good ppt for undergraduate medical students

1. CHILD MALTREATMENT
Dr. Sabona Lemessa (Assistant professor in pediatrics and child health, JUMC)
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2. Outline
Introduction
Definition
Prevalence
Etiologies and risk factors
Classification
Clinical presentation
General assessment of maltreated child
Management
Outcome
References
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3. Introduction
Ethiopian constitution, Article 36 (FDRE Constitution, 1995)
Rights of children
1. Every child has the right:
a. Not to be subject to exploitative practices neither to be required nor permitted to perform
work which may be hazardous or harmful to his/her education, health or well-being.
b. To be free of corporal punishment or cruel & inhuman treatment in schools or other
institutions responsible for the care of the child.
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4. Definition
Child maltreatment constitutes all forms of physical and/or emotional ill treatment,
sexual abuse, neglect or negligent treatment, or commercial or other exploitation
results in actual or potential harm to the child’s health, survival, development or
 potential harm to dignity in the context of a relationship of responsibility, trust or power
Abuse is defined as acts of commission and
Neglect as acts of omission resulting in actual or potential harm.
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5. cont...
They are pervasive problems worldwide, with short and long term physical and mental health
and social consequences.
Children may be subjected to more than one type of maltreatment in their childhood.
It occurs in different settings:
Parents and other family members, caregivers, friends, acquaintances, strangers.
In authority or by other children.
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6. Prevalence
Child abuse and neglect are not rare and occur worldwide.
Based on international studies, the World Health Organization (WHO) has estimated that:
18% of girls and 8% of boys experience sexual abuse as children,
23% of children report being physically abused
Survey done by UNICEF has indicated that 30% of children had been beaten or tied up by
parents in middle east (2015).
WHO estimates the rate of homicide of children is approximately 2-fold higher in low income
compared to high income countries (2.58 vs 1.21 per 100,000 population)
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7. Local data
Descriptive survey done on 321 students (age 7-17yr) in 2014 in selected elementary schools in
North Gondar showed that:
most children faced physical abuse in the form of kick with an object (73.8%), pinching
(78.5%) and slapping on head (70.73%).
psychological abuse, threatening with severe punishment (64.8%) and threatening to
leave home (57%) were also reported
In a cross-sectional study conducted among Jiren high school on 323 female students in April
2005:
68.7% of them revealed sexual abuse; verbal harassment (51.4%), sexual intercourse
(18.0%) and unwelcome kissing (17.1%).
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8. Etiologies and risk factors
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9. Classification
Four major types of child maltreatment are:-
1. Physical abuse
2. Neglect
3. Sexual abuse and
4. Emotional abuse
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10. Physical abuse
Is a non accidental physical injury to a child
Caused by a parent, caregiver, or other person responsible for a child
Includes beating, shaking, burning, and biting
Acts of serious violence should be seen as abusive even if no injury ensues;
e.g. throwing a hard object, slapping an infant's face)
While some child healthcare professionals think that hitting is acceptable under limited
conditions,
almost all know that more constructive approaches to discipline are preferable.
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11. Signs of Physical Abuse
Has unexplained injuries, such as burns, bites, bruises, broken bones, or black eyes
Has fading bruises or other noticeable marks after an absence from school
Seems scared, anxious, depressed, withdrawn, or aggressive
Seems frightened of his or her parents and protests or
Cries when it is time to go home, shrinks at the approach of adults
Shows changes in eating and sleeping habits
Reports injury by a parent or another adult caregiver
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12. cont...
Bruise
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13. Burns
13
Immersion injury patterns
Sparing of the
flexoral creases
Immersion
“stocking” burn
Immersion
“glove”burn Immersion
buttocks burn
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14. cont...
Cigarette burns on the dorsum on the hand
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15. 8/12/2022 15
Metaphysial
fracture
posterior rib #
distal humeral fracture in 12
months old
highly sensitive site of # showing
abuse

16. Abusive head trauma (AHT)
Head at Rest
Shaking baby syndrome
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17. cont...
shaken baby syndrome
Subdural heatoma
Retinal hemorrhages
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clues for abuse:-
multiple
involve > 1 layer
extend to periphery

18. physical abuse cont...
Abdominal trauma
Accounts for significant morbidity and mortality in abused children.
Young children are especially vulnerable
A forceful blow or kick can cause hematomas of solid organs as well as hematoma or rupture
of hollow organs.
The manifestations are often subtle, even with severe injuries.
Bruising of the abdominal wall is unusual, and symptoms may evolve slowly.
Delayed perforation may occur days after the injury;
Bilious vomiting without fever or peritoneal irritation suggests a duodenal hematoma
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19. From total of 227 children enrolled to study, 183 (80.6%) encountered some form of physical
punishment
21.0% of these had abusive punishment with evidence of bruises, lacerations or swelling
Abusers were mainly teachers 118 (40.7%) and parents 90 (31.0%)
verbal maltreatment in 179 (78.9%) (insult, curse, harassment or threat to harm)
no report of sexual abuse
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20. Corporal punishment
Is any punishment in which physical force is used & intended to cause some degree of pain or
discomfort, however light.
The threshold for defining corporal punishment as abuse is unclear.
One can consider any injury beyond transient redness as abuse.
Most involve hitting (‘smacking’, ‘slapping’, ‘spanking’) children, with the hand or with
an implement – whip, stick, belt, shoe, wooden spoon, etc
UNICEF report in 2015, children’s self-reports of teacher’s use of physical punishment shows,
Ethiopia is second highest with the prevalence of corporal punishment out of four countries,
4 in 10 children in school at the age of 8 and 1 in 8 at age 15 experienced corporal
punishment
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21. cont...
US- corporal punishment in the home is lawful in all states, but 31 states have banned corporal
punishment in public.
The American Academy of Pediatrics clearly opposed the use of corporal punishment in a recent
policy statement.
In Ethiopia, Corporal punishment in the family is not explicitly prohibited by law
While the constitution remains silent on corporal punishment against children in the home
setting, the family code allows it (Save the Children & ACPF, 2005).
The criminal code claims to punish maltreatment of children, however, it does not consider
corporal punishment at home as maltreatment (GIEACPC, 2018; Save the Children, 2011)
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22. Home setting corporal punishment in Ethiopia...
Article 258 of the revised family code, concerning the upbringing of children, clearly states that “the
guardian may take the necessary disciplinary measures for the purpose of ensuring [the child’s] up
bringing” (FDRE, 2000: 41).
under international law, legalizing/ practicing corporal punishment is a violation of children’s
fundamental human rights to human dignity, physical integrity, and equal protection under the law
(GIEACPC, 2013).
Domestic laws explicitly allow ‘responsible’ punishment by parents/guardians in the home setting,
specifically violated article 19(1) of CRC (international law), which requires states to protect
children from corporal punishment.
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23. Neglect
Refers to omissions in care, resulting in actual or potential harm.
Is the most prevalent form of child abuse
Is failure to provide the basic physical, emotional, educational support or
Inadequate medical needs, supervision, protection from hazards in the environment
A child whose health is jeopardized or harmed by not receiving necessary care experiences
medical neglect
leads to potentially severe and lasting sequelae.
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24. Signs of child neglect
A child who:
frequently absent from school
Begs or steals food or money
Lacks needed medical care (including immunizations, dental care)
consistently dirty and has severe body odor
Lacks sufficient clothing for the weather
Abuses alcohol or other drugs
Impaired growth
States that there is no one at home to provide care
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25. Sexual abuse
any sexual behavior or action toward a child that is unwanted or exploitative.
involvement of dependent, developmentally immature children and adolescents in sexual activities:
which they do not fully comprehend, to which they are unable to give consent, or
that violate the social taboos of family roles
Includes exposure to sexually explicit materials:
oral-genital contact, genital-to-genital contact, genital-to-anal contact, and genital fondling
any touching of private parts by parents or caregivers in a context other than necessary care
Showing pornography to a child, filming or photographing a child in sexually explicit
poses, and
encouraging or forcing one child to perform sex acts on another
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26. Signs of sexual abuse
Social withdrawal, acting out, increased clinginess or fearfulness,
Distractibility, and learning difficulties, running away from home
Has difficulty walking or sitting
Has bleeding, bruising, vaginal discharge or swelling in their private parts
Reports nightmares or bedwetting
 sexually explicit behaviors like excessive masturbation, sexualized behaviors,
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27. Out of 354 students enrolled to study, 113 (31.9%) were sexually assaulted
in the form of exposing adolescent to verbal sexual advances (32.4%)
kissing adolescent in a socially unacceptable manner (29.1%)
the combination of touching and fondling adolescent sexually (25.9%)
making adolescent to look at somebody's genitals (22.7%)
forcing to expose their genitals (18.3%)
discussing about sexual practices (16.5%)
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28. Out of a total of 45, 834 out patient visits, 275 (0.6%) children presented for alleged child abuse and
sexual abuse
sexual abuse covers 267(97.1%) and most of them were female (75.7%).
Among all the reports of child abuse and neglect, severe physical abuse identified in 8 (2.7%) of
children and one child died
The abusers were: male (98.8%), teachers (7.9%), relatives (13.4%) and neighbors (38.95%)
The median length of time taken to present to hospital after the abuse was 4 days (range: 2 hours to 3
years)
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29. Emotional maltreatment
The most elusive and difficult to define of all types of child abuse.
Results in impaired psychological growth and development.
Is a repeated pattern of damaging interactions between parent(s) or caregiver(s) and
the child that becomes typical of the relationship and
conveys to the child that he or she is flawed, unloved, or unwanted.
The pattern may be chronic or triggered by alcohol or other potentiating factors
May be active or passive, and may occur with or without conscious intent to harm the child
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30. Signs of emotional abuse
Shows extremes in behavior
Is either inappropriately adult or inappropriately infantile.
Is delayed in physical or emotional development
Shows signs of depression or suicidal thoughts
Reports an inability to develop emotional bonds with others
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31. General principles for assessing possible abuse and neglect
An interdisciplinary assessment is optimal, with input from all involved professionals
A thorough history should be obtained from the parent(s) optimally via separate interviews.
A thorough physical examination including anogenital area are necessary.
Verbal children should be interviewed separately, in a developmentally appropriate manner.
Open-ended questions (e.g., “Tell me what happened”) are the best
Some children need more directed questioning (e.g., “How did you get that bruise?”)
Others need multiple-choice questions
Leading questions must be avoided (e.g., “Did your daddy hit you?”)
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32. Gross work up (lab, imaging)
X-ray, CT scan, abdominal Ultrasound, Fundoscopy
CBC and coagulation test if bleeding disorder suspected.
Forensic evidence collection:- prepubertal child - if abuse <72 hr and direct contact
postpubertal females- up to 120 hr following the abuse
STI screening- penetration, stranger, known/high risk, symptoms, already dxed, parent/child
worry:-
NAAT- Immediately and repeat within 2 weeks of first test
HIV testing, syphilis (VDRL,RPR) and Hepatitis B (HBsAg, anti-HBs, anti-HBc)
Immediately, at 6 wks, 3 months and 6 months.
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33. General management of child maltreatment
Six steps required:-
1. appropriate communication with the family about the child’s condition
2. appropriate medical care for the child;
3. ensuring the child’s safety
4. assess child’s medical, developmental, emotional and educational needs so that appropriate
services can be provided.
5. family’s needs must be evaluated so that adequate parenting can be ensured
6. siblings should be assessed carefully to determine whether they have been maltreated.
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34. cont...
Advanced Trauma Life Support.
STI prophylaxis- N. gonorrhoeae, C. trachomatis and T. vaginalis
Prepubertal children who have no symptoms of STI and not receive antibiotic
prophylaxis give if there is excessive concern by the caregiver or child.
Post-pubertal children- The CDC recommends
Ceftriaxone 250 mg IM in a single dose + Azithromycin 1 gram orally in a single
dose + Metronidazole 2 grams orally in a single dose
Antiretroviral prophylaxis- during significant risk of exposure within 1 to 2 hours of
exposure and not more than 72 hrs.
 Exposure of vagina/rectum to semen, source likely to be infected
TDF + 3TC + Doluteglavir (DGT) for 28 days
TDF + 3TC + EFV or Kaletra or boosted Atanazavir as alternative
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35. cont..
postexposure vaccination for HPV- starting at 9 years of age
at initial examination, 1 to 2 months and 6 months after the first dose
Postexposure prophylaxis and vaccination for hepatitis B:-
If the hepatitis status of the assailant is unknown, the survivor has not been previously
vaccinated and vaccination is incomplete-
hepatitis B vaccination (without HBIG) at initial examination, 1 to 2 and 4 to 6 months
If the alleged offender is known to be HBsAg-positive, unvaccinated patients or those with
potentially incomplete vaccination-
both the hepatitis B vaccine and HBIG at initial examination,
hepatitis B vaccine at 1 to 2 and 4 to 6 months
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36. Outcomes of child maltreatment
Physical Health Consequences- may occur immediately or after months or years
Psychological Consequences:
Poor mental and emotional health
educational difficulties, low self-esteem, depression
trouble forming and maintaining relationships
post traumatic stress disorder
Diminished executive functioning and cognitive skills.
Behavioral Consequences- unhealthy sexual practices, alcohol and other drug use, future
perpetration of maltreatment
Societal Consequences- social and relationship deficits, physically aggressive and antisocial
personality
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37. Take home messages
Bruising in children is NOT normal.
Abusive Head Trauma is the most dangerous and deadly form of child physical abuse.
A thorough medical evaluation is crucial in child maltreatment.
Long term effects of child abuse vary from subtle learning and behavioral issues to complete
dependence for all care.
Physicians play a vital role in observation, documentation, and intervention in child
maltreatment
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38. Reference
1. Federal Democratic Republic of Ethiopia Country Response to the Questionnaire on Violence Against
Children By The Federal Ministry of Labor and Social Affairs Submitted to : The UN Secretary General ’ s
Independent Expert on the Study on Violence Against Children. 2005;(May):1–47.
2. Howard Dubowitz WGL. Abused and Neglected Children, Vol. 1, 1005-1031, Nelson Textbook of
Pediatrics 21st Edition.
4. Girgira T, Tilahun B, Bacha T. Time to presentation , pattern and immediate health effects of alleged child
sexual abuse at two tertiary hospitals in Addis Ababa , Ethiopia. 2014;
6. American A, Native A, Race M, Only N, Only PA, Only SA, et al. Child Maltreatment. 2018;1–9.
7. Jacobi G, Dettmeyer R, Banaschak S, Brosig B, Herrmann B. Child Abuse and Neglect : Diagnosis and
Management. 2010;107(13).
8. Bekele I, Zewde W, Neme A. iMedPub Journals Assessment of Prevalence , Types and Factors Associated
with Adolescent Sexual Abuse in High School in Limmu Gnet High School. 2017;1–7.
9. Karen J. Farst, MD, MPH, FAAP, and Rachel A. Clingenpeel, MD, FAAP, Sexually Transmitted Infections
in Child and Adolescent Sexual Assault and Abuse , A PRACTICAL GUIDE 4th Edition.
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39. Thank you
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