IS THIS ABUSE?• A girl is slapped for screaming at her mother; the slap stings, but leaves no lasting mark or pain.• A boy is punished in a way that requires stitches.• A father burns his daughter’s palms with a lighted cigarette when he finds her smoking.• A mother is careless and spills scalding coffee on her daughter, who is seriously burned.• A boy’s arm is broken after wrestling with his father for sport.• A girl is spanked so hard she is badly bruised, but the father says he did not mean to hurt her.• A boy is grounded for a week for a minor offense.• A father takes away his son’s driver’s license for getting a parking ticket.• A young mother was asked to get help and get off drugs but her baby was born addicted to drugs
DEFINITION• Any act of commission or omission by individuals, institutions or society as a whole and any conditions resulting from such acts or inaction, which deprive children of equal rights and liberties, and/or interfere with their optimal development, constitute by definition, abusive or neglectful acts or conditions.
CHILD RIGHTS• Main features of child rights are:1. Right of survival and development2. Right to have a name and nationality3. Right of freedom of expression4. Right of freedom of thought5. Right of health and medical care6. Right of education7. Right of having a good standard of living8. Right of leisure, recreation and cultural activities9. Right of administration of juvenile justice
History of child abuse• 1860 - Ambroise Tardieu – French physician – Medical, psychiatric, social and demographic features of child abuse as a syndrome• 1946 – Dr. Caffey (pediatric radiologist) – Subdural haematoma and long bone fractures inconsistent with accidental injury• 1953 – Silverman multiple fractures resulted from intentional trauma and not organic disease, as commonly thought.• 1962 – Dr. C. Henry Kempe – “The battered child syndrome” in JAMA – 447 abuse cases reported in 1962 • (2.9 million cases reported in 1992)
Shaken Baby Syndrome• Shaking is a prevalent form of abuse seen in very young children.• The majority of shaken children are less than 9 months old.• Most perpetrators of such abuse are male, though this may be more a reflection of the fact that men, being on average stronger than women, tend to apply greater force, rather than that they are more prone than women to shake children.• Intracranial hemorrhages, retinal haemorrhages and small ‘‘chip’’ fractures at the major joints of the child’s extremities can result from very rapid shaking of an infant.• They can also follow from a combination of shaking and the head hitting a surface.• There is evidence that about one-third of severely shaken infants die and that the majority of the survivors suffer long-term consequences such as mental retardation, cerebral palsy or blindness.
Battered Baby Syndrome• One of the syndromes of child abuse is the ‘‘battered child’’.• This term is generally applied to children showing repeated and devastating injury to the skin, skeletal system or nervous system.• It includes children with multiple fractures of different ages, head trauma and severe visceral trauma, with evidence of repeated infliction.• Fortunately, though the cases are tragic, this pattern is rare.
Münchausen syndrome by proxy• Münchausen syndrome by proxy (MSbP or MBP) is a controversial label for a behavior pattern in which a caregiver deliberately exaggerates, fabricates, and/or induces physical, psychological, behavioral, and/or mental health problems in those who are in their care.• With deception at its core, this behavior is an elusive, potentially lethal, and frequently misunderstood form of child abuse or medical neglect that has been difficult to define, detect and confirm.
PLAY ACTIVITIES THAT ARE HAZARDOUS:• Tossing a small child into the air• Jogging while carrying an infant on the back or shoulders• “Riding a horse” – bouncing on the knee• Swinging the child around by his/her ankles• Spinning a child around WARNING: If this happens take child to Emergency Room immediately. The child can be treated.
EpidemiologyChild abuse is a world-wide phenomenon and can affect children of all agesIt is difficult to gain a true estimate of child abuse due to the hidden nature of the problem. In industrial countries it is estimated that:• 4% to 16% of children are physically abused,• around 10% are neglected or emotionally abused,• 15% of boys and 35% to 40% of girls are exposed to sexual abuse.• Around 80% of child abuse is perpetrated by care takers or parents
Children less than 12 years of age are the most abused at 36.4%, followed by children between 15 and 18 years of age at 36%, and then children between 12 and 14 years old Orphans children are more vulnerable to abuse than others at 70%, followed by children of separated parents at 58%, and then children of divorced parents are subject to physical abuse at 42 This study has also indicated that child abuse happens more in poor families and those under poverty threshold
Parental characteristics• Low self-esteem / depression• Abused as a child• Poor impulse control• Substance abuse• Teenage parent• Unrealistic expectations of child behavior• Negative view of themselves & their children
Triggering situations• Crying baby• Child’s misbehavior• Discipline gone awry• Argument, family conflict• Toilet training
Social/Situational Stresses• Working parents• Isolation• Family/domestic violence• Non-biologically related male in the home• Poverty• Unemployment/financial problems• Single parent• Animal abuse
TYPES OF CHILD ABUSE• Physical abuse• Emotional abuse• Sexual abuse• Neglect
PHYSICAL ABUSE: Non-accidental injury of a child that leaves marks, scars, bruises, or broken bones.Behavior indicators: Aggressive or withdrawn Afraid to go home Lying Layered clothing
Health consequences of Physical abuse:• Abdominal/thoracic injuries• Brain injuries• Bruises and welts• Burns and scalds• Central nervous system injuries• Disability• Fractures• Lacerations and abrasions• Ocular damage
SEXUAL ABUSE: Fondling, sexual intercourse, assault, rape, incest, child prostitution, exposure and pornographyBehavior indicators:• Inappropriate sexual knowledge• Abrupt change in personality• Withdrawn• Poor peer relationships• Sleep disturbances• Regressive behavior
Health consequences of Sexual abuse:• Reproductive health problems• Sexual dysfunction• Sexually transmitted diseases, including HIV/AIDS• Unwanted pregnancy• Infertility
EMOTIONAL ABUSE: Rejecting, terrorizing, berating, ignoring, and isolating, that is likely to cause serious impairment of the physical, social, mental, or emotional capacities of the child.Behavior indicators:• Failure to thrive• Speech disorders• Lags in physical development• Habit disorders, conduct disorders• Sleep disorders or inhibition of play• Aggressive or passive
NEGLECT:Failure of parents or caretakers to provide needed, age appropriatecare. Including food, clothing, shelter, protection from harm,supervision appropriate to the child’s development, hygiene, andmedical care. Behavior indicators: • Hunger • Poor hygiene • Excessive sleepiness • Lack of appropriate supervision • Unattended physical problems or medical needs • Abandonment • Inappropriate clothing for weather conditions
Psychological and behavioural health consequences:• Alcohol and drug abuse• Depression and anxiety• Developmental delays• Eating and sleep disorders• Feelings of shame and guilt• Hyperactivity• Poor relationships• Poor school performance• Poor self-esteem• Post-traumatic stress disorder• Psychosomatic disorders• Suicidal behaviour and self-harm
Other longer-term health consequences• Cancer• Chronic lung disease• Fibromyalgia• Irritable bowel syndrome• Ischaemic heart disease• Liver disease
Medical Evaluation ofVictim of Suspected Abuse• History• Physical Examination• Laboratory and Radiologic Studies• Differential Diagnosis• Documentation
HISTORYTaking history from a parent / caretaker• Children should not be present!!• Interview adults who are present separately
Taking a history from the caretaker/parent• Who?• What?• When?• Where?• Why?• How?
Suspicious History• History inconsistent w/physical examination• Magical injury• Sibling blamed• History changes with time or varies between caregivers• Delay in seeking care• Self-inflicted injury incompatible w/development• Poor Parent Child Interaction• History of abuse in parents childhood• Stress or crisis in the family or parents• Unrealistic expectations of parents for the child
Suspicious Behavioral Complaint– Depressed, angry, withdrawn, other changes– School performance– Aggressive behavior, temper tantrums– Behavior with family, pets/animals– Detailed information about adult sexual behavior– Explicit demonstration of sexual play– Excessive sexual curiosity– Bedwetting– New risk taking behaviors
Physical Examination• Therapeutic and diagnostic• Complete head to toe evaluation• Growth parameters• Child behaviour• Must look at all skin surfaces – Remove ALL clothing (lack of clean clothing and poor personal hygiene indicate neglect) – Description of all skin findings (abrasions, alopecia, bites, bruises, burns, dental trauma, fractures, lacerations, ligature marks, or scars) – Ears, Neck, Mouth. – Genitalia and anal region.
Physical Exam “Red Flags”• Most common indication of physical abuse• Occurs in >50% of abused children• Bruises are uncommon in infants < 6 months. – “Those who don’t cruise rarely bruise.”• Two characteristics separate abusive from accidental bruises: LOCATION PATTERN
Laboratory and Radiologic Studies• Labs – Trauma labs – Bruising hematology workup – If fractures; Ca, Phos, Alk Phos – Consider levels; Vitamin D, PTH and Copper• Radiology Studies – Skeletal survey • All children < 2 years of age • 2-5 years: selective survey – Bone scan – CTs / MRIs• Ophthalmology• Medical photography• Examine siblings, other children in household – Twins receive IDENTICAL workup
The Skeletal SurveySkull: frontal and lateral viewsSpine: frontal, lateral thoracolumbar spine(including sternum)Chest: frontalExtremities:Upper - frontal to include shoulders andhandsLower - frontal to include lower lumbarspine, pelvis, feet
Differential Diagnosis• Must rule out medical diagnosis other than abuse
Differential Diagnosis of Bruises• Erythema multiforme – palms/soles initially, extension upwards, can become purpuric• ITP, other coagulopathies• Henoch-Schönlein purpura – normal platelets – IgA mediated vasculitis – often involves buttocks and lower extremities• Cultural practices – Cao gio (coining) – quat shat (spooning) – cupping
Differential Diagnosis of Burns First Degree Cellulitis, erysipelas Sunburn Contact dermatitis Diaper rash Drug reaction
Differential Diagnosis of Fractures• Minor falls – Do not cause fractures in most instances – Studies show very low incidence of fractures from short falls• Obstetrical/birth trauma – usually produces only humeral and clavicular fractures – no rib fractures• Prematurity – Osteopenia can lead to fractures
Differential Diagnosis Accidental FracturesToddler’s Fracture Accidental oblique fracture of tibia in children 9 months to 3 years of age Often are unwitnessed injuries of trivial nature Limp, refusal to bear weight Localized tenderness may be present, no swelling X-rays often negative
Management• Child abuse is often an ongoing process. If the diagnosis of child abuse is being considered, the parents and/or carers must be informed of all relevant investigations and referrals being made.
• Reporting to authorities (Documentation) Doctors are required to share information with other agencies, and with social work and law enforcement bodies, to ensure that the childs needs are met and he or she is protected from harm. Doctors are required to provide written reports for use in multi-disciplinary meetings, police investigations, and civil or criminal courts, and may be required to appear as witnesses (of fact or as experts) in court. Accurate reporting also involves photographs of visible injuries and forensic swabs (e.g., of bites).
• Counselling Counselling should be considered following full investigation and immediate management of injuries. Cognitive behavioural therapy is increasingly used, but must be individualised. Family therapy is also indicated in certain situations to support other members of the family.
• Management of injuries/specialist consultation Individual injuries should be managed as appropriate, irrespective of whether they are caused by abuse or accident. However, where abuse is considered, the physician should ensure that an appropriate search for additional or hidden injuries is also carried out.
HOW TO REACT IF A CHILD TELLS YOU ABOUT ABUSE:• Listen, do not interfere, assume or interrogate.• Reassure the child that he/she has done the right thing by telling you and that you are glad they told you.• Make sure they understand it was not their fault.• Remain calm and accepting, don’t over react.• Do not promise not to tell.• Be honest and tell the child what to expect.• Reassure them you will do what needs to be done to make sure it doesn’t happen again.• Determine the child’s needs for safety.
Conclusions• Child abuse is very common• Often missed by clinicians• Must have high index of suspicion• Mandated reporters must report suspicion of abuse• Complete careful histories and examinations• Document, document, document!• Avoid the misdiagnosis of abuse