering attitude, opinion, and knowledge of
child abuse and neglect.
The panels made additional recommendations to:
The responses showed the following trends: prehos-
pital providers were more comfortable managing
physical abuse than neglect; they were uncomfortable
managing sexual abuse and interacting with families
of abused and neglected children; and their confi-
• Increase focus on similarities between EMS and
child protection roles
• Develop educational materials in child protection
for EMS providers

Markenson et al. KNOWLEDGE/ATTITUDES ABOUT CHILD ABUSE
265
• Develop support systems for prehospital providers
who report child abuse and neglect
• Definition of terms
• Role of the prehospital provider
• Ensure that mandated reporting laws are imple-
mented effectively
• Challenges to the role of prehospital providers in
child protection
• Emphasize that the EMS system encompasses pre-
hospital providers, hospital-based physicians, and
hospital systems in a single continuum of care (i.e.,
avoid compartmentalizing prehospital care)
• Legal and legislative issues for the prehospital
provider
• Problems faced by prehospital providers
• Prevention and identification of high-risk situations
• Patient and family interaction
• Create opportunities for internships in which pre-
hospital providers observe child protection work-
ers, police officers, etc.
• Recognition, assessment, and treatment
• Documentation and reporting procedures
• Children with special health care needs
• Cultural competency
• Encourage increased focus on child abuse and neg-
lect at state and national EMS conferences
• Encourage increased focus on the role of EMS in
child abuse and neglect at local and national child
protection conferences
• General recommendations regarding policy, advo-
cacy, and future direction
• Communicate with national organizations to promote
the value of EMS in child protection investigations
Definition of Terms
TASK GROUPS AND SPECIFIC
RECOMMENDATIONS
Currently, there is no cross-disciplinary consensus
regarding definitions of terms in the field of child
abuse and neglect. During the meeting, the panel
reviewed glossaries taken from EMS and child protec-
tion resources, identified differences in definitions,
and selected key words and phrases to define in com-
mon (Table 1). Nationally recognized experts who
have completed work in child protection and EMS
will form definitions.
The Blue Ribbon Panel focused on the following major
issues in child protection to be considered a founda-
tion for the involvement of EMS in child protection.
These issues will help in the development of educa-
tional resources and address policy, advocacy, and
future actions regarding EMS and child abuse and
neglect. The issues included:
TABLE 2. Roles and Responsibilities of the Emergency Medical Services (EMS) Provider in Child Abuse and Neglect
Role
Responsibility
Gather information
Scene survey
Observation of patient/family interaction
Assessment of mechanism of injury
Provide appropriate medical care
Based on local protocols
Includes emotional support
Recognize suspected child abuse and neglect
Obtain education in recognition (e.g., of child development, cultural practices in the
community)
Actively look for and be open to the possibility of abuse and neglect
Involvement with curriculum development and standardization
Keeping current on child abuse and neglect recognition practices
Provide interventions
Document and report
Communicate with family and other health care providers
Evidence preservation
Understanding barriers and limitations
Training in legal issues (e.g., what to report and how to document)
Integrate with child protection services/teams
Participate in fatality review teams (legal, medical, social work)
Multilevel information exchange
Obtain feedback and results of official investigative reports
Develop follow-up mechanisms
Share “best practice” models
Undertake internships in other areas (e.g., medical, legal)
Include child abuse and neglect presentations at EMS conferences
Engage in prevention activities
Participate in community programs

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TABLE 3. Challenges to the Role of
Prehospital Providers in Child Protection
Role of the EMS Provider in
Child Abuse and Neglect
Challenges
The prehospital provider’s role in child abuse and
neglect was discussed, and associated responsibilities
were outlined (Table 2).
It was discussed that the role of prehospital
providers is to care for children, including providing
emotional support, and to adequately document their
findings. It was recommended that prehospital
providers be educated in the areas of abuse and neg-
lect, including recognition, treatment, documentation,
and reporting.
After EMS* providers develop a suspicion of child abuse or
neglect, what is their next step?
If EMS providers should report the incident, to whom do they
report it? Extent of report?
Limited time and process for prehospital providers to report
How to report if child is not transported
Possible solutions
Develop a mechanism to make prehospital provider reporting
effective
Develop resources for prehospital providers to treat severely
ill/injured patient at scene and still be able report suspicion
of child abuse and neglect
Recognition of child abuse depends partly on
knowledge of child development stages; for example,
in order to decide whether a child is malnourished,
the provider must be aware of what the normal
weight should be for the child. To assess whether a
mechanism of injury reported by the parent is plausi-
ble, the provider must know the average capabilities
of a child at that age (e.g., “Is this infant capable of
rolling off a couch?”). Prehospital providers also
require knowledge of cultural practices and special-
needs children in the community. They need to under-
stand proper reporting requirements and proper
objective documentation methods that will hold up in
court, when necessary. Most importantly, they need to
know how to get their report to someone who has the
authority to activate the system on the child’s behalf.
Work toward a system in which prehospital providers are uni
versally accepted as mandated reporters
Promote awareness of child abuse and neglect within EMS sys-
tem
Promote awareness of EMS within the child protection system
*EMS = emergency medical services.
The basic vocabularies used by prehospital
providers and child protection experts may differ,
leading to inconsistency and confusion. For example,
a prehospital provider considers assessment to mean a
physical assessment conducted at the scene, whereas
the child protection professional considers it to mean
a comprehensive physical and psychosocial evalua-
tion to determine whether there are grounds for sus-
pecting abuse and neglect. The EMS prehospital
provider should use the term suspected child abuse.
Many do not know that suspicion is the only require-
ment for initial reporting; thereafter, local authorities
will investigate to determine whether definitive proof
of child abuse or neglect exists. The definitions of sus-
pected child abuse and neglect versus child abuse and neg-
lect are key for prehospital providers in understanding
their roles.
Challenges to the Role of Prehospital
Providers in Child Protection
The panel discussed the challenges prehospital
providers face in their role in child abuse and neglect
(Table 3). For example, there is no universal concept
regarding where prehospital providers should deliver
their report. The assessment survey indicated that
TABLE 4. Legal and Legislative Issues for Emergency Medical Services (EMS) Providers
Problem
Possible Solution
Differences in states regarding who is a mandated reporter
Ambiguity in language
Recommendation to make everyone a mandated reporter
Standardize language
Are EMS providers mandated reporters when they are off duty?
Include clarification in law or regulation as has been done for other
mandated reporters
Contents of reports: how easy are they to write? Are they
formulated for EMS?
Require documentation that reflects prehospital terminology and
available information
Multidisciplinary teams within CPS* do not include EMS
Provide for prehospital inclusion where these teams are mandated
Parental consent: what to do when parents want to accompany
their child on transport or when parents refuse transport for
their child
Provide legal mechanism for transport of the possibly abused or
neglected child without parental consent
Legalities regarding cultural and religious attitudes toward
medicine and treatment
Educate prehospital providers in the legal issues regarding cultural and
religious beliefs
Lack of training in legal aspects of documentation
Education in objective documentation, including noting child’s emotions
and objectively recording what is said
*CPS = child protection services.

Markenson et al. KNOWLEDGE/ATTITUDES ABOUT CHILD ABUSE
267
TABLE 5. Problems Faced by Prehospital Providers
How does that affect the prehospital provider’s
actions?
Limited clinical exposure to child abuse/neglect because of the
low percentage of pediatric calls
• What is the prehospital provider’s liability when a
superior does not want to make a report? What
alternatives are available in such situations? What is
the prehospital provider’s civil liability?
Limited opportunity for on-scene assessments beyond those
essential to direct patient care
Lack of a clear, consistent role in reporting child abuse/neglect
from state to state and region to region
Lack of familiarity with mechanisms for reporting directly to the
child protection agency
• Are providers mandated to report when they are off
duty?
Failure of child protection agency to include providers in the
investigation/evaluation process
• What if providers suspect abuse of someone in the
household other than the patient they were called to
treat? Would they be liable if they did not report it?
Child protection services have traditionally not been educated
about the importance of emergency medical services (EMS)
in child maltreatment detection, evaluation, and, if needed,
prosecution
Legal aspects of cultural competency must also be
considered, including the use of folk medicine in the
community versus abuse or neglect, refusal of treat-
ment for religious reasons, care for undocumented
aliens, and consideration of cultural and religious
beliefs.
Lack of inclusion in interdisciplinary teams dealing with child
abuse and neglect (e.g., child fatality reviews, child protection
teams in hospitals)
Limited experience and education in recognizing subtle findings
that, when put together, might lead to the suspicion of child
abuse and neglect
Problems Faced by Prehospital Providers
some providers report suspicions to the emergency
department (ED) physician; in most cases, a social
worker subsequently reports on behalf of the ED
physician. However, professionals in CPS prefer to
receive information “early and up front,” rather than
second- or thirdhand. Should the prehospital provider
report directly to CPS?
How can the reporting process be made easier? If
another EMS call comes through before the EMTs and
paramedics leave the ED, they may not be able to
deliver a full report at that time. Emergency depart-
ments also need an effective system of reporting that
includes the prehospital provider and accounts for the
problem that ED staff, such as social workers, may not
make reports on behalf of the prehospital providers,
who are not considered part of the ED staff.
Although much of the discussion focused on key
issues related to the role of prehospital providers in
child protection, one discussion centered on specific
possible problems faced by prehospital providers
(Table 5).
Prehospital providers respond to a high volume of
adult calls but few calls involving children; of these,
even fewer will involve child abuse and neglect.
Providers must be vigilant for signs of abuse or neg-
lect during all pediatric calls, but they must also
remember that abused or neglected children may be
present during adult calls. Under the intense pressure
of the acute care environment, providers perceive that
they do not have time to perform assessments beyond
direct patient care. To address this dilemma, it is
important to develop generic guidelines that
providers can follow at all scenes. These should
include an assessment for possible child abuse and
neglect during the scene survey any time children are
present, with the goal of heightening awareness of
child abuse and neglect in any situation. This assess-
ment need not interrupt patient care and may not
require immediate documentation. It is sufficient for
providers to mentally note elements that may help in
a later investigation, documenting these findings
when the crisis is over.
Legal and Legislative Issues
The Panel defined several legal issues and recom-
mends further study to find definite solutions (Table
4). Prehospital providers need to understand suspi-
cion, scope of authority, jurisdictional lines, kidnap-
ping, and consent. Prehospital providers lack ade-
quate training in documentation of child abuse and
neglect, particularly in the legal context.
Some of the questions raised included:
There is some agreement that the essential role of
the EMS provider includes identifying, recognizing,
and reporting child abuse and neglect, but the manner
in which this translates into practice, procedures, and
guidelines varies among communities and EMS sys-
tems. The unclear role presents a problem for the
provider in knowing his or her course of action. Some
possible solutions are to encourage states to clarify
• What do EMTs know about proper collection of evi-
dence or items relevant to diagnosis and treatment
and transfer of that evidence?
• What rights do parents and children have regarding
consent for examination and transport?
• What is the definition of an emancipated minor?

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TABLE 6. Key Knowledge Points in
Identifying High-risk Situations
picture, but their observations may be additive to oth-
ers findings leading to suspicion. A problem is that
prehospital providers do not often know that, even
without reaching the level of suspicion, documenting
their findings may be helpful to others involved in
child protection.
Child protection workers generally do not contact
the prehospital provider during the investigation of
alleged child abuse or neglect. Providers have few
interactions with CPS. In many cases, CPS profession-
als do not even know that they can contact prehospi-
tal providers for information. As more prehospital
providers objectively document significant observa-
tions during emergency calls, thereby conveying valu-
able information to investigative staff, the current gap
between EMS and CPS will begin to close. Better link-
ages and communication between CPS and EMS will
help to promote this cooperation locally and national-
ly.
Currently, prehospital providers are not included in
interdisciplinary teams dealing with child abuse and
neglect, such as child fatality reviews and child pro-
tection teams in hospitals. EMS representation would
give prehospital providers an opportunity to hear
about the outcome of child abuse cases. Knowing that
something has been done to help the child will pro-
vide a strong incentive to report future findings.
Criteria CPS* uses to determine safety/lack of safety for child and
definition of safe/unsafe
Circumstances that indicate high risk
When talking about safety in regard to child protection, refer to
risk for harm and risk for maltreatment
Determinants of accidental versus nonaccidental injuries
Threat-to-harm versus harm, at-risk versus high-risk
Normal growth and development
Clinical presentations of child abuse (e.g., findings that indicate
accident vs inflicted and common symptoms)
Recognizing a hazardous environment (i.e., not just a dirty or
untidy home)
Caregiver disabilities and characteristics that create a high-risk
situation (e.g., mental and physical health, alcohol or other
substance abuse)
Criteria for rapid assessment for high-risk situations
Documentation of observations
Resources and referrals for at-risk families that do not need
immediate CPS
Effective ways to pass information and communicate concern to
hospital staff, referral agencies, or child protection workers
*CPS = child protection services.
language defining the prehospital provider’s role as a
mandated reporter of child abuse and neglect, and to
decide whether providers are expected to report
directly to the CPS agency or integrate reporting with
other reporting mechanisms
Problems are also caused by most prehospital
providers’ lack of familiarity with systems for report-
ing child abuse and neglect in their state. Suggested
solutions were to:
High-risk Situations and Prevention
Prevention is a complex challenge for CPS profession-
als and is even more so for the prehospital provider.
Because of the low volume of pediatric calls, there is
scant evidence to suggest whether EMS personnel can
carry out prevention and identification of at-risk chil-
dren, but panel members agreed that it is within their
purview.
Child protection professionals view risk as the
potential for maltreatment or harm. Their assessment
in these cases focuses on whether the child is safe in
the current environment. Terms such as at risk or high
risk do not necessarily mean that maltreatment has
occurred, but, rather, that the family requires inter-
ventions to prevent maltreatment from occurring.
These situations may not yield reportable evidence of
child abuse or neglect, yet a timely referral to social
services may serve as a method of prevention. At-risk
children could benefit if prehospital providers had the
knowledge and skills to identify these situations
(Table 6).
• Educate prehospital providers on state and local
reporting requirements
• Establish protocols and systems to facilitate the
reporting process for prehospital providers (e.g.,
add a check box to the run sheet of suspicions and
to whom/where did/do they report [ED, physi-
cian, hotline])
• Teach providers to document the scene with photo-
graphs
• Educate providers about what should be included
when reporting
• Determine how reports should be coordinated and
by whom
It may be useful to place a check box on the patient
care record so that providers could request a social
work referral when transporting an at-risk child to the
hospital. If the child is not transported, providers
could give the family a brochure with referral infor-
mation and telephone numbers. This would give pre-
hospital providers an opportunity to contribute to pre-
Recognizing child abuse often involves fitting
together many subtle clues. By themselves, these clues
may seem innocuous, but together they reveal a more
suspicious picture. Prehospital providers have limited
experience recognizing the findings that create this

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TABLE 7. Knowledge and Skills in
Patient and Family Interaction
vention efforts. Finding time for prevention-related
activities is a challenge for CPS professionals and pre-
hospital providers alike.
General approach
Listen
Ask
Patient and Family Interaction
Keep in mind you don’t know! (i.e., do not assume)
Cultural variations
Prehospital providers receive limited training in fami-
ly and patient interaction, so they are not well
equipped to cope with the volatile family situation
that may accompany potential child abuse or neglect.
CPEM research showed that EMTs and paramedics
reported the least confidence in this area. Most
respondents indicated a need for additional education
in techniques for interviewing and interacting with
the family in such situations. The Panel established
key knowledge and skills issues in this area (Table 7).
Role-playing and scenarios are the best methods for
training and educating providers in these techniques.
Scripted questions may be helpful as well. Future
technology may bring additional tools to this arena,
such as interactive video presentations.
Don’t make assumptions based on stereotypes
Be realistically supportive
Be respectful
Scripted questioning
Medically relevant
Forensically informed
Intervention strategies for the hostile patient and family (i.e.,
unsafe situations that pose danger to the patient or provider)
How to spot red flags
Documentation of interactions and statements; passing along
information
lect could be added to examinations for the national
registry and state certification. Helpful pocket
resources that address child abuse and neglect could
be developed.
Recognition, Assessment, and Treatment
The results of CPEM’s survey demonstrated that pre-
hospital providers need to broaden their view of
assessment and open their eyes wider if they are to
recognize potential child abuse and neglect or chil-
dren who are at risk. The relative scarcity of pediatric
calls contributes to this problem. Child protection pro-
fessionals use a basic assessment framework, which
assesses the questions of who, what, where, when,
and how, when investigating a suspicion of child
abuse; this could be readily adapted for prehospital
providers. Prehospital providers should be reminded
that they already acquire most of this information
when they perform the scene survey and determine
the mechanism of injury. Because most prehospital
providers have only been taught about severe physi-
cal abuse and traumatic presentations in their certifi-
cation courses, it is clear that child abuse and neglect
issues need to be incorporated into medical presenta-
tions (e.g., apnea, lethargy, seizures) going from the
general to the specific in child abuse and neglect.
Prehospital providers must be assured that they are
not expected to employ the specialized skills or fill the
role of a social worker. Their role is not to fix the prob-
lem at the scene, but, rather, to identify the problem
and pass along the information. This is how they can
actually fix it.
The Panel suggested the following scenarios for
role-playing to help with training in the areas of recog-
nition, assessment, and treatment:
• What does one do when child abuse or neglect is
suspected, and the family refuses treatment or
transport?
• Can a child be transported without obvious medical
necessity?
• What does one do if abuse or neglect is suspected,
but there is no medical need for transport?
• What does one do when the abused child is not the
patient for whom the ambulance was called?
Documentation and Reporting Procedures
The Panel agreed that the importance of proper docu-
mentation cannot be overemphasized. Documentation
reinforces memory, provides a vehicle for conveying
information to others, and increases the accuracy of
testimony, if required. During every emergency call,
prehospital providers should attune all of their senses
to their surroundings so that they can precisely
describe the environment and, if appropriate, the
mechanism of injury, even if there is no time to docu-
ment them at the scene. It is imperative to use clear,
objective language for all documentation and to avoid
opinions and judgments.
Given that prehospital providers are afforded few
opportunities to practice their recognition, assess-
ment, and treatment skills, the Panel agreed that fre-
quent educational opportunities are needed. Various
teaching methods were suggested; for example, expe-
rienced providers could act as mentors to help less
seasoned providers enhance their skills and knowl-
edge. Additional questions about child abuse and neg-
All providers, regardless of whether they are man-
dated reporters, must gain the requisite knowledge
and skills for reporting (Table 8). Education efforts
should cover the definition of reporting, who is man-

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TABLE 8. Knowledge and Skills for Documentation
help them assess children with special health care
needs for abuse and neglect (Table 9).
Importance of proper documentation
Methods for proper documentation, including phrasing and
terminology
Cultural Competency
Prehospital providers require knowledge and skills in
cultural competency so that they can appropriately
assess children from different cultural backgrounds
for child abuse and neglect (Table 10). Without this
knowledge, provider bias may emerge, greatly affect-
ing the accuracy of the evaluation. To that end, EMS
should include members of culturally diverse commu-
nities in such areas as protocol development, multi-
disciplinary teams, and general outreach. EMS partic-
ipation in community activities should be encouraged.
EMS personnel need resources that expand their
knowledge of cultural diversity within their commu-
nities. EMS agencies should be encouraged to teach
existing courses that include cultural competency
training.
Identify the mechanism of injury and child development issues
Scene documentation, including environment and mechanism of
injury
Documentation checklist for efficiency, improved patient call
reports, and better identification of suspicious cases
Details checklist (e.g., accuracy, mechanism of injury; hygiene,
prior medical care, use of proper legal documentation)
Awareness of inappropriate terminology
Recording statements of bystanders
TABLE 9. Knowledge of Children with
Special Health Care Needs (CSHCN)
CSHCN are at high risk for child abuse and neglect
Parents of CSHCN are at high risk for wrongful accusation of
abuse
Interviewing and interaction skills (use role-playing in training an
resource)
Advocacy and Future Meetings
The final portion of the meeting focused on future
needs for advocacy and subsequent meetings (Table
11). The Panel resolved that prevailing attitudes
toward education in child abuse and neglect must be
changed in order to advance the role of EMS in this
arena. It would be helpful to produce a joint position
paper on this issue with EMS and CPS.
Address CSHCN in case studies and scenarios for practice
dated to report, to whom the report is made, the
mechanism for reporting, and reporting criteria, such
as reasonable suspicion.
The Panel called for cross-disciplinary presentations
at EMS and child protection conferences so that each
discipline will understand the other’s role. EMS repre-
sentatives should be included in hospital-based and
other child protection interdisciplinary teams. In addi-
tion, it was agreed that the EMSC National Resource
Center would create, with the help of participants
from the Blue Ribbon Panel, a fact sheet on the topicof
child abuse and neglect for national distribution to the
EMS world, promoting awareness of advocacy needs.
With regard to advocacy activities to improve exist-
ing policy, most discussions focused on issues of man-
dated reporting. Many states have statutes that make
prehospital providers mandated reporters but do not
require mandated education. How can providers be
expected to report if they have no knowledge of the
law? The Panel agreed that both education and report-
ing must become mandatory. It was suggested that the
reporting process be facilitated through a checklist or
form that prehospital providers could incorporate in
their patient call record. It may be helpful to establish
an outline for the form that could be used nationally,
but each state will need to adapt this outline to its own
requirements.
Children with Special Health Care Needs
The Panel agreed that knowledge about children with
special health care needs should be integrated with
information on child abuse and neglect, because sta-
tistics have shown that these children are at high risk
for abuse and neglect. Prehospital providers should be
made aware of this so that they can watch for signs of
child maltreatment. Specific knowledge and skills can
TABLE 10. Cultural Competency Knowledge
and Skills for Child Abuse and Neglect
Child-specific cultural competency issues (most key points of
curricula in cultural competency are not specific to children but,
rather, discuss normative cultural values and practices)
Knowledge of ethnic variations in the local neighborhood
Identification of community leaders
Differentiating folk practices from child abuse and neglect for
referral purposes
Provider practices and biases
Psychosocial issues
Interviewing techniques that account for cultural practices and
norms
Interviewing across language barriers (e.g., identifying an
appropriate translator, such as a child or relative)
The Panel resolved to publish this summary of the
consensus conference simultaneously in EMS and
child protection journals, with the hope that it will
Awareness of nonverbal cues by translator when another is
translating for the patient

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271
TABLE 11. Recommendations for
Advocacy and Collaboration
ing, increased presence and participation at each
other’s conferences, and publication of research data
from this field.
Produce a joint position paper with EMS* and child protection
organizations
The authors thank the Emergency Medical Services for Children
(EMSC) Program of the Maternal and Child Health Bureau (MCHB)
of the Department of Health and Human Services for providing the
financial support for the meeting. They thank Cindy Doyle, RN, and
Dan Kavanagh, MSW, of the MCHB EMSC Program, for their direc-
tion and assistance with this project and with the meeting; and Jane
Ball, PhD, Ken Allen, Yvonnada Cousins, and the staff of the EMSC
National Resource Center, who helped to coordinate the meeting.
The authors express their appreciation to Lenora Olson, MA, and
Lawrence Cook, MStat, from the National Data Analysis Research
Center; and William Brown, NREMT-P, and Philip Dickison,
NREMT-P, of the National Registry of Emergency Medical
Technicians (NREMT) for help with data management and analysis.
The authors also thank Andrew Skomorowsky, MFA, NREMT-P,
from the Center for Pediatric Emergency Medicine, whose help in
the development and distribution of the assessment tool and coor-
dination of results dissemination was invaluable.
Deliver presentations on child abuse and neglect at EMS
conferences
Deliver presentations on EMS at child protection conferences
Add EMS representatives to hospital-based and other child
protection teams
Create a fact sheet for national distribution to the EMS world
Make education and reporting mandatory in all states
Create a checklist or form that EMS can incorporate into its record
and use for reporting
Publish meeting summary simultaneously in EMS and child
protection journals
Incorporate cross-disciplinary material into EMS and CPS*
training to delineate roles
CPS = child protection services; EMS = emergency medical services.
help personnel in EMS and CPS understand and
remember the importance of each other’s roles. Panel
participants will facilitate presentations on this topic
at EMS and child protection meetings. The Panel sug-
gested that educational materials in EMS and child
protection arenas incorporate cross-disciplinary infor-
mation on each profession’s roles. Finally, the Panel
recommended that data continue to be collected in the
area of child protection and EMS.
•
APPENDIX
Blue Ribbon Panel Participants
Beth L. Adams, RN, NREMT-P, National Association of
EMS Physicians
Seth Asser, MD, Cultural Competency Expert
Edward N. Bailey, MD, National Alliance of Children’s
Trust and Prevention Funds
Jane Ball, DrPH, RN, Emergency Medical Services for
Children National Resource Center
Rintha Batson, EMT-P, National Association of Emergency
Medical Technicians
Kathleen Brown, MD, American College of Emergency
Physicians
Cindy W. Christian, MD, Ambulatory Pediatric Association
David Corwin, MD, American Academy of Child and
Adolescent Psychiatry
Cindy Doyle, RN, BSN, MA, Maternal and Child Health
Bureau
Douglas S. Faust, PhD, American Psychological
Association
Bruce E. Herman, MD, American Academy of Pediatrics
Arthur Hsieh, MA, NREMT-P, National Association of
EMS Educators
Stephen Hise, National Association of State EMS Directors
Susan Hohenhaus, RN, CPEN, FNE, North Carolina
Emergency Medical Services for Children
Marilyn K. Johnson, RN, Emergency Nurses Association
Dan Kavanaugh, MSW, Maternal and Child Health Bureau
Carolyn Levitt, MD, National Children’s Alliance
Jeffrey T. Lindsey, MEd, EMT-P, International Association
of Fire Chiefs
Stephen Ludwig, MD, American Academy of Pediatrics
Janet McCleery, RN, CPNP, National Association of
Pediatric Nurse Practitioners
Margaret McHugh, MD, MPH, Child Protection and
Development Center of Bellevue Hospital
CONCLUSIONS
This conference provided an important first step in
bridging the gap between the child protection and
EMS worlds. The Blue Ribbon Panel recognized the
importance of the identification, recognition, docu-
mentation, and reporting in child protection that pre-
hospital personnel can provide. Although prehospital
providers are not mandated reporters in all states, it
was felt that this should be advocated, and that
providers must be educated to fulfill this role.
Prehospital providers are in the unique position of
visiting the home unannounced and seeing the actual
mechanisms of injury. They may observe child protec-
tion issues whether the child is the patient or a
bystander. Mechanisms should be established to help
providers recognize situations that do not fit the crite-
ria for mandated reporting, so that they can help the
families of at-risk children obtain social services that
may protect these children from future harm.
Child protection experts must be educated as well,
so that they will better understand the prehospital
provider’s important role in identifying and reporting
child maltreatment. The continued cooperation of
these two disciplines is essential if we are to help chil-
dren who suffer from maltreatment. Continued coop-
eration can be fostered through mutual understand-

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David R. Miller, National Council of State Emergency
Medical Services Training Coordinators
Thomas D. Morton, Child Welfare Institute
Lenora Olson, MA, National EMSC Data Analysis Resource
Center
Although these individuals were appointed to represent their
organizations, and the comments contained in this document rep-
resent the participants’ input, formal approval of this summary
was not obtained from the boards of these organizations.
Nancy A. Peddle, PhD, Prevent Child Abuse America
Denice L. Reese, RN, CPNP, National Association of School
Nurses
Center for Pediatric Emergency Medicine Staff
LaVoyce Reid, MSW, LCSW, National Association of Social
Workers
Murney Rinholm, Parent Representative
Laura Rogers, JD, National Center for Prosecution of Child
Abuse
David Markenson, MD, EMT-P (Meeting Chair)
Hedda Matza-Haughton MSW, CSW (Meeting Co-Chair)
Arthur Cooper, MD, MS
Paul Sowash, National Registry of Emergency Medical
Technicians
Local Conference Staff (National EMSC Resource Center)
Shulamit Lewin, MHS
John Stuemky, MD, International Society for the Prevention
of Child Abuse and Neglect
Yvonnada Cousins, BA
Nikita Reed
Chief Mary Ann Viverette, International Association of
Chiefs of Police
Donna M. Davidson, MPH
Susan Eads Role, JD, MLS