Child Neglect Maltreatment

When you’re rating child neglect, you are asked to indicate the type or the types of maltreatment that were indicated. This is easy to find based on the determination made by the committee as to whether the incident or instances met criteria. You are asked to indicate any or all of the following: medical, exposure to physical hazards, educational, lack of/inappropriate/inadequate supervision, abandonment, or deprivation of necessities.

For this item, you’re going to be answering whether the child was under the age of 2. The reason you’re being asked this is because it determines later branching, specifically with actual physical injury or physical impact. The ratings assigned to certain physical impacts or physical injury vary based on the age of the child.

For this item, you’re going to indicating whether or not there was any physical injury or any physical impact. You would indicate yes if there were things as severe as say loss of consciousness down through a minor superficial scratch. You’re considering any and all physical injuries or physical impacts based on maltreatment for this item.

If you’ve indicated there was a sustained physical injury or physical impact, the next question you’re going to answer is whether or not it was a severe injury or impact. The list is very straightforward and is within the item itself: Loss of consciousness, loss of functioning (which include several things like those that are listed), heatstroke or heat exhaustion, damage to internal organs (again with some language within the item itself to help you), disfigurement and death. So, it is a very straight forward item and if any of these occurred, then you indicate yes. This brings you to a severe rating for the incident.

Overview:

So, if the victim did not sustain any of these severe physical injuries or physical impacts as listed in the previous item, you are brought to this item which contains a fairly extensive list of other possible physical injuries or physical impacts. Three key points to remember:

First wording of the question itself. You are rating the most serious physical injury or physical impact. Often in cases victims report multiple types of physical injuries or physical impacts. If they do, take the most serious from what they are reporting and click it from the list in this item.

Second you will almost always be asked a pain question as a follow-up. So, let’s say your victim is reporting significant bruising, minor scratches, and pain. You indicate that bruising is the most serious, and you’d answer the type of bruise that the victim sustained, and assuming the bruising is not severe in nature, you will be asked to rate pain as a follow-up question. You will get to do that pain follow-up based on any of these that are selected as long as it’s not a severe injury from that list.

The third point to keep in mind is that there is a nice catchall category at the bottom called physical impacts not listed here. You are probably not going to use this often, but there were a few cases in the pilot that used the catchall category.

Example:

You’ll sometimes have incidents where there are several physical impacts or physical injuries. In those cases, you need to rank the physical impacts or physical injuries and select the most serious. Let’s run a few examples:

• Say dark, non-superficial bruising and a small, superficial scratch are reported. The bruising is more serious.
• Welt with broken skin on the leg or superficial bruise on the arm? Go with the welt.
• Swelling of the ankle that impacts ability to walk vs. tiny cut on the hand that only bled for a minute? The swelling is more serious.

Also, remember pain is always asked as a follow-up branch following all physical impacts or physical injuries on this list. When in doubt, select the non-pain physical injury or physical impact.

For this item, you are going to be rating how long direct pressure was required to stop the bleeding. This information is not always found in reports unless medical or police attention was required to stop the bleeding. If you’re directly interviewing someone, there are some techniques you can use to get this information. You can ask: Were you bleeding? What did you stop the bleeding? How long did you do that to stop the bleeding? And if needed you can ask some follow-up questions. Okay so you said you used gauze, how many gauze pads did you use? At any point the blood soaked through a gauze pads requiring a new one? Or instead of gauze pads fill in what they’re telling you, paper towels, bandages, and try to get at that information through your interviewing techniques. If you’re unable to ask these questions directly, use your clinical judgment and try to piece together based on the reports that you do have at hand determine the best possible option.

For this item you are going to be rating how long direct pressure was required to stop the bleeding. This information is not always found in reports unless medical or police attention was required to stop the bleeding. If you’re directly interviewing someone, there are some techniques you can use to get this information. You can ask: Were you bleeding? What did you stop the bleeding? How long did you do that to stop the bleeding? And if needed you can ask some follow-up questions. Okay so you said you used cause, how many gauze pads did you use? At any point the blood soaked through the gauze pads requiring a new one? Or instead of gauze pads fill in what they’re telling you, paper towels, bandages etc. and try to get at that information through your interviewing techniques. If you’re unable to ask these questions directly, use your clinical judgment and try to piece together based on the reports that you do have at hand to determine the best possible option.

If welts were the most serious physical injury or physical impact, you’re going to need to know the condition of the victim’s skin to accurately be able to answer the follow-up item. Specifically, your need to know whether or not there was broken skin, blistering, and in the case of older injuries scarring.

If welts were the most serious physical injury or physical impact, you’re going to need to know the condition of the victim’s skin to accurately be able to answer the follow-up item. Specifically, your need to know whether or not there was broken skin, blistering, and in the case of older injuries scarring.

If swelling was the most serious physical injury or physical impact, you are going to answer how much the swelling impacted the person’s functioning. So did the swelling significantly limit functioning, did it impact but not significantly limit functioning, or was it just noticeable swelling. If you get into the item itself, you’ll notice helpful language and examples to help you determine whether significantly limits functioning such as a swollen ankles requires crutches, or impacts but does not significantly limit functioning. In this swollen ankle example, one does not require crutches but results in a limp for the victim.

If swelling was the most serious physical injury or physical impact, you are going to answer how much the swelling impacted the person’s functioning. So did the swelling significantly limit functioning, did it impact but not significantly limit functioning, or was it just noticeable swelling? If you get into the item itself, you’ll notice helpful language and examples to help you determine whether significantly limits functioning such as a swollen ankles requires crutches, or impacts but does not significantly limit functioning. In this swollen ankle example, one does not require crutches but results in a limp for the victim.

If bruising was the most serious injury or impact, you’re going to be using two markers to answer the follow-up item. The first marker is the total area of the bruising as is measured by the size of the victim’s hand. So, what you need to do is keep in mind how old the victim is and what size they are roughly. If they are in-person, it’s easier to do it. If you’re not able to interview in-person, age and other descriptors for physical characteristics you will be using those to make determination. The other point to keep in mind is the tenderness or pain caused by the bruising. Using those two in combination, you’ll be able to answer the bruising item. Again, as with all of the other physical injuries and physical impacts, you can use some good interviewing techniques if you are able to speak with the affiliated parties for the child case. If you’re not, what you want to be doing is using a clinical judgment and piecing together the reports you do have to try answer this question.

If bruising was the most serious injury or impact, you’re going to be using two markers to answer the follow-up item. The first marker is the total area of the bruising as is measured by the size of the victim’s hand. So, what you need to do is keep in mind how old the victim is and what size they are roughly. If they are in-person, it’s easier to do it. If you’re not able to interview in-person, age and other descriptors for physical characteristics you will be using those to make determination. The other point to keep in mind is the tenderness or pain caused by the bruising. Using those two in combination, you’ll be able to answer the bruising item. Again, as with all of the other physical injuries and physical impacts, you can use some good interviewing techniques if you are able to speak with the affiliated parties for the child case. If you’re not, what you want to be doing is using a clinical judgment and piecing together the reports you do have to try answer this question.

So, to answer the pain item, you’re going to need to know two things. One, how long did the pain last? Was it less than 24 hours or was it longer than 24 hours? And you also need to know how much the pain impacted the victim. So, did significantly limit their functioning in normal activities? Were they in so much pain that it was hard to walk, hard to sit, hard to lie down? If it wasn’t, maybe it impacted but not significantly limit their functioning. So perhaps their arm or their hand hurt and was difficult to engage in self-care such as person their teeth or brushing their hair. They were able to do it, but it did impact. Maybe they reported they were uncomfortable or took them a long time due to the pain.

If the most serious physical injury or physical impact was a bloody nose, you’re going to need to have the information that follows: whether there was an actual broken nose, whether there was swelling involved. Based on that will be able to answer the item. If the nose itself is broken, that is a severe rating for the case. If there was swelling involved, you’re going be branch to the swelling item and you will be answering some specific questions based on swelling. If neither was involved be directed to the pain follow-up.

During the pilot of Severity, this item did not come up very frequently, but it came up often enough that it required its own separate spot in the list of possible physical injuries and physical impacts. The good news is for this item, all you need to know is whether medical attention was required to stop the bleeding for the cut inside the mouth or if medical attention was not required to stop the bleeding inside the mouth.

To answer the damage to eye item, you are going to need to know how victim’s vision was impacted. So, was it damage that significantly limited vision? Was it damage to the eye that impacted but did not significantly limit vision? Was it just noticeable damage to the eye? And within the item itself there are some examples for you to follow to help determine whether the physical impact to the eye significantly limited the vision, or just impacted vision.

For burn being most serious physical injury or physical impact, you need to know one of two things. You either need to know the rating of the burn, e.g., whether it was first, second, or third degree, or you need to match the description found in the item that corresponds with a first, second, or third degree burn based on interview data you collected or based on the reports that you have from medical personnel, police, or other third parties. If you look at the item itself, for each rating of first, second, and third there is a description that you can use to determine the final rating for the burn. So, you need to know the color of the skin, the pain being reported, and whether blistering happened or not.

This is a very straightforward item asking you to indicate whether there was pain or not. For this, you’re thinking of any sort of pain from really debilitating pain and severe tenderness, through slight discomfort maybe not lasting long or if it is not lasting long, it is low-level and not really impacting the victim.

Overview:

So to answer the pain item, you’re going to need to know two things. One, how long did the pain last? Was it less than 24 hours or was it longer than 24 hours? And you also need to know how much the pain impacted the victim. So, did significantly limit their functioning in normal activities? Were they in so much pain that it was hard to walk, hard to sit, hard to lie down? If it wasn’t, maybe it impacted but not significantly limit their functioning. So perhaps their arm or their hand hurt and was difficult to engage in self-care such as person their teeth or brushing their hair. They were able to do it but it did impact. Maybe they reported they were uncomfortable or took them a long time due to the pain.

Example:

For pain, you want to think about two things: how long the person experienced the pain (less than 24 hours or more than 24 hours), and how much the pain impacted the victim? Was the pain experienced in the course of normal activities, was it reported but not felt during normal activities, felt routinely, or did it limit functioning? Sleeping, self-care (brushing hair, brushing teeth, getting dressed), sitting, gross motor movement (depending on age – walking, running, crawling, pulling up), fine motor movement (depending on age – writing with a pen, coloring, putting on makeup)

Some examples:

• A school age child who is unable to sit still at a desk the week after the incident has limited functioning in normal activities.
• A school age child who feels the discomfort while sitting but is able to sit still as necessary without his/her concentration being disrupted at a desk the week after the incident feels it during normal activities.
• Someone who is unable to dress without assistance or without changing their wardrobe a couple of days after an incident has limited functioning.
• Someone who has pain in the arm while brushing hair and teeth but is able to complete those activities a few days after the incident feels it in the course of normal activities.

Overview:

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. And then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So, what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation or recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife.

Let’s change the actual incident. Let’s say that the husband threw the knife, but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No? 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has actual injury here. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations, let’s say she doesn’t catch her fall, and she falls down more stairs. That could perhaps cause a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So, in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell sleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder try to get to the pool, but the neighbor was able to run over to the backyard to give a child away from the pool before the child fell in, and the child was unable to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high here for a loss of consciousness and loss of functioning.

In the recreations would be reasonable to say that the neighbor did not witness this and intervene? Certainly, you can add that to recreations. Would be possible to change the scenario in ways that there was not potential for serious injury? No because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” Can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Example:

Let’s use a scenario you may be familiar with from our other videos:

Parents were outside BBQing and drinking beer. 22-month-old was left alone in living room for approximately 30 min. The living room does not have screen or glass doors leading out to the yard, so the parents could not see or hear the child easily. Living room had numerous boxes, lamps, extension cords, etc. due to recent move to this home. Child tripped over one of the items, hit face on coffee table and had some swelling in her face. This happened a week ago. Child is able to eat and drink normally now, but in the 3 days after the incident, she required softer foods (like applesauce, yogurt, scrambled eggs, chicken salad) in her diet, and said it hurt to chew bigger chunks of food (like cubes of cheese or pork chops).

This would be a high impact on the child’s physical functioning, but what’s the potential?

Given the actual physical impact, it is reasonable to assume that if replayed 100 times, the child could have had a greater physical impact – like resulting in swelling so bad that the child required a liquid diet. That child was incredibly lucky.

Let’s change it a bit. Let’s say the child fell, had minor swelling this time, a small cut on the lip and a small bruise on the face. Is the potential still incredibly lucky? It is probably a little bit lower than that. There is an actual physical impact, so you have the bruise, the cut, and the swelling, and it is still a dangerous situation. If we played 100 times, could the child have gotten a more serious injury? This child was very lucky.

Overview:

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. And then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So, what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation or recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife.

Let’s change the actual incident. Let’s say that the husband threw the knife, but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No? 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has actual injury here. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations let’s say she doesn’t catch her fall, and she falls down more stairs. That could perhaps cause a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So, in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident, if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell sleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder try to get to the pool, but the neighbor was able to run over to the backyard to give a child away from the pool before the child fell in, and the child was unable to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high here for a loss of consciousness and loss of functioning.

In the recreations would it be reasonable to say that the neighbor did not witness this and intervene? Certainly, you can add that to recreations. Would be possible to change the scenario in ways that there was not potential for serious injury? No because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” Can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Example:

Let’s use a scenario you may be familiar with from our other videos:

Parents were outside BBQing and drinking beer. 22-month-old was left alone in living room for approximately 30 min. The living room does not have screen or glass doors leading out to the yard, so the parents could not see or hear the child easily. Living room had numerous boxes, lamps, extension cords, etc. due to recent move to this home. Child tripped over one of the items, hit face on coffee table and had some swelling in her face. This happened a week ago. Child is able to eat and drink normally now, but in the 3 days after the incident, she required softer foods (like applesauce, yogurt, scrambled eggs, chicken salad) in her diet, and said it hurt to chew bigger chunks of food (like cubes of cheese or pork chops).

This would be a high impact on the child’s physical functioning, but what’s the potential?

Given the actual physical impact, it is reasonable to assume that if replayed 100 times, the child could have had a greater physical impact – like resulting in swelling so bad that the child required a liquid diet. That child was incredibly lucky.

Let’s change it a bit. Let’s say the child fell, had minor swelling this time, a small cut on the lip and a small bruise on the face. Is the potential still incredibly lucky? It is probably a little bit lower than that. There is an actual physical impact, so you have the bruise, the cut, and the swelling, and it is still a dangerous situation. If we played 100 times, could the child have gotten a more serious injury? This child was very lucky.

Overview:

For this item you’re being asked to provide a rating of the current physical functioning of the child. For this, you would be thinking about what’s happening in front of you. Is the child reaching developmentally appropriate milestones for their physical and bodily abilities? Is the child experiencing any issues when it comes to using their body in terms of their motor skills as it relates the maltreatment? And is the child experiencing any sensory issues? For example, if a child has numerous untreated or not properly treated ear infections, that could have an impact on their ability to hear properly. So, again, thinking about the current physical, bodily, sensory functioning and relating any of those issues back to maltreatment.

Example:

This example is going to cover two items – current impact on physical functioning and likely impact on physical development due to medical neglect.

Let’s say a 5-year-old’s school contacted CPS because he did poorly on hearing test, and child reported frequent earaches over the past few years. Interview with mom revealed his has not received proper medical attention for chronic ear infections. Mom is not consistent with using prescribed drops, has not completed follow-up appointments, and has not seen specialist about possible tubes.

When an ear infection is present, child experiences pain, finds it hard to sleep, play, eat – that’s our current impact on physical functioning, and it sounds like the child is highly impacted.

Chronic, untreated ear infections could also cause long-term issues with hearing. When it comes to likely impact on physical development, the pattern of acts makes it extremely likely that the child’s physical development will be impacted. The mother has not been compliant with treatment for a few years and the child is already experiencing hearing loss.

Overview:

In this item, you are considering the child’s physical development: what would their bodily development look like in the future? So, an example of this would be a child who has multiple ear infections in their younger years. They are likely to have physical development issues in terms of their hearing development and their hearing capacity in the future. Also, children who are not meeting their current height and weight goals, and there are factors that can contribute to keeping them below average or not meeting those goals in the future, that can impact their physical development.

Example:

This example is going to cover two items – current impact on physical functioning and likely impact on physical development due to medical neglect.

Let’s say a 5-year-old’s school contacted CPS because he did poorly on hearing test, and child reported frequent earaches over the past few years. Interview with mom revealed his has not received proper medical attention for chronic ear infections. Mom is not consistent with using prescribed drops, has not completed follow-up appointments, and has not seen specialist about possible tubes.

When ear infection is present, child experiences pain, finds it hard to sleep, play, eat – that’s our current impact on physical functioning, and it sounds like the child is highly impacted. Chronic, untreated ear infections could also cause long-term issues with hearing. When it comes to likely impact on physical development, the pattern of acts makes it extremely likely that the child’s physical development will be impacted. The mother has not been compliant with treatment for a few years and the child is already experiencing hearing loss.

Overview:

Current cognitive functioning is a snapshot of how the child is doing in relation to cognitive milestones. For younger children, so for infants and toddlers, those things are pretty straightforward. So, you’re looking at any delays in their communication, their problem-solving abilities, their ability to regulate their reactions. In older children, often the milestones are tied into their school achievements. This is not exactly the same as school functioning, so if the child is not doing well in school that is not necessarily the same thing. What you want to be thinking about is does this child currently meet those achievement milestones and those achievement goals for their peers given their grade in school level.

Example:

For cognitive functioning, you need to think about appropriate milestones. Some examples of cognitive functioning:

• A kindergarten-age (around 5-6) child who cannot count to 10, draw a few letters or numbers, cannot follow simple directions, and cannot identify a few body parts would be extremely impacted. If only one or two of those milestones weren’t being met, that would likely be somewhat impacted.
• Let’s say an older teenager who has trouble with complex thinking, executive functioning, and expressing self through words – this would be extremely impacted.

For assessing level of impact, think about how many ways the child is impacted, but also think about how impacted they are. For example, a teenager who has limited executive functioning could be more impacted than a teenager who sometimes struggles with verbally expressing him- or herself. Or a teen who has been bumped from all his honors classes into average classes and is still struggling, possibly – it’s still relative to where they were and where that child should be.

Overview:

For this item, you’re being asked to provide a snapshot of the child’s current social functioning. So, ask yourself: Is the child participating in appropriate social activities given his or her age? If they’re not, you should ask yourself: Is this a situation that perhaps the child is so fearful or so anxious that they can’t get over that hurdle and are isolating themselves and not engaging in those age-appropriate situations? When the child is participating in social activities, ask how are they doing. And are they engaging in appropriate situations with their peers, their siblings, their classmates, their neighbors, their friends, with people in positions of authority (parents, grandparents, teachers, school administrators)? Questions such as: Are they getting into fights? Are they having difficulties with those interactions? And you should be factoring those two pieces in. So number one are they engaging, and if not why, is there an isolating incident component? And two, what does that engagement look like? Is it appropriate for their age?

Example:

Remember, a child can have impacted social functioning in two ways – “acting out” or withdrawing.

Quick example for “acting out” – 8-year-old child often gets into physical fights with same age-peers. As a result, neighbors no longer invite child to play, teachers have put child on restricted recess for the next month, where child is not allowed to go on playground during nice weather.

Example for withdrawing – before incident, 15-year-old went to Friday night coffee house at school and wrote for the school paper. Following the incident, she comes home immediately after school and sits in her room until dinner, and no longer goes to clubs or activities she used to enjoy.

Overview:

For this item, you’re being asked to rate the current functioning of the child is related to their psychological functioning and their somatic functioning. What you want to ask yourself is: does this child exhibit any symptoms or are they reporting any symptoms that would impair their standard psychological and somatic functioning. So are they reporting difficulties with concentration, feeling anxious, feeling depressed, having stomach issues, back issues, neck issues, being more tired than usual, and that is related to the maltreatment (either caused or exacerbated by the maltreatment) and how that is impacting there current functioning as related to their psychological and somatic functioning.

Example:

Let’s say an 8-year-old girl was left home alone while parents went to a bar in the middle of the night (lack of supervision). Parents got into fight at bar and continued the fight when they got home. The daughter came out into living room and saw parents pushing each other, and the mother threw a few items (books, shoes) across the room at the father as daughter tried to hug father (exposure to physical hazards). Neighbors called police when they heard the fighting.

The daughter is reporting difficulty sleeping at night, because she’s nervous that her parents might leave again or get into another fight, and that the police will come to the house. She also reports daily stomach aches. She was not reporting the anxiety or stomach aches prior to the incident. This is an example of how the maltreatment highly impacted the child’s psychological and somatic functioning.

Now, let’s bump it up. Say the child was reporting clinically significant symptoms of depression or anxiety – either close to meeting the number of symptoms needed for a diagnosis or enough to meet diagnosis – and that the stomach aches resulted in numerous school absences, changes in diet like not eating as much or as often due to stomach discomfort, etc. That moves it into extremely impacted psychological and somatic functioning.

Say the child reported something like, “I sometimes feel butterflies in my stomach and get a little nervous when mom and dad sound mad at each other, but no other times. That doesn’t happen often. Maybe once every few weeks.” That would be somewhat impacted psychological and somatic functioning. No symptoms reported would be did not impact.

Overview:

This item has to deal with current functioning. What’s happening front of you? For this item, you want to be considering the child’s current functioning in psychological domain, cognitive domain, and social domain. So, this one on its face kind of looks like an easier item, because you are only dealing with the information in front of you. We need to make sure though, because it is the multifaceted item, is that you’re getting all of the relevant reports. So how is a child doing in school if school-aged, dealing with peers, dealing with people in authority (such as school administrators and teachers), how are they doing with their siblings, with their same age peers and friends. We need to be evaluating all of these different components when it comes to an overall snapshot of their current functioning.

Example:

For this item, you need to evaluate three domains – psychological, cognitive and social functioning. Now, it’s not a simple formula. You can’t say something like, “Only psychological functioning was impacted, so it’s somewhat.” You really need to do a full-picture evaluation.

Maybe the child is experiencing some social functioning issues but is doing okay in other areas. That sounds like somewhat impacted. If the child is feeling depressed and anxious, and is having trouble with friends, that sounds like highly impacted. If one area is significantly impacted enough – say a child is having lots of depressive symptoms – this will likely cut across other domains of functioning.

Overview:

For this item, you’re being asked how the act or the pattern of acts will impact the child’s future functioning, in this case as it relates to psychological, social, and cognitive functioning. So, you want to take a step back and ask yourself: “what is the child going to look like in 5, 10, 15, 20 years from now as it relates back to that psychological cognitive and social functioning?”

Within the item itself, you’re being asked to make this rating based on the act or the pattern of acts, so you really want to focus on the nature of the maltreatment here. Is the maltreatment such that right now the child might look one way, but the child is likely to look different in the future? So maybe the impact isn’t being felt greatly now, maybe it is, but in the future, it is likely to have an even greater impact than it is currently.

Example:

For this item, you need to evaluate three domains – psychological, cognitive and social functioning. Now, it’s not a simple formula. You can’t say something like, “Only psychological functioning was impacted, so it’s somewhat.” You really need to do a full-picture evaluation.

Maybe the child is experiencing some social functioning issues but is doing okay in other areas. That sounds like somewhat impacted.

If the child is feeling depressed and anxious, and is having trouble with friends, that sounds like highly impacted.

If one area is significantly impacted enough – say a child is having lots of depressive symptoms – this will likely cut across other domains of functioning.

Overview:

For this item, you’re being asked to provide a rating of the current physical functioning of the child. For this you would be thinking about what’s happening in front of you. Is the child reaching developmentally appropriate milestones for their physical and bodily abilities? Is the child experiencing any issues when it comes to using their body in terms of their motor skills as it relates the maltreatment? Is the child experiencing any sensory issues? For example, if a child has numerous untreated or not properly treated ear infections, that could have an impact on their ability to hear properly. So, again, thinking about the current physical, bodily, sensory functioning and relating any of those issues back to maltreatment.

Example:

For this example, parents were outside BBQing and drinking beer. 22-month-old was left alone in living room for approximately 30 min. The living room does not have screen or glass doors leading out to the yard, so the parents could not see or hear the child easily. Living room had numerous boxes, lamps, extension cords, etc. due to recent move to this home. Child tripped over one of the items, hit face on coffee table and had some swelling in her face. This happened a week ago. Child is able to eat and drink normally now, but in the 3 days after the incident, she required softer foods (like applesauce, yogurt, scrambled eggs, chicken salad) in her diet, and said it hurt to chew bigger chunks of food (like cubes of cheese or pork chops).

This would be a high impact on the child’s physical functioning because chewing was limited for 3 days. If the swelling was so bad that the child was on a liquid diet, that would be extremely impacted.

Overview:

Here’s one of the typical current functioning items that you will see in the Severity Scales. But in this case, it relates directly back to the fear and anxiety caused or exacerbated by the incidents. So, when you’re thinking about the child, bear in mind those symptoms that are either reported or simply observed. So was the child verbalizing saying they are in fact feeling fearful or anxious, and how is that impacting the functioning. Or are they not saying it but perhaps acting in a way that implies they are in fact fearful or anxious after the incident that is impacting those five major areas of functioning.

Example:

For this item, you need to focus on two things: fear/anxiety caused or exacerbated by the maltreatment AND the impact on overall level of functioning.

Sometimes, clinicians focus on the fear/anxiety – like the child was really scared in the moment, say while watching parents have physical fight in Exposure to Physical Hazards – but do not think about overall level of functioning.

Overall level of functioning requires you to think about the child’s behavior in relevant domains – like social interaction at school, home, with family, friends, etc.

Here’s an example: Teacher called CPS after 9-year-old wasn’t engaging in class work, fell asleep once in class during independent reading, and wasn’t really playing with friends during recess. Child is typically engaged in schoolwork and likes interacting with classmates. When teacher spoke with child about these behaviors, child said he wasn’t sleeping at night due to fear of father. He said that’s making it hard to do schoolwork, and he doesn’t feel good enough to play with friends.

This would be highly impacted given the change in school performance and social life.

Overview:

Current cognitive functioning is a snapshot of how the child is doing in relation to cognitive milestones. For younger children, so for infants and toddlers, those things are pretty straightforward. So, you’re looking at any delays in their communication, their problem-solving abilities, their ability to regulate their reactions. In older children, often the milestones are tied into their school achievements. This is not exactly the same as school functioning, so if the child is not doing well in school that is not necessarily the same thing. What you want to be thinking about is does this child currently meet those achievement milestones and those achievement goals for their peers given their grade in school level.

Example:

For cognitive functioning, you need to think about appropriate milestones.
Some examples of cognitive functioning:

• A kindergarten-age (around 5-6) child who cannot count to 10, draw a few letters or numbers, cannot follow simple directions, and cannot identify a few body parts would be extremely impacted. If only one or two of those milestones weren’t being met, that would likely be somewhat impacted.
• Let’s say an older teenager who has trouble with complex thinking, executive functioning, and expressing self through words – this would be extremely impacted.

For assessing level of impact, think about how many ways the child is impacted, but also think about how impacted they are. For example, a teenager who has limited executive functioning could be more impacted than a teenager who sometimes struggles with verbally expressing him- or herself. Or a teen who has been bumped from all his honors classes into average classes and is still struggling, possibly – it’s still relative to where they were and where that child should be.

Overview:

For this item, you’re being asked how the act or the pattern of acts will impact the child’s future functioning, in this case as it relates to psychological, social, and cognitive functioning. So, you want to take a step back and ask yourself: “what is the child going to look like in 5, 10, 15, 20 years from now as it relates back to that psychological cognitive and social functioning?”

Within the item itself, you’re being asked to make this rating based on the act or the pattern of acts, so you really want to focus on the nature of the maltreatment here. Is the maltreatment such that right now the child might look one way, but the child is likely to look different in the future? So maybe the impact isn’t being felt greatly now, maybe it is, but in the future, it is likely to have an even greater impact than it is currently.

Example:

In the overview explanation, I said that you need to project into the future, 5, 10, 15 years from now, while keeping the nature of the maltreatment in mind. Things might look OK now but could be worse in the future based on the act or pattern of acts. Here’s an example to highlight what this might look like:

Say mother with history of depression has primary custody of 10-year-old daughter. Daughter often misses school because mother has difficulty managing her symptoms and often sleeps late. Daughter has acceptable grades and likes seeing friends when she goes to school. She reports that a few classmates make fun of her for missing so much school.

So, she seems fine now, but her inconsistent attendance and socialization could be an issue when the coursework gets more challenging. She may not have learned enough of the foundational content knowledge, or the discipline and organization needed to be successful. Also, school is a way to socialize, and limiting that could cause later issues.

For this item, you’re going to be answering whether the child was under the age of 2. The reason you’re being asked this is because it determines later branching, specifically with actual physical injury or physical impact. The ratings assigned to certain physical impacts or physical injury vary based on the age of the child.

For this item, you’re going to indicating whether or not there was any physical injury or any physical impact. So, you would indicate, yes, if there were things as severe as say loss of consciousness down through a minor superficial scratch. You’re considering any and all physical injuries or physical impacts based on maltreatment for this item.

If you’ve indicated there was a sustained physical injury or physical impact, the next question you’re going to answer is whether or not it was a severe injury or impact. The list is very straightforward and is within the item itself: Loss of consciousness, loss of functioning (which include several things like those that are listed), heatstroke or heat exhaustion, damage to internal organs (again with some language within the item itself to help you), disfigurement and death. So, it is a very straight forward item and if any of these occurred, then you indicate yes. This brings you to a severe rating for the incident.

So, if the victim did not sustain any of these severe physical injuries or physical impacts as listed in the previous item, you are brought to this item which contains a fairly extensive list of other possible physical injuries or physical impacts. Three key points to remember:

First wording of the question itself. You are rating the most serious physical injury or physical impact. Often in cases victims report multiple types of physical injuries or physical impacts. If they do, take the most serious from what they are reporting and click it from the list in this item.

Second you will almost always be asked a pain question as a follow-up. So, let’s say your victim is reporting significant bruising, minor scratches, and pain. You indicate that bruising is the most serious, and you’d answer the type of bruise that the victim sustained, and assuming the bruising is not severe in nature, you will be asked to rate pain as a follow-up question. You will get to do that pain follow-up based on any of these that are selected as long as it’s not a severe injury from that list.

The third point to keep in mind is that there is a nice catchall category at the bottom called physical impacts not listed here. You are probably not going to use this often, but there were a few cases in the pilot that used the catchall category.

For this item, you are going to be rating how long direct pressure was required to stop the bleeding. This information is not always found in reports unless medical or police attention was required to stop the bleeding. If you’re directly interviewing someone, there are some techniques you can use to get this information. You can ask: Were you bleeding? What did you stop the bleeding? How long did you do that to stop the bleeding? And if needed you can ask some follow-up questions. Okay so you said you used gauze, how many gauze pads did you use? At any point the blood soaked through the gauze pads requiring a new one? Or instead of gauze pads fill in what they’re telling you, paper towels, bandages etc. and try to get at that information through your interviewing techniques. If you’re unable to ask these questions directly, use your clinical judgment and try to piece together based on the reports that you do have at hand to determine the best possible option.

So, this is a very straightforward item asking you to indicate whether there was pain or not. For this, you’re thinking of any sort of pain from really debilitating pain and severe tenderness, through slight discomfort maybe not lasting long or if it is not lasting long, it is low-level and not really impacting the victim.

So, to answer the pain item, you’re going to need to know two things one how long did the pain last. Was it less than 24 hours or was it longer than 24 hours? And you also need to know how much the pain impacted the victim. So, did significantly limit their functioning in normal activities? Were they in so much pain that it was hard to walk, hard to sit, hard to lie down? If it wasn’t, maybe it impacted but not significantly limit their functioning. So perhaps their arm or their hand hurt and was difficult to engage in self-care such as brushing their teeth or brushing their hair. They were able to do it, but it didn’t impact. Maybe they reported they were uncomfortable or took them a long time due to the pain.

Overview:

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. And then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So, what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation or recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife.

Let’s change the actual incident. Let’s say that the husband threw the knife, but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No? 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has actual injury here. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations let’s say she doesn’t catch her fall, and she falls down more stairs. That could perhaps cause a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So, in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell asleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder try to get to the pool, but the neighbor was able to run over to the backyard to give a child away from the pool before the child fell in, and the child was unable to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high here for a loss of consciousness and loss of functioning.

In these recreations would be reasonable to say the neighbor did not witness this and intervene? Certainly, you can add that to recreations. Would be possible to change the scenario in ways that there was not potential for serious injury? No because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” Can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Example:

Let’s use a scenario you may be familiar with from our other videos:

Parents were outside BBQing and drinking beer. 22-month-old was left alone in living room for approximately 30 min. The living room does not have screen or glass doors leading out to the yard, so the parents could not see or hear the child easily. Living room had numerous boxes, lamps, extension cords, etc. due to recent move to this home. Child tripped over one of the items, hit face on coffee table and had some swelling in her face. This happened a week ago. Child is able to eat and drink normally now, but in the 3 days after the incident, she required softer foods (like applesauce, yogurt, scrambled eggs, chicken salad) in her diet, and said it hurt to chew bigger chunks of food (like cubes of cheese or pork chops).

This would be a high impact on the child’s physical functioning, but what’s the potential? Given the actual physical impact, it is reasonable to assume that if replayed 100 times, the child could have had a greater physical impact – like resulting in swelling so bad that the child required a liquid diet. That child was incredibly lucky.

Overview:

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. And then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So, what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation or recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife.

Let’s change the actual incident. Let’s say that the husband threw the knife, but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No? 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has actual injury here. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations let’s say she doesn’t catch her fall, and she falls down more stairs. That could perhaps cause a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So, in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell sleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder try to get to the pool, but the neighbor was able to run over to the backyard to give a child away from the pool before the child fell in, and the child was unable to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high here for a loss of consciousness and loss of functioning.

In the recreations would be reasonable to say that the neighbor did not witness this and intervene? Certainly, you can add that to recreations. Would be possible to change the scenario in ways that there was not potential for serious injury? No because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” Can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Example:

Let’s use a scenario you may be familiar with from our other videos:

Parents were outside BBQing and drinking beer. 22-month-old was left alone in living room for approximately 30 min. The living room does not have screen or glass doors leading out to the yard, so the parents could not see or hear the child easily. Living room had numerous boxes, lamps, extension cords, etc. due to recent move to this home. Child tripped over one of the items, hit face on coffee table and had some swelling in her face. This happened a week ago. Child is able to eat and drink normally now, but in the 3 days after the incident, she required softer foods (like applesauce, yogurt, scrambled eggs, chicken salad) in her diet, and said it hurt to chew bigger chunks of food (like cubes of cheese or pork chops).

This would be a high impact on the child’s physical functioning, but what’s the potential here? Given the actual physical impact, it is reasonable to assume that if replayed 100 times, the child could have had a greater physical impact – like resulting in swelling so bad that the child required a liquid diet. That child was incredibly lucky.

Let’s change it a bit. Let’s say the child fell, had minor swelling this time, a small cut on the lip and a small bruise on the face. Is the potential still incredibly lucky? It is probably a little bit lower than that. There is an actual physical impact, so you have the bruise, the cut, and the swelling, and it is still a dangerous situation. If replayed 100 times, could the child have gotten a more serious injury? This child was very lucky.

Overview:

Here’s one of the typical current functioning items that you will see in the Severity Scales. But, in this case, it relates directly back to the fear and anxiety caused or exacerbated by the incidents. So, when you’re thinking about the child, bear in mind those symptoms that are either reported or simply observed. So was the child verbalizing saying they are in fact feeling fearful or anxious, and how is that impacting the functioning. Or are they not saying it but perhaps acting in a way that implies they are in fact fearful or anxious after the incident that is impacting those five major areas of functioning.

Example:

For this item, you need to focus on two things: fear/anxiety caused or exacerbated by the maltreatment AND the impact on overall level of functioning.

Sometimes, clinicians focus on the fear/anxiety piece – like the child was really scared in the moment, say while watching parents have physical fight in Exposure to Physical Hazards – but do not think about overall level of functioning.

Overall level of functioning requires you to think about the child’s behavior in relevant domains – like social interaction at school, home, with family, friends, etc.

Here’s an example: Teacher called CPS after 9-year-old wasn’t engaging in class work, fell asleep once in class during an independent reading exercise, and wasn’t really playing with friends during recess. Child is typically engaged in schoolwork and likes interacting with classmates. When teacher spoke with child about these behaviors, child said he wasn’t sleeping at night due to fear of father. The child said that’s making it hard to do schoolwork, and he doesn’t feel well enough to play with friends.

This would be highly impacted given the change in school performance and social life.

Overview:

For this item you’re being asked to provide a snapshot of the child’s current social functioning. So ask yourself: is the child participating in appropriate social activities given his or her age? If they’re not, you should ask yourself: is this a situation that perhaps the child is so fearful or so anxious that they can’t get over that hurdle and are isolating themselves and not engaging in those age-appropriate situations? When the child is participating in social activities, ask how are they doing. And are they engaging in appropriate situations with their peers, their siblings, their classmates, their neighbors, their friends, with people in positions of authority (parents, grandparents, teachers, school administrators)? Questions such as: are they getting into fights? Are they having difficulties with those interactions? And you should be factoring those two pieces in. So number one are they engaging, and if not why, is there an isolating incident component? And two, what does that engagement look like? Is it appropriate for their age?

Example:

Remember a child can have impacted social functioning in two ways – “acting out” or withdrawing.

Quick example for “acting out” – 8-year-old child often gets into physical fights with same age-peers. As a result, neighbors no longer invite child to play, teachers have put child on restricted recess for the next month, where child is not allowed to go on playground during nice weather.

Example for withdrawing – before incident, 15-year-old went to Friday night coffee house at school and wrote for the school paper. Following the incident, she comes home immediately after school and sits in her room until dinner, and no longer goes to clubs or activities she used to enjoy.

Overview:

For this item, you’re being asked to rate the current functioning of the child is related to their psychological functioning and their somatic functioning. What you want to ask yourself is: does this child exhibit any symptoms or are they reporting any symptoms that would impair their standard psychological and somatic functioning. So are they reporting difficulties with concentration, feeling anxious, feeling depressed, having stomach issues, back issues, neck issues, being more tired than usual, and that is related to the maltreatment (either caused or exacerbated by the maltreatment) and how that is impacting there current functioning as related to their psychological and somatic functioning.

Example:

Let’s say an 8-year-old girl was left home alone while parents went to a bar in the middle of the night (lack of supervision). Parents got into fight at bar and continued the fight when they got home. The daughter came out into living room and saw parents pushing each other, and mother threw a few items (books, shoes) across the room at the father as daughter tried to hug father (exposure to physical hazards). The neighbors called police when they heard the fighting.

The daughter is reporting difficulty sleeping at night, because she’s nervous that her parents might leave again or get into another fight, and that the police will come to the house. She also reports daily stomach aches. She was not reporting the anxiety or stomach aches prior to the incident.

This is an example of how the maltreatment highly impacted the child’s psychological and somatic functioning.

Now, let’s bump it up. Say the child was reporting clinically significant symptoms of depression or anxiety – either close to meeting the number of symptoms needed for a diagnosis or enough to meet diagnosis – and that the stomach aches resulted in numerous school absences, changes in diet like not eating as much or as often due to stomach discomfort, etc. That moves it into extremely impacted psychological and somatic functioning.

Say the child reported something like, “I sometimes feel butterflies in my stomach and get a little nervous when mom and dad sound mad at each other, but not at other times. That doesn’t happen often. Maybe once every few weeks” That would be somewhat impacted psychological and somatic functioning.

No symptoms reported would be did not impact.

Overview:

For this item, you’re being asked how the act or the pattern of acts will impact the child’s future functioning, in this case as it relates to psychological, social, and cognitive functioning. So, you want to take a step back and ask yourself: “what is the child going to look like in 5, 10,1 5, 20 years from now as it relates back to that psychological cognitive and social functioning?”

Within the item itself, you’re being asked to make this rating based on the act or the pattern of acts, so you really want to focus on the nature of the maltreatment here. Is the maltreatment such that right now the child might look one way, but the child is likely to look different in the future? So maybe the impact isn’t being felt greatly now, maybe it is, but in the future, it is likely to have an even greater impact than it is currently.

Example:

In the overview explanation, I said that you need to project into the future, 5, 10, 15 years from now, while keeping the nature of the maltreatment in mind. Things might look OK now but could be worse in the future based on the act or pattern of acts.

Here’s an example to highlight what this might look like: Say a mother with history of depression has primary custody of 10-year-old daughter. Daughter often misses school because mother has difficulty managing her symptoms and often sleeps late. Daughter has acceptable grades and likes seeing friends when she goes to school. She reports that a few classmates make fun of her for missing so much school.

So, she seems fine now, but her inconsistent attendance and socialization could be an issue when the coursework gets more challenging in the future. She may not have learned enough of the foundational content knowledge, or the discipline and organization needed to be successful. Also, school is a way to socialize, and limiting that could cause later issues.

If welts were the most serious physical injury or physical impact, you’re going to need to know the condition of the victim’s skin to accurately be able to answer the follow-up item. Specifically, your need to know whether or not there was broken skin, blistering, and in the case of older injuries scarring.

If swelling was the most serious physical injury or physical impact, you are going to answer how much the swelling impacted the person’s functioning. So did the swelling significantly limit functioning, did it impact but not significantly limit functioning, or was it just noticeable swelling. If you to get into the item itself, you’ll notice there’s some helpful language and some examples to help you determine whether significantly limits functioning such as a swollen ankles requires crutches, or impacts but does not significantly limit functioning. In this swollen ankle example, one does not require crutches but results in a limp for the victim.

If bruising was the most serious injury or impact, you’re going to be using two markers to answer the follow-up item. The first marker is the total area of the bruising as is measured by the size of the victim’s hand. So, what you need to do is keep in mind how old the victim is and what size they are roughly. If they are in-person it’s easier to do it. If you’re not able to interview in person, age and other descriptors for physical characteristics you will be using those to make determination. The other thing to give in mind that the tenderness or pain caused by the bruising. Using those two in combination, you’ll be able to answer the bruising item. Again, as with all of the other physical injuries and physical impacts, you can use some good interviewing techniques if you are able to speak with the affiliated parties for the child case. If you’re not, what you want to be doing is using a clinical judgment and piecing together the reports you do have to try answer this question.

So, to answer the pain item, you’re going to need to know two things one how long did the pain last. Was it less than 24 hours or was it longer than 24 hours? And you also need to know how much the pain impacted the victim. So, did significantly limit their functioning in normal activities? Were they in so much pain that it was hard to walk, hard to sit, hard to lie down? If it wasn’t, maybe it impacted but not significantly limit their functioning. So perhaps their arm or their hand hurt and was difficult to engage in self-care such as brushing their teeth or brushing their hair. They were able to do it, but it didn’t impact. Maybe they reported they were uncomfortable or took them a long time due to the pain.

To answer the damage to eye item, you are going to need to know how impacted the victim’s vision was. So, was it damage that significantly limited vision? Was it damage to the eye that impacted but did not significantly limit vision? Was it just noticeable damage to the eye? And within the item itself there are some examples for you to follow to help determine whether the physical impact to the eye significantly limited the vision, or just impacted vision.

If the most serious physical injury or physical impact was a bloody nose, you’re going to need to have the information that follows: whether there was an actual broken nose, whether there was swelling involved. Based on that you will be able to answer the item. If the nose itself is broken, that is a severe rating for the case. If there was swelling involved, you’re going to be branched to the swelling item and you will be answering some specific questions based on swelling. If neither was involved, you’ll be directed to the pain follow-up.

During the pilot of Severity, this item did not come up very frequently, but it came up often enough that it required its own separate spot in the list of possible physical injuries and physical impacts. The good news is that for this item, all you need to know is whether medical attention was required to stop the bleeding for the cut inside the mouth or if medical attention was not required to stop the bleeding inside the mouth.

For burn being most serious physical injury or physical impact, you need to know one of two things. You either need to know that the rating of the burn whether it was first, second, or third degree, or you need to match the description found in the item that corresponds with first, second, or third degree burn based on interview data you collected or based on the reports that you have from medical personnel, police, or other third parties. If you look at the item itself, for each rating of first, second, and third there is a description that you can use to determine the final rating for the burn. So you need to know the color of the skin, the pain being reported, and whether blistering happened or not.

Overview:

For this item, you’re being asked to provide a rating of the current physical functioning of the child. For this you would be thinking about what’s happening in front of you. Is the child reaching developmentally appropriate milestones for their physical and bodily abilities? Is the child experiencing any issues when it comes to using their body in terms of their motor skills as it relates the maltreatment? Is the child experiencing any sensory issues? For example, if a child has numerous untreated or not properly treated ear infections, that could have an impact on their ability to hear properly. So, again, thinking about the current physical, bodily, sensory functioning and relating any of those issues back to maltreatment.

Example:

For this example, parents were outside BBQing and drinking beer. 22-month-old was left alone in living room for approximately 30 min. The living room does not have screen or glass doors leading out to the yard, so the parents could not see or hear the child easily. Living room had numerous boxes, lamps, extension cords, etc. due to recent move to this home. Child tripped over one of the items, hit face on coffee table and had some swelling in her face. This happened a week ago. Child is able to eat and drink normally now, but in the 3 days after the incident, she required softer foods (like applesauce, yogurt, scrambled eggs, chicken salad) in her diet, and said it hurt to chew bigger chunks of food (like cubes of cheese or pork chops).

This would be a high impact on the child’s physical functioning because chewing was limited for 3 days. If the swelling was so bad that the child was on a liquid diet, that would be extremely impacted.

For this item, you are going to be rating how long direct pressure was required to stop the bleeding. This information is not always found in reports unless medical or police attention was required to stop the bleeding. If you’re directly interviewing someone, there are some techniques you can use to get this information. You can ask: Were you bleeding? What did you stop the bleeding? How long did you do that to stop the bleeding? And if needed you can ask some follow-up questions. Okay so you said you used gauze, how many gauze pads did you use? At any point the blood soaked through the gauze pads requiring a new one? Or instead of gauze pads fill in what they’re telling you, paper towels, bandages etc. and try to get at that information through your interviewing techniques. If you’re unable to ask these questions directly, use your clinical judgment and try to piece together based on the reports that you do have at hand to determine the best possible option.

If welts were the most serious physical injury or physical impact, you’re going to need to know the condition of the victim’s skin to accurately be able to answer the follow-up item. Specifically, you need to know whether or not there was broken skin, blistering, and in the case of older injuries scarring.

If swelling was the most serious physical injury or physical impact, you are going to answer how much the swelling impacted the person’s functioning. So did the swelling significantly limit functioning, did it impact but not significantly limit functioning, or was it just noticeable swelling. If you to get into the item itself, you’ll notice there’s some helpful language and some examples to help you determine whether significantly limits functioning such as a swollen ankles requires crutches, or impacts but does not significantly limit functioning. In this swollen ankle example, one does not require crutches but results in a limp for the victim.

If bruising was the most serious injury or impact, you’re going to be using two markers to answer the follow-up item. The first marker is the total area of the bruising as is measured by the size of the victim’s hand. So, what you need to do is keep in mind how old the victim is and what size they are roughly. If they are in person, it’s easier to do it. If you’re not able to interview in person, age and other descriptors for physical characteristics you will be using those to make determination. The other thing to give in mind that the tenderness or pain caused by the bruising. Using those two in combination you’ll be able to answer the bruising item. Again, as with all of the other physical injuries and physical impacts, you can use some good interviewing techniques if you are able to speak with the affiliated parties for the child case. If you’re not, what you want to be doing is using a clinical judgment and piecing together there proceed to have to try answer this question.

Overview:

For this item, you’re being asked to provide a rating of the current physical functioning of the child. For this you would be thinking about what’s happening in front of you. Is the child reaching developmentally appropriate milestones for their physical and bodily abilities? Is the child experiencing any issues when it comes to using their body in terms of their motor skills as it relates the maltreatment? And is the child experiencing any sensory issues? For example, if a child has numerous untreated or not properly treated ear infections, that could have an impact on their ability to hear properly. So, again, thinking about the current physical, bodily, sensory functioning and relating any of those issues back to maltreatment.

Example:

For this example, a 3-year-old child has been on highly restrictive plant-based diet for the past few months to match mother’s new diet and is not taking recommended vitamins and supplements. The child is not meeting norms in height and weight, complains of being hungry while at day care, and is showing delays in cognitive and motor functioning. This would be an extreme impact.

Let’s say the child was not meeting norms in height and weight, mom was giving vitamins and supplements, but inconsistently. The child had no developmental delays. Child appears to have lower energy at day care. This would be highly impacted.

In this item, you are considering the child’s physical development: what would their bodily development look like in the future? So, an example of this would be a child who has multiple ear infections in their younger years. They are more likely to have physical development issues in terms of their hearing development and their hearing capacity in the future. Also, children who are not meeting their current height and weight goals. There are factors that can contribute to keeping them below average or not meeting those goals in the future, that can impact their physical development.

Overview:

For this item, you’re being asked how the act or the pattern of acts will impact the child’s future functioning, in this case as it relates to psychological, social, and cognitive functioning. So, you want to take a step back and ask yourself: “what is the child going to look like in 5, 10, 15, 20 years from now as it relates back to that psychological cognitive and social functioning?”

Within the item itself, you’re being asked to make this rating based on the act or the pattern of acts, so you really want to focus on the nature of the maltreatment here. Is the maltreatment such that right now the child might look one way, but the child is likely to look different in the future? So maybe the impact is being felt greatly now, maybe it is, but in the future, it is likely to have an even greater impact than it is currently.

Example:

In the overview explanation, I said that you need to project into the future, 5, 10, 15 years from now, while keeping the nature of the maltreatment in mind. Things might look OK now but could be worse in the future based on the act or pattern of acts.

Here’s an example to highlight what this might look like: Say mother with history of depression has primary custody of 10-year-old daughter. Daughter often misses school because mother has difficulty managing her symptoms and often sleeps late. Daughter has acceptable grades and likes seeing friends when she goes to school. She reports that a few classmates make fun of her for missing so much school.

So, she seems fine now, but her inconsistent attendance and socialization could be an issue when the coursework gets more challenging. She may not have learned enough of the foundational content knowledge, or the discipline and organization needed to be successful. Also, school is a way to socialize, and limiting that could cause later issues.

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. And then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So, what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation or recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife.

Let’s change the actual incident. Let’s say that the husband threw the knife, but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No? 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has actual injury here. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations let’s say she doesn’t catch her fall, and she falls down more stairs. That could perhaps cause a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident, if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell sleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder try to get to the pool, but the neighbor was able to run over to the backyard to give a child away from the pool before the child fell in, and the child was unable to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high here for a loss of consciousness and loss of functioning.

In the recreations would be reasonable to say that the neighbor did not witness this and intervene? Certainly, you can add that to recreations. Would be possible to change the scenario in ways that there was not potential for serious injury? No because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” Can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. And then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation or recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife.

Let’s change the actual incident. Let’s say that the husband threw the knife, but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No? 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has an actual injury here. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations, let’s say she doesn’t catch her fall, and she falls down more stairs. That could perhaps cause a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So, in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident, if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell sleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder try to get to the pool, but the neighbor was able to run over to the backyard to give a child away from the pool before the child fell in, and the child was unable to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high here for a loss of consciousness and loss of functioning.

In the recreations would be reasonable to say that the neighbor did not witness this and intervene? Certainly, you can add that to recreations. Would be possible to change the scenario in ways that there was not potential for serious injury? No because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” Can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Current cognitive functioning is a snapshot of how the child is doing in relation to cognitive milestones. For younger children, so for infants and toddlers, those things are pretty straightforward. So, you’re looking at any delays in their communication, their problem-solving abilities, their ability to regulate their reactions. In older children, often the milestones are tied into their school achievements. This is not exactly the same as school functioning, so if the child is not doing well in school that is not necessarily the same thing. What you want to be thinking about is does this child currently meet those achievement milestones and those achievement goals for their peers given their grade in school level.

Overview:

For this item, you’re being asked to rate the current functioning of the child is related to their psychological functioning and their somatic functioning. What you want to ask yourself is: does this child exhibit any symptoms or are they reporting any symptoms that would impair their standard psychological and somatic functioning. So are they reporting difficulties with concentration, feeling anxious, feeling depressed, having stomach issues, back issues, neck issues, being more tired than usual, and that is related to the maltreatment (either caused or exacerbated by the maltreatment) and how that is impacting there current functioning as related to their psychological and somatic functioning.

Example:

Let’s say an 8-year-old girl was left home alone while parents went to a bar in the middle of the night (lack of supervision). Parents got into fight at bar and continued the fight when they got home. Daughter came out into living room and saw parents pushing each other, and mother threw a few items (books, shoes) across the room at the father as daughter tried to hug father (exposure to physical hazards). Neighbors called police when they heard the fighting.

The daughter is reporting difficulty sleeping at night, because she’s nervous that her parents might leave again or get into another fight, and that the police will come to the house. She also reports daily stomach aches. She was not reporting the anxiety or stomach aches prior to the incident. This is an example of how the maltreatment highly impacted the child’s psychological and somatic functioning.

Now, let’s bump it up. Say the child was reporting clinically significant symptoms of depression or anxiety – either close to meeting the number of symptoms needed for a diagnosis or enough to meet diagnosis – and that the stomach aches resulted in numerous school absences, changes in diet like not eating as much or as often due to stomach discomfort, etc. That moves it into extremely impacted psychological and somatic functioning.

Say the child reported something like, “I sometimes feel butterflies in my stomach and get a little nervous when mom and dad sound mad at each other, but no other times. That doesn’t happen often. Maybe once every few weeks.” This would be somewhat impacted psychological and somatic functioning.

No symptoms reported would be did not impact.

Overview:

For this item, you’re being asked how the act or the pattern of acts will impact the child’s future functioning, in this case as it relates to psychological, social, and cognitive functioning. So, you want to take a step back and ask yourself: “what is the child going to look like in 5, 10, 15, 20 years from now as it relates back to that psychological cognitive and social functioning?”

Within the item itself, you’re being asked to make this rating based on the act or the pattern of acts, so you really want to focus on the nature of the maltreatment here. Is the maltreatment such that right now the child might look one way, but the child is likely to look different in the future? So maybe the impact is being felt greatly now, maybe it is, but in the future, it is likely to have an even greater impact than it is currently.

Example:

In the overview explanation, I said that you need to project into the future, 5, 10, 15 years from now, while keeping the nature of the maltreatment in mind. Things might look OK now but could be worse in the future based on the act or pattern of acts.

Here’s an example to highlight what this might look like: Say mother with history of depression has primary custody of 10-year-old daughter. Daughter often misses school because mother has difficulty managing her symptoms and often sleeps late. Daughter has acceptable grades and likes seeing friends when she goes to school. She reports that a few classmates make fun of her for missing so much school.

So, she seems fine now, but her inconsistent attendance and socialization could be an issue when the coursework gets more challenging. She may not have learned enough of the foundational content knowledge, or the discipline and organization needed to be successful. Also, school is a way to socialize, and limiting that could cause later issues.

For this item, you’re being asked to provide a rating of the current physical functioning of the child. For this you would be thinking about what’s happening in front of you. Is the child reaching developmentally appropriate milestones for their physical and bodily abilities? Is the child experiencing any issues when it comes to using their body in terms of their motor skills as it relates the maltreatment? And is the child experiencing any sensory issues? For example, if a child has numerous untreated or not properly treated ear infections, that could have an impact on their ability to hear properly. So, again, thinking about the current physical, bodily, sensory functioning and relating any of those issues back to maltreatment.

Overview:

Here’s one of the typical current functioning items that you will see in the Severity Scales. But in this case, it relates directly back to the fear and anxiety caused or exacerbated by the incidents. So, when you’re thinking about the child, bear in mind those symptoms that are either reported or simply observed. So was the child verbalizing saying they are in fact feeling fearful or anxious, and how is that impacting the functioning. Or are they not saying it but perhaps acting in a way that implies they are in fact fearful or anxious after the incident that is impacting those five major areas of functioning.

Example:

For this item, you need to focus on two things: fear/anxiety caused or exacerbated by the maltreatment AND the impact on overall level of functioning.

Sometimes, clinicians focus on the fear/anxiety – like the child was really scared in the moment, say while watching parents have physical fight in Exposure to Physical Hazards – but do not think about overall level of functioning.

Overall level of functioning requires you to think about the child’s behavior in relevant domains – like social interaction at school, home, with family, friends, etc.

Here’s an example:

Teacher called CPS after 9-year-old wasn’t engaging in class work, fell asleep once in class during independent reading, and wasn’t really playing with friends during recess. Child is typically engaged in schoolwork and likes interacting with classmates. When teacher spoke with child about these behaviors, child said he wasn’t sleeping at night due to fear of father. He said that’s making it hard to do schoolwork, and he doesn’t feel good enough to play with friends.

This would be highly impacted given the change in school performance and social life.