HB493

Good policy to enhance child welfare.

As a Registered Nurse I strongly support this bill mandating Abuse Prevention Training to all Health are Workers!

Good morning, I am writing to express my firm support for HB 493. I am a long-time pediatric emergency medicine physician here in New Hampshire and now the director for the Child Advocacy and Protection program at Dartmouth. As a pediatric emergency medicine physician, child abuse pediatrician and member of New Hampshire’s Child Fatality Review Committee, I have seen the devastating results of child physical and sexual abuse at every stage of my career. It is clear that medical providers are uniquely positioned to both identify signs of possible abuse and respond to children who disclose abuse. However, missed opportunities persist and some have deadly consequences. Medical providers frequently recall after the fact that “something wasn’t right”. They may recall being unsure if or how they should make a report. They are often unaware that there is medical specialist on call 24 hours a day through the Dartmouth CAP program to assist in decision making. They report little to no training in HOW to respond to children who disclose abuse, saying “I really didn’t know what to say”. HB 493 requires health professionals caring for children to complete focused and practical training in recognizing and responding to indicators of possible abuse as a condition of licensure. New Hampshire has come far in advancing child protection work. We have a team of committed workers and leadership at DCYF. We have a cadre of expert medical providers specializing in evaluating concerns or abuse and neglect. And yet, we continue to experience gaps in connecting these specialized services with those providers who see children day to day. We have acquired the tools we need to keep children safe. HB 493 ensures that medical providers are trained in using them.

To Members of the Children and Family Law Committee As a former member of this committee and a retired practicing pediatrician who spent much of my career evaluating children who were abused and neglected, I fully support this important legislation. As well trained as pediatric health care providers are, our knowledge needs to be periodically updated in this field to be reminded of the subtle signs of abuse and to keep providers abreast of the resources available to assist with these emotionally charged and difficult cases. Too many signs of abuse have been overlooked resulting in missed diagnoses with dire consequences. One hour of training every two years is not too much to ask of those looking after our children. Please advance this bill to the Senate in order that children may receive the care they deserve. Skip Berrien, MD Exeter

Good morning, I am writing to express my full and strong support for HB 493. I am a pediatrician since 1989 practicing in New Hampshire since 2019. I have been the medical director of the child abuse program at the University of Iowa for 19 years and at the child advocacy and protection program at Dartmouth health for the last six years. As a pediatrician, child abuse pediatrician and member of New Hampshire’s child abuse task force and Child Fatality Review Committee, I have seen and become aware of many missed diagnosis of child physical and sexual abuse cases in the last quarter century of my career. Everybody would agree that medical providers are uniquely positioned to both identify signs of possible abuse and respond to children who disclose abuse. However, missed opportunities persist due to lack of ongoing and comprehensive education of medical providers, leading to sometimes, deadly consequences. Medical providers frequently are unsure if or how they should make a report to child protection services. They are often unaware of the existence of Dartmouth health child advocacy and protection program and the expertise on the child abuse and neglect available to them 24 hours a day, just a phone call away.They report little to no training in HOW to respond to children who disclose abuse, saying “I really didn’t know what to say”. HB 493 requires health professionals caring for children to complete focused and practical training in recognizing and responding to indicators of possible abuse as a condition of licensure. New Hampshire has come far in advancing child protection work. We have a team of committed workers and leadership at DCYF. We have a cadre of expert medical providers specializing in evaluating concerns or abuse and neglect. These experts have come together in the last five years and have created the tools of various scope provide this very much needed training to medical providers. However, despite lengthy efforts to advertise the availability of these tools, on a These experts have come together in the last five years and have created the tools of various scope provide this very much needed training to medical providers. However, despite lengthy efforts to advertise the availability of these tools, in the last four years, less than 100 medical providers across New Hampshire have completed any of these available, accredited, evidence based courses. Thus, we continue to experience gaps in connecting these specialized services with those providers who see children day to day. HB 493 will ensure that office of professional licensing and certification (OPLC) will help medical providers to obtain the needed training in order to ensure proper protection of children from child abuse and neglect. I apologize for any typos since I am sending the support letter while I am traveling internationally. Resmiye Oral, MD

Dear Members of the Committee for Child and Family Law, My name is Dr. Ritu Gupta Ullal, and I am a physician at Dartmouth Hitchcock in Nashua. I hold a medical license in NH and am board certified in Family Medicine. In addition to delivering primary care, I have also worked in the fields of Urgent Care and Substance Use Disorder. Over the last four years I have been providing specialized medical evaluations for children when there is a concern for abuse or neglect. I am writing in support of House Bill 493. The US Census estimates there are ~250,000 children under the age of 18 living in New Hampshire. (https://data.census.gov) A large percentage of these children and adolescents will come across the healthcare system for at least urgent medical needs if not for their routine check-ups. Therefore, it is critical for physicians, nurse practitioners, and physician assistants to be able to identify signs or symptoms concerning for child abuse or neglect, and to know how to properly engage with state agencies equipped to further evaluate the child’s safety. When there is early recognition and reporting of possible concerns, state agencies are able to assess the safety of the child and help connect the child, any siblings, and parents/guardians with needed resources. When provided in a timely manner, these resources can promote healing, impart education, and prevent further harm or potential fatalities. As a parent of 2 children with chronic health needs, a daughter of aging parents, a patient myself, and a physician who has provided medical care for 20 years, I can confirm your understanding that healthcare providers are pressed for time during a medical visit. Thus, for a healthcare provider to recognize signs of maltreatment, or connect that a given medical history does not adequately explain a presenting injury - there needs to be regular training on how to identify and address signs of child abuse. As a physician in the Child Advocacy and Protection Program, I am part of a small team that delivers trauma-informed care to children and families referred for evaluation of possible abuse or neglect. Unfortunately, there have been numerous times that we learn a certain injury or concerning finding was either completely missed or wasn’t brought to attention by a healthcare provider, despite an opportunity in the months or years prior. This leads to ongoing abuse that could have been prevented if the available resources were properly utilized. Here is one example: I recently evaluated a set of 3 siblings, (ages 10, 7, and 2 years old) after the 7-year-old shared with a teacher that their mom burns them with heated spatula, hot sticks, iron, and other objects. On medical exam, the 10-year-old had a recent slotted-spatula-shaped burn mark, and several older patterned scars with well-defined borders (consistent with intentional burns) on different parts of his body -lower arm, thighs, back. It is noted that this child received regular well-child exams and yet these concerning scars had not been reported to DCYF. For over 13 years, I have been a medical provider of Dartmouth Health (one of the largest employers in NH). Having done 13 annual mandatory ‘trainings’ – I can tell you firsthand that the current training offered by clinics and hospitals are often limited to a couple slides reminding medical providers that they are mandated reporters of suspected abuse. It is the same set of slides for all other staff in our system and does not include clinically-relevant training. It is not substantive. In NH, all adults are already mandated reporters of suspected child abuse or neglect, thus the existing hospital-based training is not providing specialized medical knowledge, tools, or skills with regards to recognition of abuse and neglect and next steps to take. HB 493 will ensure that all healthcare providers who care for children under 18years old are receiving regular training on the signs and symptoms of concerning abuse. After a consultation, with informed permission – I often connect with a child’s PCP to discuss needed follow up. I commonly have PCPs ask about trainings that might be helpful to them or their colleagues. I regularly hold annual meetings with a few practices that have made it a priority to offer a one-hour training (Lamprey Health, Dartmouth-Nashua), though it is at a time that not all providers across all their practices can attend. A 1-hour online course would allow for the professional to take this on their own time and incorporate it into their regular CME. Thank you for your time and consideration. Respectfully, Ritu Gupta Ullal, MD Ritu.G.Ullal@hitchcock.org Hollis, NH

Lest history repeat itself

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