Trauma-Informed Approach to Mandated Reporting of Child Abuse – PediaCast CME 099

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Description

  • Dr Kristin Crichton and Tishia Gunton visit the studio as we consider our role as mandated reporters of suspected child abuse and neglect. How can we best fulfill our duty to report while maintaining a positive and supportive relationship with the family? Tune in to find out!

Instructions to obtain CME/CE Credit

  1. Read this information page.
  2. Listen to the podcast.
  3. Complete the post-test at Nationwide Children’s CloudCME.

Topics

  • Child Abuse and Neglect
  • Mandated Reporting
  • Trauma-Informed Care

Presenters

Learning Objectives

At the end of this activity, participants should be able to:

  1. Differentiate when injuries in children would indicate the completion of a non-accidental trauma (NAT) work up.    
  2. Explain how to have a conversation with parents when you have concerns for child physical abuse.
  3. Identify the process for reporting to child protective services (CPS) and the anticipated response from CPS.
  4. Determine when and how to follow up with the parents after you make a mandated report on their child.

Links

Disclosure Statement

  • No one in a position to control content has any relationships with commercial interests.

Commercial Support

  • Nationwide Children’s has not received any commercial support for this activity.

CME/CE Information

  • In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
  • Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
  • As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
  • Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Contact Us

  • CMEOffice@nationwidechildrens.org

 

Episode Transcript

Dr Mike Patrick: This episode of PediaCast CME is brought to you by the Center for Family Safety and Healing at Nationwide Children's Hospital.

Hello everyone and welcome once again to PediaCast CME. It is a continuing medical education podcast for healthcare providers. This is Dr. Mike coming to you from Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 99. We're calling this one trauma-informed approach to mandated reporting of child abuse.

I want to welcome all of you to the program. So, we have a little bit of a heavy talk for you this week, but it is an important one Because child abuse and neglect is a common problem in the United States with millions of kids and families impacted by these events every year. Over 4 million annual reports are made to Child Protective Services, and these reports involve over 7 million children each year.

It also turns out that childhood deaths from abuse and neglect are one of the highest causes of death in young kids, and actually higher than car accidents and pediatric cancer. So, this is something that unfortunately is common, and as mandated reporters, all of us as pediatric providers. You know, really want to know what the process looks like.

What are we looking for? Who and when do we report? It's an important part of our job to make these reports when we have a suspicion of neglect or abuse, we don't have to have proof, just any suspicion at all. And again, we'll, we'll talk a little bit more about what may cause such a suspicion, but it is important that we understand that it is our job to report when we have.

Any sort of concern, uh, whatsoever at the same time, we also want to maintain a positive supportive relationship with the families we serve, even when we have suspicions of abuse or neglect. So that can be hard to walk that line. between support and mandated reporting. Although I guess in a sense, mandated reporting is supporting children and their families because we want kids to be healthy and to live their best lives.

And sometimes that means parents just need to figure out some things, some things that maybe they didn't understand were dangerous, or maybe they didn't Have their priorities in the right place, and it can really be life changing when we make these reports and then families get the support that they need through the various agencies that that protect Children and families, and that really amounts to reporting with a trauma informed lens.

Because this is a traumatic event for our families. And so, we, it's something we have to do because we're mandated reporters, but we also care about our families. And so that's why we really want to do this through a trauma informed lens. Now that sounds good, but what exactly do we mean by that? You know, how do we do this as we think about the trauma that it does create in a family’s life?

Well, stick around because we are going to dive into the details. Of a trauma informed approach to mandated reporting of child abuse. Of course, in our usual PDA cast fashion, we have two terrific guests joining us in on the conversation. Dr. Kristen Crichton is a child abuse pediatrician with child and family advocacy at Nationwide Children's Hospital.

And Tishia Gunton is a clinical medical social worker also at Nationwide Children's Hospital. Don't forget, you can claim free CME credit for listening to this podcast, and it is category one credit. It's easy to do. Simply head over to the show notes for this episode at PediaCastCME. org. You'll find a link to the post test in the show notes.

Follow that link to cloud CME, click on the materials tab, CME credit. Taken past the posttest and the category one credit is yours. And we do offer credit not only to physicians, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since nationwide children's is jointly accredited by many professional organizations, it's likely we offer the exact credits you need to fulfill your state's continuing medical education requirements.

Of course, you want to be sure the content of the episode matches your scope of practice. In today's case, this really. as mandated reporters really matches the scope of everyone's practice who takes care of kids. Complete details are available at PediaCastCME. org. Finally, I want to remind you the information presented in our podcast is for general educational purposes only.

We do not diagnose medical conditions. Or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PediaCast CME terms of use agreement, which you can find at PediaCastCME. org. So let's take a quick break. We'll get our experts settled into the studio, and then we will be back to talk about a trauma informed approach to mandated reporting of child abuse and neglect.

It's coming up right after this.

Dr. Kristin Crichton is a child abuse pediatrician at Nationwide Children's Hospital, medical director of the Child Advocacy Center at the Center for Family Safety and Healing, and an associate professor of pediatrics at the Ohio State University College of Medicine.

Tishia Gunton is a clinical medical social work supervisor at Nationwide Children's. Both have a passion for supporting children and families impacted by child abuse. Our topic today sheds light on the important task of reporting suspicions of child abuse and neglect to child protective services and, or law enforcement, but doing this from a trauma informed lens and with the goal of maintaining a positive and supporting relationship with the family.

Before we dive into this topic, let's give a warm PDA cast. Welcome to our guests, Dr. Kristen Crichton and Tishia Gunton. Thank you both so much for joining us today.

Dr Kristin Crichton: Thanks so much for having us. It's great to be here. Happy to be here.

Dr Mike Patrick: Yeah, we are really glad that both of you are here as well. So, Kristen, if we could just start with a little bit about the epidemiology of abuse.

So, you know, how common is child abuse and neglect? I'm sure it's way more common than we want it to be.

Dr Kristin Crichton: It is. It's way more common than we want it to be, and I think it's way more common than we think. I remember when I, when I started this role, one of my family members, you get lots of interesting responses from people when you do this, but one of my family members said, oh, so you just sit in your office and wait for someone to be abused.

And it turns out we don't have to wait very long. So, there's over 4 million reports made to child protective services annually involving over 7 million children a year. And those are just the cases that are reported to children's services. And we know that so much child maltreatment goes unreported.

And then of those, only about 50 percent are screened in and then half a million are substantiated, which means that Children's Services has found concern for maltreatment in that, in that setting. So, it's, it's a big problem and I think it's, it's under recognized both in the, in society but also in the medical field.

And unfortunately, over 1500 children die every year as a result of maltreatment. That's more than car accidents or pediatric cancers. So, it's something that we need to have on our radar as, you know, any clinician working with, with children to make sure we keep them, keep those kids safe.

Dr Mike Patrick: Yeah. Yeah, absolutely.

And then, you know, as I think about, engaging with families, when we have a suspicion for abuse, and we'll talk a little bit more about what would cause us to have suspicions, suspicion is really the big word, right? Like we're not accusing someone of abuse or saying that abuse happened, but we also don't want to, you know, ignore it.

And then something worse happens down the road. So, it's really kind of walking a fine line, right?

Dr Kristin Crichton: It definitely is. And I, I think this is a hard conversation to have, and we would be remiss to pretend otherwise. I think frontline workers, like emergency medicine physicians like yourself, are really tasked with kind of understanding the barriers to making that, making that diagnosis and having that conversation.

I think if we could just acknowledge that it creates moral distress within us as, as providers and clinicians and acknowledge that. Then we can kind of start to think about, well, just because I feel uncomfortable doesn't mean that we don't need to have this difficult conversation. We need to acknowledge this is hard, but at the end of the day, what's more important than how I feel, and my discomfort is that this child is safe.

So, we want to reframe, this is an opportunity to intervene to protect a child, potentially saving their life. So, the first thing I would encourage is just get, get as comfortable as you can saying out loud. We can't talk in euphemisms. We can't say, oh, this might be something else concerning. We need to say.

The injury that we see is more injury than we would expect from the accidental history you're describing, or children that are this young can't cause the injury to themselves and we're worried that someone has hurt your child. Just like you said, we're not accusing the people that are, that are in front of us, the caregivers that are with the child.

We're trying to engage and work with them to keep that child safe and healthy. So, we need to be clear. That's going to help them understand what we're worried about. We don't want to sugarcoat what we're talking about, because then they're not going to understand how to protect their child. We've had cases where there's a concern that something happened with the babysitter.

And when the family didn't understand what we were worried about, the child went back to the same babysitter and had more injury. So, if we can't explain this is what we're worried about, the parents can't. Protect their child. So, it's hard. But the other thing is that families will also catch on if we're being kind of cagey and misleading.

So, we want to make sure we're being as clear as we possibly can, even though it's uncomfortable.

Dr Mike Patrick: And that's important because over 1500 children die every year in the United States from maltreatment. And that's more than car accidents or pediatric cancer. So, I mean, it really is A big cause of childhood death, and we have an opportunity to intervene and prevent that from happening.

Dr Kristin Crichton: Absolutely. And I think one of the other things that can help, you know, particularly clinicians that are on the front line is to kind of be prepared for the types of questions families may bring up. Things like, are my kids going to be taken away? You're saying I abused my child. I think having kind of some scripting around that.

I am a medical provider. I am here to take care of your child from the medical lens. I'm not Children's Services. I'm not. I'm not the police. I'm not determining if you abuse your child. I am here to say, I'm worried that the injuries don't match what you're describing happened. I'm worried someone has hurt your child.

It is not up to us to decide who. We also can't predict whether a child's going to be taken away. We work with children's services and law enforcement. Those are our partner agencies, and we will give them all of the information that the family shares with us to try and create the best, safest discharge plan for the child.

When, when people hear that we're reporting to CPS, they may say, I came here for help, or if I hurt my kid, why would I bring them in here? And we, we hear all of these often. And I think at the end of the day, most caregivers want their children to be safe and healthy. And so, it's not, we're not here to explain to them why they brought their kid in.

We're just here to say, we want to help you keep your child safe. And when we're concerned, this is what we have to do.

Dr Mike Patrick: Yeah. And because I would think that it really is the minority of cases where someone intentionally hurts their child. You know, you can have a kid who there's, you know, not enough supervision.

And so, the child went through a screen on the second floor of their house and fell out the window. And of course that's going to get reported, but it's not like the parent left the screen there in a manner in which the child could push through it on purpose.

Dr Kristin Crichton: Right. So, so that's a form of neglect and neglect is the most commonly reported form of, of maltreatment.

And I agree that often, you know, there's supervisory concerns and I have a child. I cannot, she comes up with all different kinds of ways to hurt herself. I understand accidents happen and, and we can't keep our eyes on our kids 100 percent of the time. So, creating that safe environment is important. I think when we think about the intentionality of, of a child being hurt, I don't, I don't know that that's necessarily our responsibility to think about again.

I think that's something for children's services and law enforcement to sort out. And we're here from the medical side. So, I, we're looking at the injuries on the child and we're thinking about whether we're worried or not and the rest of it. I would, you know, we let our partner agencies sort that out.

Dr Mike Patrick: And I think for from frontline person in the emergency department, I feel like it's a little bit different for me because I don't have most likely a relationship with this family coming into this problem. So, it's easy for me to say I'm doing what I would do for anyone. It doesn't matter who you are.

You could be the CEO of this hospital and. You know, if the child came in with these injuries, this is what we do for everyone. And, you know, to say, and often I will say like, I'm not saying that you've done anything, but I'm concerned that someone did, and we need to figure that out. So, I feel like it's easier for me, but someone who's had a long relationship with a family, I would imagine that it's more difficult in that, in that situation.

Dr Kristin Crichton: It is. And I think that that's something that Tisha can speak to and kind of in terms of continuing that therapeutic relationship.

Dr Mike Patrick: Yeah. Yeah. So important. Before we go there, I just want to talk a little bit about what should make us as clinicians, uh, suspect non accidental trauma and when do we do a workup and, and what does that workup entail?

Which I know that's, you could do a whole hour on this alone, but if you could just give us kind of a reminder of, uh, what we're looking for.

Dr Kristin Crichton: Yeah, I could do a whole hour and I think I probably have if anyone wants to go back in the archives of PediaCast CME, just do a little shout out for our past episodes.

And we'll put a link to that in the show

Dr Mike Patrick: notes so folks can find it.

Dr Kristin Crichton: Thanks. So, I think the first thing we want to think about is, is age. I think age really helps us kind of sort out when we're worried. First of all, babies and young infants. They just really can't generate the force to cause injuries on themselves.

So, any child that's under four months old, that really isn't ambulatory. So, they're not pulling, they're not crawling, they're not pulling to stand. They might be starting to sit and can fall over and bonk their head, but that would not cause a significant injury. We want to make sure we're getting. An idea of everything that happened before and after the injury and exactly what that, that accident look like.

We want to make sure we're getting a thorough undressed cutaneous exam. You want to make sure you're looking at hidden areas like behind the ears, the oral frenula. So, under the upper lip, under the lower lip, and under the tongue. Look at the buttocks, look at the genitalia, and really any child who's non ambulatory with a bruise, even just one bruise, should raise concern for non-accidental trauma.

We know from the literature that when we look for occult or hidden injuries in these children, we find them Frequently, frequently enough that it's worth doing the work up. For kids that are six months and under, that workup would include neuroimaging. That needs to either be a head CT or MRI of the brain.

An ultrasound is not sufficient to image under the convexities, which is where we need to look for head injury. We want to get that skeletal survey. So that's the 20 plus images, looking at the bones, all the bones of the body, getting different views. It's including those oblique views of the ribs. That's for all kids under two years old, low threshold for the kids in that two to three range.

And then we want to get lab work to screen for abdominal trauma. So that's lipase. And if those are elevated, then we would go ahead and get that abdominal CT. Again, ultrasound is not sensitive enough in these cases. So that's kind of the big version of the workup. As kids get a little bit older and we can do a more reliable neurological exam, we can, we can take that neuroimaging off.

So, for kids, from six months up to about two years, we would do the skeletal survey and lab work. And then those kids were starting to look more at where the bruises are. So, is it over a forehead, chin, knees, shins? Those are bony prominences where kids are going to have lots of injury. That's very normal.

My six-year-old shins are covered in bruises right now because she's at camp and she's a maniac. But we don't expect to see the bruises over softer areas. So, ears. cheek, jaw, specifically those submandibular areas, the neck, abdomen, buttocks, genitalia, those are all concerning areas. And we would, we would want to think about doing a workup in those kids without a good accidental history.

We want to think about if the injury, is shaped or patterned. So, if it looks like a hand, it's probably a slap mark. If it's a looped injury, it could be from a cord. And then as kids get even older, they can often answer questions about what has happened to them. So, we can ask is, you know, how did you get this injury?

And, and that can be very helpful. Kids typically are, are, Not going to lie, they're going to discuss what happened to them. They may be afraid, so it's important to create a safe environment as we can. And we want to ask non leading questions. We don't want to say like, oh, your babysitter hit you, right? We want to say, tell me about what happened.

How did this injury happen? The other thing we want to think about is there, it is legal to spank a child, that's corporal punishment, and in Ohio, the Ohio revised code does allow for, for spanking. The laws are not very specific in terms of when to be concerned for physical abuse versus discipline, but We think about it when there's a mark lasting longer than just a little bit of redness.

So, if the, uh, the discipline leaves a bruise, then we would report that to children's services in, in our institution. And then again, as, as kids get older and they're teenagers, again, we can, we can ask what's happened to them. The other thing that comes up, uh, of course. And this is again, could be a whole other hour is disclosures of sexual abuse.

And when kids disclose sexual abuse, we need to, we need to ask questions. We need to understand what, where that concern is coming from as well.

Dr Mike Patrick: Yeah. Yeah, absolutely. All really important points. One thing that, that struck me was the number of x rays. In the skeletal survey, and I have gotten to the point where when I tell families about this, I really let them know upfront from me that there's going to be a lot of x rays because we really want to make sure that there's no fractures that we're missing, but it's probably not a good idea just to say, oh, we're going to get an x ray and then they go to the radiology department and there's 20 films and then that makes for a very awkward conversation with the x ray tech.

And it's not. Yeah. That person's job to explain why we need so many films. So, is there a scripting that you have when you explain to parents why we're getting so many x rays?

Dr Kristin Crichton: There is. And we're actually, again, in our institution, we're so, so privileged to have amazing social workers and they have developed a handout that we give families with anticipatory guidance about what those x rays are going to look like.

And. I really appreciate what you said about that anticipatory guidance and letting families know this is not just one x ray. We're going to take about 24 x-rays and we tell families it's because baby's bones are very small, and we need to make sure we're seeing them from multiple different angles to ensure that we don't miss an injury.

And parents are going to feel concerned about radiation exposure and I think that's an important question and it's very reasonable to ask. Okay. At children's hospitals, especially, we're able to use very low doses of radiation so that one skeletal survey, which is that collection of 20 plus x rays, is really less than, less radiation dose than a, than a CT.

So even though it seems like a lot of imaging, it's, it's very low dose and our radiologists do a great job of, of making sure we, Only use the radiation that we need to and we want to be careful and the benefit in these cases really outweighs the risk because we need to make sure that we are looking for fractures and we know again based on the literature that when we look for them in kids.

With injuries that are concerning for abuse. We often find other injuries. And if we didn't do these x rays, we wouldn't find them and finding those fractures, even if they don't require casting or require a medical intervention. When we find those fractures, we can share with Children's Services.

Look, here's another injury and that can help them formulate their plan for how to keep the child safe.

Dr Mike Patrick: Because while in any specific instance, we can't say a hundred percent, but if there are past injuries that maybe weren't recognized, and there's one now that we're concerned about, that might make it a little bit more likely that there could be future injuries.

And that's really what we want to prevent. Absolutely. Um, what about the siblings of children where there's a concern for abuse? So, you know, a kid comes into the ER, we're, we're, we're suspicious, we're worried there's other kids in the house. What do you recommend for them?

Dr Kristin Crichton: So we actually recommend the same workup that I outlined, that same age based workup for Thorough skin check, making sure we're looking at all the skin, making sure we're looking at those hidden areas behind the ears, under the diaper, et cetera, and then doing the neuroimaging for kids that are six months and under, the skeletal surveys for kids that are under two, and then those screening labs for abdominal trauma up to age five, and while that seems like a lot for Um, A child that potentially doesn't have an outward side of injury.

Again, the literature tells us that when we're concerned about a child's safety in that environment, the other children are at risk. And so, any other children that are in the same care environment, whether they're technically siblings or not, because we know lots of families live in lots of different configurations, or it could be a babysitter situation.

Any of those children that share the care environment. need to be evaluated for additional injury because we want to make sure we're protecting those kids. Interestingly, the, the literature also tells us that children who are multiples, so twins and triplets, are particularly high risk. And we've had, you know, certainly sets of siblings that we've seen where if we hadn't done the workup, if we hadn't brought the child in, we wouldn't know they, they had injury because there's no outward signs.

And babies often don't have outward signs. of bruises or other physical findings until we do that workup. So, we need to make sure we look at, at, at all the kids. We want to do that when it's safe and reasonable. When we're having this conversation with families, they're already very stressed. And so, if what they're hearing is you also need to go out in the middle of the night from the ED and figure out a way to bring your other kids in, that’s going to be stressful.

And we don't want to put children at additional risk. So, we, we can talk to families, we can coordinate with child protective services to create a plan to bring the kids in to be assessed. But we do want to make sure that all of those children are in a safe place at that time and bring them in for assessment when it is reasonable.

Dr Mike Patrick: And that's something that could happen in the child assessment center. If you know, there's not like a pressing need to take a look at them immediately. That's not always through the emergency department. Correct.

Dr Kristin Crichton: Correct. We recommend children to and undergo to the emergency department because of the need for imaging and getting that imaging really, unfortunately requires going through the emergency department.

Not that the emergency department is unfortunate. We just don't want to send kids there unnecessarily, but we need to have them there. But kids over two, we can see at the Child Advocacy Center or for those listeners that are in the nationwide space, we can also see them at our Child Assessment Team Clinic, which is a separate clinic that we also operate.

Uncertain days of the week, which makes it a little bit limited, but we can see them in either clinic. Yeah,

Dr Mike Patrick: absolutely. But if there's a pressing need, you know, then we'd have everybody come on into the to the emergency department. And then Tisha, I want to bring you into the conversation in terms of reporting.

Tell us a little bit about how that happens, because I feel like as a provider, I You know, I just say, you know, we need to let Children's Services know, and or we need to let law enforcement know just that's we're mandated by the state to do that. And then there's this black box where the social worker just takes care of it.

So, what is that? What does that look like in terms of actually making a report?

Tishia Gunton: Yeah, and I really appreciate that part of your practice is telling the family because that's actually the first step. And being a mandated reporter is having that really clear and transparent conversation with the family, just like you're doing about all of that workup, right?

And so, we start out in a trauma informed way by just meeting them where they're at, answering their questions, so making sure that the family is aware and saying all of that out loud. So sometimes it feels a little overwhelming or scary to say law enforcement. Sometimes. Families and providers, they get that children's services is being called.

The law enforcement piece might be different, but per our own hospital policy, we report Depending on the type of abuse to children's services and law enforcement, so sometimes it's only one or another, but if we report to both, the hope is that they're collaborating together when we only report to one agency and not the other, the agency who doesn't receive the report may not have all the information.

So, we want to share information in a strengths-based way. We want it coming from us because we're the ones that talk to the family. One agency is sharing with another agency, but they're not getting information directly from us. How can we tell that family story in a way that is strengths based and helpful to them?

And so that's how we manage that at our hospital and nationwide. In the state of Ohio. Mandated reporters have to report to at least one. So at least children's services or police. And I think that it's important to remember too that when we're making those reports, we're letting families know that we're telling the whole story.

So, my job isn't just to say, hey, children's services, hey, police, I'm really worried. It's I'm worried. Here's what the medical team is sharing. And here's what the family is sharing about what happened and what their circumstances are.

Dr Mike Patrick: Yeah, yeah, that's, that's so important to, to really have the whole story and because we don't want to come across as judgmental.

Or accusing, we just are relaying information that we are concerned about. And I would imagine that both of those agencies, so both child protective services and law enforcement, you know, that sounds really scary to families. And so, is there ways that you, you know, kind of soften that, that these people are here to help you?

Tishia Gunton: So, I actually think that it's about stopping and recognizing first, that there might not be a way to soften it. We can lean into the fact that this is really difficult and acknowledge that for families. That this could be really hard and scary to hear that we're making a report, and that I'm here for any questions that they have.

That our medical team, including our social workers, we don't work for children's services, but I can try to provide as much information as I can around what could happen next. Now, when you, when you talk about, you know, talking with families around what will happen next, and that it can be helpful, I try to hone in on the fact that Children's Service's goal isn't to take their children.

That, that isn't their goal. It's not their stated goal, and they have very specific roles and guidelines that they have to follow. And if they're going to be involved with a family, I do try to let families know that they have a lot of different resources. And supports that could be available. I don't try to over promise.

And again, I try to lean into the fact that there might not be a way to make this feel less scary in the moment, but I'm going to try to walk you through this as much as I can and answer all,

Dr Mike Patrick: all of your questions. And we don't all, we don't really know maybe what prior history this family has with either of these agencies.

And so, we want to reassure people, but you know, there may be reason why they are concerned. And this is where things can get heated if you don't handle it appropriately, you know, as now it's not just, uh, I brought my child in because I was worried. And now you're calling the police and maybe our families had.

Run ins with the police before. And so, there's all sorts of complicated things that can be in the background. And I think that's one of the reasons we really love having the social workers involved in helping us all sort through that. So, kudos to you, Tisha, because it's not an easy job for sure. What, what is the difference by the way, between what you do and what the child protective services caseworkers do?

Tishia Gunton: So, like I said, that's, it's really important for us to recognize that we don't work for children's services. We are medical social workers embedded on multidisciplinary teams, and we communicate with children's services when there are concerns. But we are very clear with families that we do not investigate that is children's services role.

And in fact, as a medical social worker, I want to make sure that the family understands that I'm there to support them and their child. So, I've had lots of conversations with families, both. During the initial stages of mandated reporting, but after the fact, and it's really helpful for them to realize that there's somebody that's listening to them.

So, I want them to know that if there's problems getting a hold of their caseworker, if they're not understanding something, if they want to make sure that CPS is actually understanding what we're reporting, that, you know, there could be, like, I'm not sure they actually get it. I want to be able to facilitate that conversation for them.

And we are continuing to build relationships with families through this process, and it helps that they just know that someone is willing to follow up on their concerns. There's been many times where Children's Services is acting in one way, and we wonder, do they know all the information? And that's for us to take a pause and make sure that they know that, and that's for that family.

Dr Mike Patrick: Yeah. Now, when you, when you do report to Child Protective Services, they don't necessarily have to launch an investigation, correct? You're just, you're just relaying information to them and then they're the ones who decide whether they want to ask more questions, or they're not really concerned about this given situation.

Tishia Gunton: Yes, absolutely true. So, the thing to remember about children's services too, is that they follow some really strict guidelines and algorithms, and they cannot be subjective. They have to follow law about when they can be involved in a family's life. But it's really important to tell families what that process looks like.

So, children's services and, and the scripting can be used with families. You should tell families, when we report to Children's Services, they have up to 24 hours to decide whether or not they are screening in or screening out a case. And if they're screening in a referral that was made, they will make contact with the family.

But if they're screening out the case, and they're deciding not to investigate, the family will never know, so they will never be contacted by Children's Services. That's really important because I've worked with families who have sat around wondering, when is Children's Services going to show up at my doorstep?

And they shouldn't have to live with that for days or weeks. So, letting them know ahead of time that they should hear from Children's Services. With some sort of urgency.

Dr Mike Patrick: Yeah. So, if it once 24 hours has passed from the reporting period and parents haven't heard anything, they're probably, they're not going to hear anything from children's services.

But this, the same is not necessarily true with law enforcement, correct?

Tishia Gunton: That's right. So, while I, when I talk with families, I tell them that, you know, Children's Services has this really strict guideline that they have to follow, and they are, they are mandated themselves to follow up in a really timely manner.

Law enforcement works a little different. They don't have this special time frame or mandate to follow up with families, and so I'm really transparent about that. They don't necessarily expect to follow up with families within a 24-hour period.

Dr Mike Patrick: And, and they may even just come to the hospital, but, and children's services may do that as well, right?

Sometimes, you know, these agencies come in and see folks at the hospital itself.

Tishia Gunton: Totally correct. So, I'm trying to also be really transparent with families. That's part of the anticipatory guidance is that. Children's services or law enforcement may choose to intervene or meet with you prior to your discharge from the hospital.

And that's not to say that we're asking them not to leave the hospital or we're saying that they must meet with them. That's totally up to families. But they should have a heads up that somebody would like to meet with them and spend time getting to know the situation and hear directly from them what their concerns are or are not.

Dr Mike Patrick: Yeah, absolutely. One, one final question with regard to reporting. It's pretty straightforward. I think when we're talking about an emergency department, we have social workers that are there 24 seven to help us out. Most. Primary care pediatricians and family practice doctors and nurse practitioners do not have the luxury of having a social worker embedded in their office.

So, what is that process look like in primary care? I mean, I would think that if, you know, there's suspicion, they're going to send the child somewhere that they could get a workup, but you're also worried, you know, are they going to, are they really going to show up there? And are you the one in the primary care office that needs to be doing the reporting?

Or if you send them to an ER, do you let them do it? How does that all work?

Tishia Gunton: That's a really good question. And aside from the recommendation that all primary care physicians should have a social worker,

Dr Mike Patrick: I agree, by the way,

Tishia Gunton: I know that's not necessarily realistic, but the recommendation that I would make is if you are concerned as a primary care doctor or an outpatient provider of some sort, make sure that the conversation is had with the family that goes a long way with building relationships and continuing to develop rapport and tell them that you're concerned and reporting.

So, the reason why we want to do mandated reporting as soon as we're concerned, especially in regard to these outpatient providers, is that, to your point, the family might not show up for that future workup. There might not be an opportunity to have that conversation with the family. There might not be the opportunity for somebody else to weigh in about whether or not they are concerned.

And so, as a mandated reporter, In the state of Ohio, you are mandated to report when you're suspicious of maltreatment. And so having that really clear conversation with the family, making that report, and then the mandated reporting agencies, children's services and law enforcement, they also know what your recommendations are.

So, they know that you've recommended that the family should go to the emergency department.

Dr Mike Patrick: And so that's definitely a number that you want to have in your primary care office, children, child protective services. In your local area, your County, that's something that you should, hopefully you have called them because, you know, when we think about how frequently children are neglected and abused, it's going to show up in everyone's practice.

And so, if you've never called a child protective services, maybe you should be a little bit more suspicious about injuries that you see in the office. I would think. Now, what about a law enforcement then? So, if I'm a, if I'm a primary care physician, should I also be calling law enforcement or because I have this relationship with the family that I want to preserve and that just, I don't know.

It just seems like a step further, if that makes sense.

Tishia Gunton: So that's going to be up to individual clinical judgment. In the state of Ohio, you need to report to one or the other, so children's services or law enforcement. Like I said earlier, I think there is benefit in calling when there are concerns and you feel like you need to portray your medical opinion, your clinical judgment about what the concerns are, because you don't necessarily want agencies getting that information from one another and not talking directly to the source.

But I totally get where you're coming from. And you are meeting your mandate by reporting to one or the

Dr Mike Patrick: other. Yeah. But state laws may be a little bit different depending on where you are. So that's something I would think that your local, like local chapter of the American Academy of Pediatrics might be able to help.

You know, they may know what the laws are in your state. If you have any questions about who you're supposed to report to here in Ohio, it's one or the other. And then they'll get in touch with the other if they, if they, you know, feel it's, it's appropriate, uh, Kristen, I want to turn the conversation back to you.

And one of the things that we often see is parents being resistant. Toward the workup that we think needs to happen. And so, we can, you know, make it as nice as possible and say, this is what we do for everyone. But when we tell them there's all these x rays and they're going to get poked with needles to get lab work done, how do you address their resistance to that process?

Yeah.

Dr Kristin Crichton: Yeah, I think like we talked about a little bit with the skeletal survey. First, I think it's very reasonable for families to question this. And, and I think first saying like, yeah, I acknowledge this is a lot and it feels like a big workup for, for example, a two-month-old with a bruise. Like my kid has a bruise.

Why are you doing x rays? And so, I think it, it goes to that explaining, well, in. in babies this age, they can't do anything to cause these injuries to themselves. And so, we really need to do these other studies to evaluate for other injuries that we can't see. And families will say, like, wouldn't I know if my baby had a broken arm?

And so, this is where, you know, we kind of have to use our medical judgment, say, no, in fact, we don't, we often don't know. Small, small infants don't have the motor skills developed to then have an absence of those motor skills to tell us that something is hurting. We see rib fractures in babies all the time that have no other injuries or outward signs of injury.

And even in these young infants, when we're doing the, the neuroimaging with the head CT or the MRI of the brain. Again, it's not because I really like to radiate kids’ heads. It's because their neurologic development isn't to the point where we can do a good neurologic evaluation without imaging. So, we really have to do these other studies in order to ensure that we're not missing an injury.

And again, it's, it's kind of aligning with the family, you know, we really just want to make sure we're understanding everything that's going on with your child. We would really hate to miss another injury and it's important to, to look at. Look, look at all their bones, look at their brain, do the lab work to screen for abdominal injury and, and I think, you know, if we think about the things that happen in the trauma bay and the, the fast ultrasounds and the quick screens and, and, you know, using maybe less invasive or less radiation.

Those are great tools for ruling out something that the surgeons need to do surgery on right now. But that's not the kind of injury we're looking for. We're looking for any injury because these babies shouldn't have any injury. And the forensic information is really important for us to partner with Children's Services and law enforcement to act in these children's best interest.

So, we have to look for this other injury in order. In order to help protect these children. I think one approach to this is to explain to families or think about it in a way that you would think about doing an LP in a 16-day old with a fever. You know, we don't debate or discuss, well, your baby has a fever.

They might have sepsis. We might need to do an LP. Like we just, it is, this is when we see these injuries, this is what we do. Families can decline. They can't. I can't. We cannot make them do these, these imaging studies or the lab work. But I think if we present it as this is the procedure where we often can align with them to get it done.

If they decline, we tell Children's Services that. That's not a threat. It's just a statement. If we are unable to, you know, kind of talk to a family about, about doing the appropriate screening and we think we need to do it, then, well, we're going to report the injury and we will also be sharing in that report that The medical evaluation is incomplete to look for further injury and that at this point, the caregivers are not following the medical recommendations.

Dr Mike Patrick: So, if they if they leave your office or they leave the hospital before you have sorted this out and reported, you don't try to stop them. You just let law enforcement and. Child protective services know what's happened. You just report the situation.

Dr Kristin Crichton: Correct. We don't throw our bodies in front of people.

We want to keep everyone safe. And so, we just let families know again. This isn't a fight. This isn't an argument. This is a medical recommendation. We need to understand if your child has additional injuries. We need to do these x rays. We need to do the C. T. And it's not a fight. If we're not going to be able to do it, we'll let Children's Services and law enforcement know.

I will say that this is an area where talking to law enforcement earlier and getting them engaged can be helpful because law enforcement can act, at least in Ohio, law enforcement can act a little bit more quickly to go check on the child, do a welfare check and help facilitate bringing the child to the ED to get those recommended studies.

Dr Mike Patrick: So, we wouldn't threaten that the police are going to come get you, but they might.

Tishia Gunton: Correct. They might. They might. I would actually add, I've, you know, I've worked with Dr. Creighton a lot, and I'm wondering if you can speak to a little bit about, like, alternatives or how you can be flexible with families that are saying, I don't want to do this, because I've seen you do that really well.

And. To me, that signals, when there's hesitation about parts of the workup, it signals that maybe their concerns or questions haven't been addressed.

Dr Kristin Crichton: Yeah, so I think that making sure they, they understand, like, what, what is the barrier? What is the concern? And then we can, you know, talk about if it's a level of radiation, we can talk about the radiation exposure and, and all of the things I, I said earlier about.

Low dose radiation. I think if a family says I'll do the skeletal survey, but not the neuroimaging I'll do that's fine. We'll start there do a skeletal survey I'm still going to share with Children's Services that are our workup is incomplete one of the other things that comes up is that part of the evaluation for Occult injury is doing a skeletal survey at time zero and then a follow up skeletal survey 10 to 14 days later.

This is the American Academy of Pediatrics Guidelines for Evaluation for Abuse, and that's because we know that baby's bones are growing and changing, and the fractures in these tiny bones can be very subtle, and we may not see them apparent on x ray until there's some callus formation, so a little bit of that bone bridging around the, the fracture.

So, we're telling these families, we just did 20 x rays on your baby and we're going to do that again in two weeks. And I understand and appreciate their discomfort and sometimes dismay at this recommendation. Again, I, we talk about why that is. And I tell them that the first skeletal survey is not complete.

We had the second one is when it's complete and that's part of the workup. And if they want, some families will say, you can x ray the areas where I know that the injury happened. And if that's what they'll do. Okay, I'm still going to let Children's Services know that, well, we didn't get all of it, but something's better than nothing.

And sometimes by just saying like, okay, well, if that's what you're comfortable with, then families will just go ahead and say, okay, do the whole work up. But again, I think meeting them where they are and trying to understand their hesitation is important. Yeah,

Dr Mike Patrick: yeah, absolutely. Tisha, when, when parents are resistant or, you know, they're arguing it or because they look at it as advocating for their child, well, maybe, probably, I mean, in most situations, they're probably not trying to hide some other injury that they know about.

They're really concerned about the radiation exposure. Because maybe they have an older kid who's gone to the ER and we're like, we don't do CAT scans on everybody anymore because of all the radiation exposure. So, you know, they may have been primed that this is a dangerous thing. And then there may be situations where they are worried that you're going to find something.

But their response is not indicative of something having happened in the past, right? They may just be advocating for their child.

Tishia Gunton: Absolutely. And I use that as a strength. I say, you care a lot about your kid and you're worried. I think it's totally okay for them to ask questions, to be hesitant, and that may be their response to a really stressful situation.

And they are protective, and they want to make sure that they're making the right decision, but it doesn't have anything to do with whether or not they've necessarily been involved in the maltreatment concern. We can't speak to that. It's kind of like grief. People have different responses to grief.

People have different responses to stress and hearing something that's really stressful. So, I think it's normal for a caregiver to question, you know, what's happening? Why are we doing this?

Dr Mike Patrick: Yeah. We've, we've made a really big point here of being transparent with families, telling them exactly what's going to happen, what we're going to do.

Is there ever a time when you don't necessarily want to tell the caregiver that you're reporting to child protective services and or law enforcement?

Tishia Gunton: It's really rare, but there are circumstances when we would actually recommend not sharing with a caregiver that you've reported. And ultimately it comes down to your clinical judgment.

And I think about, is telling them going to put your patient at imminent risk? And to give you an idea, I've been doing this for over 10 years, and I can only think of a handful of times when I haven't told a parent that we're making a report. But I've made a decision not to share. And so, you think about it in this way.

Is there a safety concern or is this just an awkward conversation? And sometimes it's just a difficult conversation.

Dr Mike Patrick: Yeah. And, but if it, but if they're truly a safety concern, so if you are worried and maybe it's because this family has been in your facility before and have had certain reactions. And you're worried that if I say it, they're just going to run and maybe not be found.

I mean, there may be situations where ultimately the safety of the child is our number one priority. And so that might mean making a report without telling someone who might do something, you know, in response to that, but most people aren't going to do that. So that's why we are transparent with most people because that's really the best practice in most cases.

Dr Kristin Crichton: I would say this could also come up more in the outpatient world with older children. If an older child is disclosing that the caregiver that brought them to that appointment today, that they're going to leave your office in the same car with, has hurt them and that they are afraid, and for whatever reason, there's just not another option.

I mean, we want to make sure we're sending kids out safely, but at some point, a caregiver Has the legal right to take their child home until, until someone that is not us from the medical field has intervened, then that may be the time where you, you, you want to let the child know you're safe and telling me and I'm not going to tell your parent, I do have to tell children services and law enforcement.

We are mandated reporters, but and letting them know that is okay. And we, we don't have to share it with the caregiver. So, I can imagine this coming up more in the outpatient setting. Okay. But I think if we're referring a child in for, you know, into the E. D. for additional workup or once they're already here, we can, we can typically be transparent, but I do want to, there's nothing in the law that or any laws that say you have to tell a family that you've made a report.

Dr Mike Patrick: And that just comes down to your judgment and to the, and sometimes there's a lot of complicated data points that go into making that, that judgment. Tisha, what do we do if, so we've reported to child protective services, and they elect maybe not to do an investigation, but we continue to have concerns.

What, what do you do in that case?

Tishia Gunton: Oh, that totally happens. That happens with some amount of frequency. And I think the first step is continuing the conversation with the family, being really open about the fact that you're concerned and why you're concerned. Sometimes family is here that a report was screened out or they don't hear anything from children's services or law enforcement, and they take that as the answer that it actually wasn't concerning.

And so, if you remain concerned, having the upfront and open conversation and explaining why you're concerned, but when CPS. When Children's Services doesn't follow up the way that you would hope or you feel like the kid is still at risk, I think following up with them to answer any questions that they have, asking to be a partner in this decision, maybe re reporting if you remain concerned, or even asking to speak with a supervisor, which I know feels like You know, you speak with a supervisor when you don't get the answer that you like.

That's how Children's Services works. They receive reports and then they staff it. And so, if we can talk with the people who make those ultimate decisions, we may be able to answer other questions that'll shed some light on the medical component and why we were so concerned to begin with.

Dr Mike Patrick: Yeah. And I would imagine just as in any industry, you're going to have case workers with children's services who are more experienced than others.

Some are going to be newer in their career, some later in their career. And so, you know, you're going to, you're going to get a variety of responses. And as long as you're communicating as well as you can, all of the data concerning this event, hopefully someone's listening. And if they're not, you can always ask to talk to a supervisor.

Dr Kristin Crichton: Yes, there are options. Yes. I'm going to chime in with one other thing here. Sorry. I want to also say that just because our experience tells us that sometimes children's services doesn't act in a way that we expect them to, or we hope that they will, doesn't mean that in the future when we have another similar situation arise, we can say, last time this happened, they didn't do anything.

So, I'm not going to report this one because. It does not matter what Children's Services does or doesn't do, the mandate to report is still on you as a clinician, and what we don't know is any of the other pieces of the puzzle that Children's Services is working with. So maybe when you had the specific incidents in the past, that was the first report that was ever made on that family, didn't find anything else to act on, but in this case, even though to you as a provider, you're seeing the same kind of injury in the same kind of kid, And when you report that, you're the ninth person to report, because we don't know who else has reported or what else is going on.

And that can lend to the child being in a safer environment. So just because you think they don't do anything for this kind of case doesn't mean you're absolved of reporting. We're always mandated reporters.

Dr Mike Patrick: That is a really important, important point, I think. So really, if we have suspicion, always report, even if in the past, those reports didn't amount to anything because again, there's lots of data we may not know about in both of those cases.

So, I can see that's really, really important. Tisha, how do we follow up with families, especially like his primary care? Folks, like we had this concern, we made the report. Do well first, do we even know what comes of that? Or is that only between the family and child protective services? Like, do they get, do they loop back around to the reporting doctor?

Tishia Gunton: In the state of Ohio, you as a mandated reporter are privy to that information. So, you should receive a letter in the mail that tells you what happened to that report.

Dr Mike Patrick: Okay. And then how do we follow up with the family? Cause we want to maintain that relationship.

Tishia Gunton: And I think that it's really important to acknowledge for providers that this could feel like an awkward conversation to re-engage the family after you've had maybe a really difficult conversation around mandated reporting.

And I think keeping in mind that our ultimate goal is to keep kids safe is important. So, the best way to do that is to. Attempt to rebuild relationships with families when there's been some sort of distress or something that was uncomfortable or difficult so that the family will continue bringing their kid in for care.

Dr Mike Patrick: Yeah. Yeah. So, so important. And I think just having empathy and, and actually having a good relationship with families before the situations ever come up is probably one of the best ways to, to keep that relationship going, even when you've hit a bump in the road. Yeah.

Tishia Gunton: Yeah, there's going to be likely some really big emotions and feelings surrounding any mandated report.

So, it's just really important to check in once they've been able to process that. So, how are they doing since the mandated reports were made? Did they get questions answered when it comes to the children's services caseworker that's visiting their home? Are they still wondering about something? I find that when families are in distress or they're hearing something for the first time, they just need some time to process.

And so, having somebody come back and say, do you have any questions? Don't assume that they completely even understood why the report was made at that point. And so, they tend to really value that. We're just checking in with them.

Dr Mike Patrick: Uh, Kristen, you probably get this question often, and that is how, how do you do this work?

Being a child abuse pediatrician and really making this the focus of your career must be incredibly difficult. And yet I think it's probably rewarding in many ways too. So how do you, how do you keep going with your job?

Dr Kristin Crichton: I mean, Tisha is one of the, one of the many ways we have an amazing team and I think that we're just like we tell people to be transparent with, with families, we're transparent with each other when we're having hard days and bad days and, and they happen.

I will also say that hard days and bad days happen in every aspect of medicine. There's no, there's no area in medicine that's devoid of a rough day. Most people don't come to their doctor because they're feeling great. Although I love preventive medicine. And so, I think just kind of this happens. Kids are so resilient and they're so amazing and they really can bounce back from a lot of a lot of things and knowing that if we can get them into a safe, healthy environment that they will thrive is very, very rewarding and fulfilling.

The other thing is that intellectually. This job is never boring. We have kids come up with, like I said, kids come up with all kinds of ways to hurt themselves accidentally. And one of the things that I love to do, I mean, I don't love when kids get hurt, but one of the things I love to do is go tell family, hey, you know, part of my job is being an expert on injuries.

And I'm really not worried that, that something intentional has happened to your child. I think this accident Makes sense. And so being a reassuring presence can be helpful. It's also we've diagnosed a number of medical conditions We haven't touched on that in this episode But one of the things we always think about is there an underlying medical condition that's contributing to this child Breaking bones more easily or bleeding more easily and sometimes we do find those so it's important to look for them So there's lots of aspects that, that make it, make it good.

Dr Mike Patrick: And if we hadn't done the report that there may have been a much longer delay in the diagnosis of whatever condition contributed to those, those injuries. Yes, absolutely. And then we've mentioned the Center for Family Safety and Healing at Nationwide Children's Hospital. Kristen, can you tell us a little bit more about the center?

Dr Kristin Crichton: Yeah, the center is, we're located right across the street from the hospital on Livingston Avenue, and it's a really amazing multidisciplinary. Place where we have clinic space where the Child Advocacy Center where we see children for concerns of exposure to violence and child maltreatment, we’re housed here with partners from Columbus Police and Franklin County Children's Services but additionally there are resources for adults and Survivors of intimate partner violence.

We have legal services here legal lawyers for children Which is offers services to families that may need additional legal help We have caregiver support because we know that when a family is experiencing maltreatment, often the child is not the only one in crisis. And then we also Have helped me grow and our nurse family partnerships are under the center umbrella as well as well and those are you know, our partnership community partnerships that go out to the communities to help families really thrive So it's a lot of different areas all kind of aligned to help reduce family violence Yeah,

Dr Mike Patrick: and I'll put a link in the show notes over at PediaCastCME .org to the center for family safety and healing also the child assessment center and we have a well-developed child abuse pediatrics fellowship as well.

And since this is a CME podcast, we may have medical students and residents who are listening. And so, if you're interested in this as a, as a future career, we'll put a link to the fellowship. In the show notes,

Dr Kristin Crichton: I'm an associate program director. So, reach out. Yes. Love to hear from you. Yes,

Dr Mike Patrick: absolutely.

100%. And I will say the facility is so nice. When I was a resident training, it was tucked into the corner of a very old building. There was one child abuse pediatrician, Dr Charlie Johnson. I still remember his name. And he was it. And so, it's really, it really has grown. And of course, Central Ohio has also really grown.

And so, you know, you're going to see more cases and more just because there's more kids and it's a wonderful facility and certainly is preventing a lot of future injuries and deaths that that's really hard to count because they don't happen.

Dr Kristin Crichton: True. Yes.

Dr Mike Patrick: All right. Well, once again, Dr. Kristen Creighton with the Child and Family Advocacy at Nationwide Tisha Gunton, Clinical Medical Social Worker at Nationwide Children's.

Thank you both so much for stopping by today.

Dr Kristin Crichton: Thanks so much for having us. Thank you Music We'll see

Dr Mike Patrick: you next time. We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PDA Cast CME a part of it. Really do appreciate that. Also, thank you to our guests this week, Dr.

Kristen Crichton and Tisha Gunton, both with Nationwide Children's Hospital. Don't forget, you can find our podcast wherever podcasts are found or in the Apple and Google podcast apps, I heart radio, Spotify, SoundCloud, Amazon music, YouTube, and most other podcast apps for iOS and Android. Our landing site is PediaCastCME.

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I don't know. So, you have listened to the podcast. Now be sure to claim your free category one continuing medical education credit. Really easy to do. Just head over to the show notes for this episode at PediaCastCME .org. You'll find a link to the post test in the show notes. Follow that link to cloud CME, click on the materials tab, take and pass the posttest and the category one credit.

is your super easy. And again, we offer credit to physicians, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. You want to be sure the content of the episode matches your scope of practice, which once again, should be. Complete details are available at PediaCastCME.

org. Also don't forget we have an evidence-based podcast for moms and dads. Uh, lots of pediatricians and other medical providers tune in. We cover pediatric news. We answer listener questions, and we interview pediatric and parenting experts. It's called PediaCast. Just. Plain PediaCast without the CME shows are available at the landing site for that show PediaCast .org. Also available wherever podcasts are found simply search for a PediaCast. Thanks again for stopping by and until next time This is dr. Mike saying stay informed keep it evidence based and take care of those kids so long everybody

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