monthly article for May 2003

Unexplained Injuries
©2003 Action for Child Protection, Inc.

Introduction

Child safety models across the country include unexplained injuries as a threat of danger. Dealing with an unexplained injury could be among the most challenging and serious family issues that you face when assessing child safety.

Unexplained injuries should provoke deep concern among CPS staff.

An unexplained injury includes

• Injuries for which caregivers simply can provide no explanation for how it occurred - they say they have no idea or
• Injuries for which the caregivers' explanation is not consistent with the nature of the injury, the capacity of the child and the situational context.

Dave and Rennie's 9-Month-Old Daughter has an Unexplained Injury

This ten minute case vignette involves an excerpt from an interview with parents at the hospital. Physicians have indicated that the child's injury is non-accidental; however, the parents have no explanation for how it occurred. As you watch consider anything you see or hear that suggests to you a possible explanation.

The Way to Discovering What Happened is Information

When you are seeking an explanation for an injury you are not conducting an inquisition
or attempting to determine guilt. Remaining neutral and objective is crucial. It is
appropriate to look for responsibility, qualification of circumstances and representation of
family life and functioning (specifically parent-child interaction) Always respect
caregiver's feelings.

In-depth information collection can be like an exploratory conversation. As you frame
questions in ways that fit parents' communication style, reassure caregivers that you need
to know as much as possible in order to understand and arrive at an explanation of the
injury. Remember, denial is a natural response and can represent actual ignorance, fear,
confusion, guilt and shame or manipulation

To the extent that an unexplained injury can be explained, the answer exists somewhere
within the situation, home, caregiver, family and child. So, join with caregivers since
you share a common in the answer. Enlist the caregiver for help to solve the lack of an
explanation. Assess the content and information provided by the caregiver by looking for
consistency, conflict., logical, and reasonableness.

The Assessment Can Lead to an In-Depth Examination of the Family Situation

The Home Situation

• Atmosphere and climate (e.g. calm and stable);
• State (e.g. clutter, neat, etc.)
• Routine
• Physical structure and setting
• Specific child surroundings/habitat
• Household composition
• Family and non family members who have access to the child

It is crucial to explore the injury event and surrounding circumstances in extreme detail. The following questions serve as examples of the kind of probing that is needed to explained serious injuries.

• Previous CPS involvement: reports, findings, open case?
• History of medical contacts related to child injuries?
• When was the injury noticed?
• What was going on prior to and when the injury was noticed?
• How was the child hours/days before event?
• How was the child immediately before injury or condition was noticed?
• What was the caregiver doing (minutes/hours) prior to noticing?
• What did the caregiver notice - a specific description?
• What did the caregiver think and feel upon noticing the injury?
• What did the caregiver do upon noticing the injury and when?
• Were others around; did they notice; what did they think/feel about the injury?
• What understanding does caregiver have of the (diagnosed) injury?
• What history can the caregiver provide about the child's activity and susceptibility/vulnerability?
• How does the caregiver explained what happened?

Probing for understanding involves testing out the explanation given by the caregiver. Ask each person with some knowledge of the situation (in particular caregivers) for a recounting of the explanation. As explanations are repeated examine loose ends. Delving deeper occurs when you ask for more understanding and clarification. If caregiver cannot explain, press for why he or she cannot and how he or she feels about it. You can pose hypothetical questions to explore the person's perceptions and thinking process: "What do you think might be a possibility of what happened?" Alternatively you can pose hypothetical explanations yourself and ask the caregiver to respond. Testing the explanation includes summarizing and informing the caregiver about what you know and believe in detail.

When the Explanation Remains Elusive

When satisfactory explanations do not come easily or quickly, a bulldog determination is needed to continue the search.

Study the Child

As your assessment continues seek information about the child from caregivers and other professionals. Consider the child's physical robustness and developmental status. Evaluate the child's activity level and temperament. Look for characteristics that could be provocative such as physical features or limitations, overly dependent, highly needy or limited responsiveness. Be clear in your own mind about the nature of the injury (accidental/non-accidental) and the reasonableness of the child's contribution to the experiencing the injury. Certainly you will want to check the child's history: health, accidents, injuries, etc...

Study the Parenting

When an explanation does not emerge the most extensive part of your assessment should be directed at the caregiver. You will want to know about the caregiver's own childhood including:

• Influence of childhood on parenting
• Attitudes about own childhood
• How parented
• How children were treated in home
• Nature of discipline
• Parenting style used by caregivers' parents

• Why did caregiver want or have children?
• What were the circumstances/plans that preceded births of all children?
• What is best/worst part of parenting?
• What was pregnancy like for identified child? compared to other children?
• What was delivery like of identified child?
• What has raising the child been like?
• Can the parent provide a minute-by-minute description of daily routine involving the child?
• How does the caregiver manage and control the child?
• How much time does the caregiver spend with the child and under what circumstances?
• How does the caregiver describe the child?
• Can the caregiver identify the child's strengths and limitations?
• Does the child remind the caregiver of anyone?
• What does the caregiver expect of the child?
• How demanding is the child according to the caregiver?
• What appears to be the nature of attachment between the child and either caregiver?

As you continue to seek an explanation for the injury, observe and assess the nature, frequency and quality of caregiver - child contact, particularly when the child is separated from the family such as in the hospital.

Be Informed About Caregivers

A study of the caregiver(s) should consider history, emotional and physical health and the person's civil and criminal record.

The question of stress is a critical one deserving thorough exploration. You will want to identify the presence of general stress and its sources. Consider whether there has been the onset of a crisis particularly in reference to the injury event. Determine whether there is any child rearing related stress. As you evaluate take note of how the caregiver relates to your inquiry into stress.

Other areas you should explore include geographic, social and emotional isolation; the presence of support; social contact and activity; loss of relationships; and loneliness.

The question of caregiver self control is a huge one. This considers whether caregiver emotional responses are reasonable and appropriate to situations. You can observe whether the caregiver can control emotions that are displayed. Notice, as you explore issues about the family and in particular the injury event, if the caregiver emotes and communicates by blurting out, acting over controlled, exaggerating, hesitating or
acting overly dramatic. Impulsiveness may be exemplified in speech, behavior, and life management, ways to solve problems, actions, thoughts and conclusions. Think about whether it appears that the caregiver exerts unusual energy managing and controlling feelings or in creating an acceptable self-presentation.

It is important to understand things that influence caregiver thinking and functioning such
as substance use (street or prescription), religion, obsessions (e.g. TV, computer, reading,
etc.) or certain people.

When analyzing what you think and understand about caregivers, there are a couple of things you ought to consider.

1 - Judge caregivers' state of mind as expressed through life satisfaction, feelings
about self, reasonableness and reality orientation.

2 - Examine the meaning of caregiver participation as expressed through cooperation, openness, consistency, trustworthiness, investment, motivation, stability, calmness and lack of self-concern.

Caregivers who are attempting to defend themselves will present behavior and communication that keeps you at a distance and off balance.

Seek Information from Other Sources

Information collection and analysis should include the extended family. Certainly the health and well being of the extended family should be noted. Seek out confirmation and corroboration related to the caregiver's childhood, parenting approach, the child, caregiver-child interaction, and the relationship between caregivers and other family members. It is important to gain the viewpoint of the extended family concerned with the injury and how it might have occurred.

It can be helpful, enlightening and sometimes confirming to check with others involved with the family: friends, neighbors, baby sitters, day care providers, pediatrician, other health providers, minister, other professionals, etc. The line of inquiry can consider general information about the family, the caregivers' individual functioning, and identification of stresses, concerning history, parenting, parent-child relationship, child functioning and so forth. You should be certain to obtain a full medical exam of the child including consideration of previous injuries.

When No Explanation Emerges

CPS must continue its safety focused responsibility even when no explanation is forth coming: Reasonably we all must accept that even with the most rigorous inquiry sometimes cause, explanation and responsibility are never fully known.

When a child is young/vulnerable and the injury is serious and apparently non-accidental, CPS involvement should continue.

When an unexplained injury remains a mystery, remember that a safety plan with extensive exposure to the home should stay in place to assure the child continues to be safe at home.

You should continue to forge the partnership with caregivers to assure protection of the
child and the provision of any services that have been deemed to be needed and useful. It
makes good sense to continue to appeal to the caregivers' own interest and motivation to
assure that no subsequent injury occurs. And remember, you should also be sensitive to
the safety and well being of non identified children.

What happened to Dave and Rennie's Daughter?

Rennie was responsible for the injury. There was a strain on the couple's relationship;
Rennie was feeling isolated and unappreciated; Dave's Friday nights out were occurring
more often than reported and Rennie resented his going out but more so Dave's lack of
appreciation for how she was feeling. The baby was fussy and demanding that Friday
night. Rennie ran out of patience and handled the child roughly while forcing her to lie
down in her bed. The injury resulted from the rough handling, however, Rennie was not
aware at the time that the child was injured. The next morning when the injury was
discovered Rennie went into denial refusing to allow herself to admit to her overreaction
the night before.