Child abuse malaysian medical student 2012 13Presentation Transcript
Reports of Child Abuse In Malaysia Statistics from the Department of Social WelfareThe complications of Child Abuse Will Be Presented At The End Of Presentation.
Child Abuse (Classification)Mohd Syafiq Bin Shahbudin 06-06-102
NeonaticideDefinition:• It is killing of a premature or full term baby within 24hours after birth.• This case rarely in developed country. It is done usually by young single uneducated mother by act of commission or omission.
Cultural aspect:• The Chinese, as late as the 20th century, dispatched newborn daughters because they were unable to transmit the family name.Causes:1) forbidden intercourse of unmarried young girl.2) been raped and lead to unwanted child from the assailant.
InfanticideDefinition:• It is killing of newly born, live born infant within 12 months after birth.Etiology:• The mother with maternal psychosis (especially puerperal depression) is almost always the perpetrator.
EuthanasiaDefinition:• It is killing of a handicapped (physical, mental or both) child usually under 3 years by a parent.Perpretrator:• The mother is usually the maker.
Causes :• low economic status of the parents that can’t afford to maintenance their handicapped child.• no support from government and public to help unlucky parents like an association to assist parents by giving free consultation, equipments to facilitate handicapped child.• poor mental state of the parents.• unfaithful parents.
Syndrome of repetitive physical child abuse• It occurs more frequently in families of lower socioeconomic standard.• The child is usually in the age group 6 weeks – 5 years and experiencing pleomorphic assaults often with increase in severity and frequency
Causes:1) Great stress - Many people who commit physical abuse were abused themselves as children. As a result, they often do not realize that abuse is inapproriate discipline.2) Poor impulse control - This will prevents them from thinking about the result from their actions.
Statistic:• The rate of child abuse is fairly high. The most common form is neglect
By: Muhamad AriffBin Mohd Randzan 06-6-109
(5) Child neglect:It may take many forms: Physical neglect (food, hygiene, clothes). Safety neglect. Medical neglect. Educational neglect. Emotional neglect.
(6) Murder-suicide: Often whole family is killed usually in one accident.(7) Murder-homicide: The great majority of victims are girls after sexual assaults.
(8) Sexual abuse:1- Assaultive: producing injury or severe emotional trauma.2- Non-assaultive: causing no or little physical trauma & less emotional stress.
(9) Emotional abuse: It is persistent rejection or coldness of parents or guardian toward a child which affect his behavior & development.
Omar Mokhtar Bin Che Azani 06-6-67
Risk Factors Parental factors Family factors Child factors Environmental factors
Parental Factors Personality characteristics and psychological well-being History of childhood abuse Substance abuse Attitudes and knowledge Age (young parents 15-20 years)
Personality characteristics andpsychological well-being No consistent set of characteristics or personality traits has been associated with abusive parents. Some characteristics frequently identified in those who are physically abusive or neglectful include: low self-esteem, poor impulse control depression anxiety antisocial behavior
History of childhood abuse A parents childhood history plays a large part in how he or she may behave as a parent. Individuals with poor parental role models or those who did not have their own needs met may find it very difficult to meet the needs of their children. There are individuals who have not been abused as children who become abusive, as well as individuals who have been abused as children and do not subsequently abuse their own children.
Substance abuse Substance abuse can interfere with a parents mental functioning, judgment, inhibitions, and protective capacity.
Attitudes and knowledge Negative attitudes and attributions about a childs behavior and inaccurate knowledge about child development may play a contributing role in child maltreatment. For example, some studies have found that mothers who physically abuse their children have both more negative and higher than normal expectations of their children, as well as less understanding of appropriate development of the children.
Age Mothers who were younger at the birth of their child exhibited higher rates of child abuse than did older mothers. Other contributing factors, such as lower economic status, lack of social support, and high stress levels may influence the link between younger childbirth— particularly teenage parenthood—and child abuse.
Family Factors Family structure Marital conflict and domestic violence Stress Parent-child interaction
Family structure Children living with single parents may be at higher risk of experiencing physical and sexual abuse and neglect than children living with two biological parents. Single parent households are substantially more likely to have incomes below the poverty line. Lower income, the increased stress associated with the sole burden of family responsibilities, and fewer supports are thought to contribute to the risk of single parents maltreating their children In addition, studies have found that compared to similar non-neglecting families, neglectful families tend to have more children or greater numbers of people living in the household
Marital conflict and domesticviolence 30 to 60 % of families where spouse abuse takes place, child maltreatment also occurs. Children in violent homes may witness parental violence, may be victims of physical abuse themselves, and may be neglected by parents who are focused on their partners or unresponsive to their children due to their own fears. A child who witnesses parental violence is at risk for also being maltreated, but, even if the child is not maltreated, he or she may experience harmful emotional consequences from witnessing the parental violence.
Stress Stress is also thought to play a significant role in family functioning. Physical abuse has been associated with stressful life events, parenting stress, and emotional distress in various studies.
Parent-child interaction Families involved in child abuse seldom recognize or reward their childs positive behaviors, while having strong responses to their childs negative behaviors. Abusive parents have been found to be less supportive, affectionate, playful, and responsive with their children than parents who do not abuse their children. Research on maltreating parents, particularly physically abusive mothers, found that these parents were more likely to use harsh discipline strategies and verbal aggression and less likely to use positive parenting strategies.
Child Factors The abnormal or disable child The rejected child Other child characteristics
The abnormal or disablechild Children with physical, cognitive, and emotional disabilities appear to experience higher rates of maltreatment than the other children. In general, children who are perceived by their parents as "different" or who have special needs including children with disabilities, as well as children with chronic illnesses or children with difficult temperaments may be at greater risk of abuse. The demands of caring for these children may overwhelm their parents. Disruptions may occur in the bonding or attachment processes, particularly if children are unresponsive to affection or if children are separated by frequent hospitalizations. Children with disabilities also may be vulnerable to repeated abuse because they may not understand that the abusive behaviors are inappropriate, and they may be unable to escape or defend themselves in abusive situations.
The rejected child This child may be unwanted sex or pregnancy. This unwanted child usually will be maltreat because the parent itself do not want to have that child. For example, the mother who was raped tend to abuse her child to show her anger and revenge towards the rapist. The study shows that parent who want the children will treat their child better than the parent who have the child from the unwanted sex or pregnancy.
Other child characteristics Some studies suggest that infants born prematurely or with low birth-weight may be at increased risk for maltreatment The relationship between low birth-weight and maltreatment may be attributable to higher maternal stress heightened by high caregiver demands, but it also may be related to poor parental education about low birth-weight, lack of accessible prenatal care, and other factors, such as substance abuse or domestic violence.
Child factors such as aggression, attention deficits, difficult temperaments, and behavior problems or the parental perceptions of such problems have been associated with increased risk for all types of child maltreatment. These factors may contribute indirectly to child maltreatment when interacting with certain parental characteristics, such as poor coping skills, poor ability to empathize with the child, or difficulty controlling emotions. In addition, these same child characteristics may be reinforced by the maltreatment.
Environmental Factors Poverty and unemployment Social isolation and social support Violent communities
Poverty and unemployment Poverty and unemployment show strong associations with child maltreatment, particularly neglect. Poverty particularly when interacting with other risk factors such as depression, substance abuse, and social isolation can increase the likelihood of maltreatment. Low income creates greater family stress, which, in turn, leads to higher chances of maltreatment. Parents with low incomes, despite good intentions, may be unable to provide adequate care while raising children in high-risk neighborhoods with unsafe or crowded housing and inadequate daycare
Some other characteristics may make parents more likely to be both poor and abusive For example, a parent may have a substance abuse problem that impedes the parents ability to obtain and maintain a job, which also may contribute to abusive behavior Poor families may experience maltreatment at rates similar to other families, but that maltreatment in poor families is more frequent
Social isolation and socialsupport Some studies indicate that compared to other parents, parents who maltreat their children report experiencing greater isolation, more loneliness, and less social support. Social isolation may contribute to maltreatment because parents have less material and emotional support, do not have positive parenting role models.
Violent communities Children living in dangerous neighborhoods have been found to be at higher risk than children from safer neighborhoods for severe neglect and physical abuse, as well as child sexual victimization.
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INVESTIGATIONSIN A CASE OFCHILD ABUSEAhmad Farhan Bin Mahabot06-6-9
MEDICAL HISTORY Conducting Professional Interviews Good rapport Open-ended Qs General to Child alone specific Confidentiali ty
MEDICAL HISTORY Suggestive findings: A history that does not match the nature or the severity of the injury Vague parental accounts or accounts that change during the interview Accusations that the child injured him/herself intentionally Delay in seeking help Child dressed inappropriately for the situation
GENERAL SIGNS Emotional abuse Excessively withdrawn and fearful Anxious about doing something wrong Extremes in behaviour Lack of attachment with the parent/caregiver Acts inapproppriately adult or infantile
GENERAL SIGNS Physical abuse Unexplained injuries e.g. bruises, burns or cuts Certain pattern such marks from hand or belt Always watchful or ‘on alert’ for bad things Wears inapproppriate clothing to cover injuries Admitting to punishment that seems excessive
GENERAL SIGNS Child neglect Wears ill-fitting and filthy clothes Consistently bad hygiene Untreated ilness and physical injuries Left alone in unsafe environment Begs or steals food or money
GENERAL SIGNS Sexual abuse Trouble walking or sitting Starting to wet at bed and having nightmares Doesn’t want to change clothes in front of others Lustful act and seductive behaviour Medical conditions like STDs or pregnancy
PHYSICAL EXAMINATION& REGIONAL SIGNSof child abuse. Prepared by: NOOR AZILA BINTI ABDULLAH 06-6-21
PHYSICAL EXAMINATIONDetailed documentation of concerning findings :1. BODY DIAGRAM & PHOTOGRAPH Nutritional neglect, Fail to meet expected growth Photo of injuries2. CLOTHING Signs of neglect (dirty, ill-fitting, stained, unwashed, bad odour), Wearing clothes inappropriate to the weather (to cover bruises)
3. REGIONAL EXAMINATION & SIGNSsearch for other signs that may indicate a non-traumatic cause of injury
ABUSIVE HEAD INJURIES This area is vulnerable to injury because of a child‟s small stature. It may be the closest body part to an adult‟s hand or fist. It is where the crying, back talk, bad language, etc. is emanating from.
GENERAL SIGNS OF HEADINJURYSome children will present with clear signs of head injury.They will either be : unconscious or show signs of brain injury (such as fitting, paralysis or extreme irritability)However, some children may present with less obvioussigns, such as: increased head circumference, poor feeding, excessive crying.
“SHAKEN BABY SYNDROME”(CAFFEY‟S SYNDROME/BATTERED CHILDSYNDROME)• Excessive violent shaking or sudden impact to head• Most commonly in children less than 2 years of age.• Characterized by retinal, subdural and/or subarachnoid hemorrhages• May present with coma or seizures without obvious evidence of scalp trauma
Intracranial haemorrhageoccurs as a result ofsevere angularacceleration, deceleration& direct impact as thehead strikes a solidobject.The chest is compressedresulting in rib fractures.Arms & legs move aboutin a whiplash movementresulting in the typicalcorner or bucket-handle-fractures in themetaphyseal region.
SKULL FRACTURESSkull fractures are commonchild abuse injuries, butthey are also common inaccidental trauma.Patterns of skull fracturethat suggest child abuseare: LEFT: eggshell fractures in a child who died of cerebral injury after being thrown of a height• Multiple eggshell fractures RIGHT: skull fracture crossing suture in• Occipital impression abused child fractures• Fractures crossing sutures
Face injuries SLAPPING MARKSCUT WOUNDS & BRUISES BRUISES & PETECHIAE
Black eye (Raccoon eye)
Ear injuries Post-auricular bruising Bite mark Subgaleal hematoma & Fingernail prints
Fractured teeth as a Mouth injuries result of a backhand blow to the face.Brusing on softpalate from forcedoral sex. Trauma from a direct blow to the childs mouth. Torn frenulum Tongue laceration --note that this child had no teeth that could have caused this.
Neck injuries Strangulation markChoking mark Burn on side of the neck
CHEST INJURIESEXTERNAL INJURIES RIB FRACTURES Old posterior rib fractures very indicative of non accidental trauma.Skin of the chest showing They are not evident on x-ray“belt-marks” & bruises. in the acute stage, as little displacement occurs. They are identified in the healing stage as a result of associated callus.
INTERNAL ORGAN INJURIES Visceral injury is seen at autopsy of young infants, but it is rarely documented radiologically in living victims less than 1 year of age. The mortality rate is 50% due to patients and doctors delay„ Common abdominal injuries in -- children are brought to the abused children are: hospital days after the injury, when perforation already has • liver laceration resulted in peritonitis and • duodenal perforation/ sepsis. hematoma • pancreatic laceration.
VISCERAL INJURIES A, A round, fading bruise over the right lower abdominal wall. Note the marked abdominal distention. B, At surgery she was found to have diffuse peritonitis, and two large rents were discovered in the jejunal mesentery. C, A long segment, found to be necrotic with a perforation, and adjacent bowel that appeared nonviable were resected.
Student name : Mohammad Amin bin KhairudinStudent number : 06-5-86
Limbs : Bruises – around joints ( especially wrist,forearm,upper arm,thighs and ankles ) from gripping in order to swing or shake the infant Fractures – at any site in diaphysis , may be multiple Spiral fractures – indicate twisting injury Traction – Avulsion of parts of metaphysic and slipped epiphysis Joint effusions
Bites :Abuser bites, self- inflicted bites and other children bites must be distinguished. Favorite sites : Arms,back of hands,cheeks,shoulders,buttocks Shape : Two opposing semicircles with abrasion,contusion,or both Size : Dental arch size determines whether it is done by adult,child,or animal
Bite mark example
Burns : 1. Dry burns - Burns in unlikely sites e.g. buttocks and perineum.Children may be sat on hot plates,branded with irons or hot metals. - Cigarette burns on areas normally covered by clothing usually multiple and of different ages. 2. Scalds - Over hot bath water - Deliberate pouring of hot water - Dipping in hot liquid Poisoning : Occurs more commonly in baby sitters.The drugs used more are antihistamines,cough mixtures and laxatives.
Scald example 1
Scald example 2
By Kamarul Azhar bin Mohamed 06-06-79
For children younger than 2 years suspected of having been physically abused, a skeletal survey is recommended to rule out skeletal injury. To evaluate for missed physical abuse and unsuspected fractures Provide the diagnosis of abuse in 50% of the children with positive skeletal survey results
Fracture may cross the diaphysis in an oblique or transverse plane Fracture may occur at metaphysis known as classic metaphyseal lesion(corner/bucket handle lesion)
Highly specific and classic metaphyseal lesion (CML) occurs when a torsional force is applied to the immature primary spongiosa adjacent to a cartilaginous growth plate. Fractures of the posterior rib, scapula, spinous process, and sternum(bones which are ordinarily difficult to break) Fractures in different stages/ages of healing Fractures are usually multiple
multiple bilateral rib fractures of different ages
Useful in patients with: ◦ Head injury, especially with skull fractures ◦ Acute neurological findings ◦ Physical examination show retinal haemorrhage ◦ Visceral injuries and retroperitoneum haemorrhage Common findings in cases of abuse: ◦ Subdural especially interhemispheric and subarachnoid hemorrhage ◦ Duodenal and proximal jejunum injuries
Subarachnoid hrg Subdural hrg
CT scanning of the thorax(lung injury) and abdomen(duodenal injury)
CT scanning of the liver injury
More sensitive to small subdural and subarachnoid haemorrhages, contusions of cortex and deep white matter lesions. Used when CT findings is confusing such as: ◦ for differentiating a hypoattenuating subdural hematoma from cerebrospinal fluid (CSF) ◦ detecting small and chronic extra-axial fluid collections.
Detect most commonly brain parenchymal injuriesshear injury contusion gray matter– edema white matter junction corpus callosum midbrain
No role in the evaluation of acute abusive injury. May be used: ◦ In unstable patients being examined in the emergency department for initial screening for visceral injuries and free fluid. Less sensitive than CT scanning
assists in identifying new rib fractures and subtle long bone fractures not apparent on the skeletal survey especially at the costovertebral junction
Has high sensitivity and low specificity in cases of child abuse. Correlation with x-ray is always necessary
Child Abuse Complications Fine / Penalty• Health and physical • Punishable under the Child Act (2001) and the Penal effects Code (revised 1997).• Intellectual and cognitive • Offenders may be liable to development a maximum fine of RM 50,000 ( about 100,000• Emotional, psychological, EGP ) or up to 20 years and behavioral imprisonment, or both depending on the offence. consequences • Offenders may also be punished with whipping in addition to the fine and/or imprisonment
Health and physical effects• The immediate effects of bruises, burns, lacerations, and broken bones• Longer-term effects of brain damage, hemorrhages, and permanent disabilities.
Intellectual and cognitive development• Evidence of lowered intellectual and cognitive functioning in abused children as compared to children who had not been abused, and other studies find no differences.• Research has consistently found that maltreatment increases the risk of lower academic achievement and problematic school performance. Abused and neglected children in these studies received lower grades and test scores than did no maltreated children.
Emotional, psychological, and behavioral consequences• Emotional and psychological Consequences o Low self-esteem o Depression and anxiety o Post-traumatic stress disorder (PTSD) o Attachment difficulties o Eating disorders o Poor peer relations o Self-injurious behavior (e.g., suicide attempts).
Emotional, psychological, and behavioral consequences
Child Abuse (Prevention)Mohd Syafiq Bin Shahbudin 06-06-102
Prevention :• Recognize the warning signs of abuse• Have alcohol or drug problems• Have a history of abuse or was abused as a child• Have emotional problems or mental illness• Have high stress factors, including poverty• Not look after the childs hygiene or care• Not seem to love or have concern for the child
• Counseling or parenting classes may prevent abuse when any of these factors are present. Watchful guidance and support from the extended family, friends, clergy, or other supportive persons may prevent abuse or allow early intervention in cases of abuse.
References• http://emedicine.medscape.com/article/4071 44-overview• http://emedicine.medscape.com/article/9156 64-overview• Lectures of forensic medicine textbook by staff members of department of forensic medicine and clinical toxicology, faculty of medicine, Alexandria University.