Child abuse is reported every 10 seconds. It includes physical, emotional, medical, educational, and sexual abuse as well as neglect. Physical abuse may present as bruises, fractures, burns, or internal injuries that are inconsistent with the caregiver's explanation, recurrent over time, or located in unusual areas for the child's age. Emotional abuse can cause low self-esteem and psychological issues. Sexual abuse involves inappropriate sexual acts with a child. Neglect includes withholding food, medical care, love or education. Abuse can cause both short and long term medical, mental, social, and developmental harm. Physical signs or behavioral changes should prompt consideration of child abuse.

2. CHILD ABUSE
Iman Al-Hatmi – R1 Family Medicine

3. A report of child abuse is made every 10 seconds !

10. Definition of Child Abuse
 Child abuse consists of any act or failure to act
that endangers a child's physical or emotional
health and development

15. When to suspect child abuse
 Risk factors in the family set up
 Presentation
 History
 Physical examination

16. Presentation
 Child attitude/behaviour
 Care provider attitude/behaviour
 Age/Developmental age
 Type/site of injury
 Frequent visits

17. Changes in child behavior
(history/observation)
1. clingy, seems needy
2. problems in school: not
paying attention
3. aggressive, Withdrawn,
anxious, quiet,
hyperactive / attention-
seeking
5. fear of certain
people/places
6. Suicidal thoughts
7. discipline problem
8. Disturbing memories, sleep
problems, nightmares
9. have no feelings (anger)
10.Headaches, stomach
aches, nausea, other
psychosomatic physical
complaints
11. Excessive bathing or poor
hygiene
12. Appears depressed
13. Paranoid thoughts

18. Cont.
14. Emotional eating
(over/under)
15. Using drugs/alcohol
16. Bed wetting
17. Forgetful
18. Return to younger
babyish behavior
19. Overly compliant, too
well-mannered, too
clean/too obedient to be
considered normal for that
age.
20. Running away
21. Low self-esteem, overly
self critical
22. Frequent mood swings
23. developmental Delay
24. seek affection
inappropriately from people
they know, people they
have just met or stranger

19. History
 Delay in reporting the injury
 Inconsistent history (same informant/time)
(different informants)
 Injuries are not consistent with caretaker’s
version of what happened,
 Injuries inconsistent with child’s stage of
development
 Recurrent injuries

20. Physical examination
 Bruises, scratches, redness, welts, cuts,
fractures, burns or internal injuries
 Different injuries over a period of time
 Site and shape of injury

21. Neglect
 Physical : withholding food, clothing, shelter
 Emotional : withholding love, comfort
 Medical : withholding needed medical care, Delay in
presentation to medical care, Refusing necessary investigations or
treatment, LAMA
 Educational: depriving the child from available educational
opportunities
 Presentation :
 Failure to thrive
 Severe nappy rash or infestation
 Poor development of emotional attachment to the child’s care-giver
 Delay in development, speech and language
 Poor attendance of immunization & school

22. Cont.
 Lack of supervision:
 Failure to properly supervise and protect children
from harm as much as is feasible
(What forms in Oman?)

23. Emotional maltreatment
 Failure to provide an appropriate and supportive
environment for the development of a child
 Withdrawal of love by rejecting the child
 Criticism, threats
 Name calling
 Presentation:
 poor self-esteem, poor ability to enjoy things,
nightmares, attempts to run away

24. Cont.
 One of the most difficult forms to uncover, yet it can
leave deep and damaging psychological scares in the
children who encounter it
 Parents/carers may not understand the pressure they
are inflicting upon their children

25. Sexual abuse
 Involvement of dependent, developmentally
immature children and adolescents in sexual
activities that they don’t fully comprehend, are
unable to give informed consent to and that
violate social taboos of family roles
 It can be:
 Genital exposure
 Fondling
 Genital, anal or oral sexual activities or intercourse,
including rape
 Involvement in pornography

26. Cont.
 Victims F>M abusers M>F
 Abuser can be someone in the family, trusted
adult e.g. baby sitter or a stranger
 Presentation :
 Highly sexualized behavior towards adults or
children
 Unexplained pregnancy
 Unexplained change in behavior or school work

27. Presentation
 Disclosure
 Behavior (sexualized behavior, Unexplained
change in behavior or school work)
 Suspicion by care provider
 Symptoms (urinary, anal, …)
 Unexplained pregnancy
 Physical findings (Genital ulcer
or infection, STDs)
 Witnessed abuse
 Perpetrator confession

28. Sequelae – short & long term
 Medical- STIs, pregnancy, substance abuse,
IBS, pelvic pain,
 Mental - anxiety, panic disorder, depression,
obsessive compulsive behavior, suicide
attempts, attachment problems
 Social- running away, homelessness, poor
school performance, own children abused,
marital conflict

29. Physical abuse “definition”
 Non-accidental physical injuries of a child that
results in actual physical harm from an interaction,
which is reasonably within the control of a parent
or person in a position of responsibility, power, or
trust

30. Physical abuse
 In a physically abused child there may be:
 delay in reporting injury
 inconsistent history
 different witnesses provide markedly different
explanations for the injury or injuries
 no explanation or vague explanation for a
significant injury
 inappropriate reaction of care-giver
 recurrent injuries
 injuries inconsistent with child’s stage of
development

31. Bruises
 The commonest presentation (dating is not
accurate practice)
 on forehead & shins of non-mobile babies
 from fingertips on baby’s head
 around mouth from trying to stop crying
 slap marks, bite marks, belts marks
 within pinna, behind ear
 torn frenulum from forcing a bottle into the mouth

34. 3/4/2018M Al Saadoon 2008

40. Head & abdominal injuries
 Direct force resulting in head injuries, spleen &
liver injuries
 Shaking: subdural and retinal hemorrhage
 Presentation: irritability, poor feeding,
increasing head circumference, convulsions,
reduced level of consciousness, a full
fontanelle

41. Thermal Injury/Burns
 Single burn site,
Asymmetry, Small
irregular lesion,
Irregular splash
marks
 Sharp demarcation
between burned and
normal skin
 Stocking-glove
distribution
 Absence of splash
marks
 Multiple burn sites
 Pattern burn;
symmetry
ACCIDENTAL INFLICTED

45.  Physical abuse should be considered in the
differential diagnosis in a child < 18 months
presenting with fracture/s in the absence of
overt history of important trauma or a known
medical condition that predisposes to bone
fragility
Kemp AM et al, BMJ, 2008