Child abuse can take several forms, including physical, sexual, emotional abuse and neglect. Physical abuse may present as bruises, burns, fractures, head injuries, or abdominal trauma in children. Sexual abuse involves inappropriate sexual activities with children. Emotional abuse includes acts that terrify or humiliate children. Neglect refers to failure to provide basic needs. Accurate documentation of injuries and a thorough medical examination are important for management, along with referral to appropriate support services and authorities.

1. Child Abuse
Khairul Kamarudin

2. Definitions
• Abuse is defined as acts of commission(doing something wrong) that
leads to an undesirable outcome.
• Child abuse refers to the physical and emotional mistreatment, sexual
abuse, neglect and negligent treatment of children, as well as to their
commercial or other exploitation resulting in actual or potential harm,
to the child’s health, survival, development or dignity.

3. Types
• Child abuse is generally divided into four different types of abuse
which are :
• Physical abuse
• Sexual abuse
• Emotional abuse
• Neglect

4. Physical Abuse
• Physical injury (ranging from minor bruises to severe fractures or death)
• as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other objects),
burning, or otherwise harming a child.
• considered abuse regardless of whether the caretaker intended to hurt the child.
• Intention to hurt may not be present
• may have resulted from over-discipline or physical punishment
• from irritation over a crying baby and inability to cope
• If parents spank a child, it should be limited to the buttocks, should occur over clothing, and should never involve the head and neck.
• Bullying,and shaken baby syndrome (link) are form of physical abuse
• Bleeding in the outer lining of the brain of a young child , usually below 2 years old, is called subdural haemorrhage (see Fig. 1) Subdural
bleeding together with fractured ribs and bleeding within the eye is called the shaken baby syndrome.
• caused by violent acceleration/deceleration injury from shaking . The infant’s relatively large head and poor neck support make it predisposed
to acceleration and deceleration forces associated with rotational forces, much like in a whiplash injury. The soft, pliable skull and brain lead to
stress on the bridging veins which tear with the force applied, leading to a subdural haemorrhage.
• This usually happens when the parent does not know what to do with a crying baby, who continues to cry leading to frustration and impatience
in handling the baby. They may shake the baby hard for a few seconds in an attempt to stop the baby from crying or slap the baby out of rage.
Or shake the baby’s cradle so hard causing baby falls out of the cradle.

5. Physical Abuse
• Abusive injuries are sometimes occult, and children
can present with nonspecific symptoms.
• The history provided by the parent is often
inaccurate because the parent is unwilling to provide
the correct history
• The child may be too young or ill to provide a history
of the assault. An older child may be too scared to do
so.
• History that seems incongruent with the clinical
presentation of the child raises concern for physical
abuse.

7. Sexual Abuse
• The 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
• The activity is intended to satisfy or gratify the needs of the adult or another child.
• Sexual abuse 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 is inappropriate.
• Sexual abuse occasionally is recognized by the discovery of an unexplained vaginal, penile, or anal injury or by the
discovery of a sexually transmitted infection.
• physical examination should be complete, with careful external inspection of the genitals and anus.
• For children who present within 72 hours of the most recent assault, special attention should be given to
identifying acute injury.

8. Emotional Abuse
• includes verbal abuse and humiliation and acts that scare or terrorize a
child
• this resulting in depression, anxiety, poor self-esteem, or lack of empathy,
but its always difficult to proving.
• almost always present when other forms of abuse are identified:
• patterns of belittling (include school bullying)
• habitual scapegoating ( act of blaming a person for something bad that someone else
has done)
• Denigrating (to attack the reputation of : defame ) ,humiliating
• rejecting treatment
• confinement of child in a dark closet

9. Neglect
• omissions in care, resulting in actual or potential harm.
• Neglect happens when kids live in a home where the adults do not offer their
basic needs:
• Physical -(e.g., failure to provide necessary food or shelter, or lack of appropriate supervision)
• Medical -(e.g., failure to provide necessary medical or mental health treatment)
• Educational & supervisional – (e.g., failure to educate a child or offer special service
provision)
• Emotional
• inattention to a child’s emotional needs
• failure to provide psychological care
• permitting the child to consume alcohol or use drugs
• Consider cultural values, standards of care and level of poverty before reporting
as neglect

10. Clinical Manifestations
• Bruises are the most common manifestation of
physical abuse.
• Features suggestive of inflicted bruises include
(1) bruising in a preambulatory infant
(2) bruising of padded and less exposed
areas (buttocks, cheeks, ears, genitalia),
(3) patterned bruising or burns conforming
to shape of an object or ligatures around
the wrists,
(4) multiple bruises, especially if clearly of
different ages.

11. Clinical Manifestations
• Bites have a characteristic pattern of 1 or 2
opposing arches with multiple bruises.
• They can be inflicted by an adult, another child,
an animal, or the patient.
• Burns may be inflicted or caused by inadequate
supervision. Immersion burns, when a child is
forcibly held in hot water, show clear
delineation between the burned and healthy
skin may have a sock or glove distribution.
• Symmetric burns / burn leave patterns
representing object are especially suggestive of
abuse,

13. Clinical Manifestations
• Fractures that strongly suggest abuse
include classic metaphyseal lesions,
posterior rib fractures, and fractures of the
scapula, sternum, and spinous processes,
especially in young children.
• These fractures all require more force than
would be expected from a minor fall or
routine handling and activities of a child.
• In abused infants, rib , metaphyseal , and
skull fractures are most common.

14. Clinical Manifestations

15. Clinical Manifestations
• Abusive head trauma (AHT) may be
caused by direct impact, asphyxia, or
shaking.
• The poor neck muscle tone and relatively
large heads of infants make them
vulnerable to acceleration deceleration
forces associated with shaking, leading to
AHT.
• Signs and symptoms may be nonspecific,
ranging from lethargy, vomiting (without
diarrhea), changing neurologic status or
seizures, and coma.

16. Clinical Manifestations
• Abdominal trauma , Young children vulnerable because of their
relatively large abdomens and lax abdominal musculature.
• A forceful blow or kick can cause hematomas of solid organs (liver,
spleen, kidney) from compression against the spine, as well as
hematoma (duodenal) or rupture (stomach) of hollow organs.
• Children may present with cardiovascular failure or an acute
condition of the abdomen. Bilious vomiting without fever or
peritoneal irritation suggests a duodenal hematoma.

17. Outcomes of Child Maltreatment
• Physically abused children are at risk for many problems, including conduct
disorders, aggressive behavior, posttraumatic stress disorder (PTSD), anxiety and
mood disorders, decreased cognitive functioning,and poor academic
performance.
• Maltreatment is associated with increased risk in adolescence and adulthood for
health risk behaviors (e.g., smoking, alcohol/drug abuse), mental health problems
(e.g., anxiety, depression, suicide attempt), physical health problems (e.g., heart
disease, arthritis), and mental health problems.
• Maltreated children are at risk for becoming abusive parents. The neurobiologic
effects of child abuse and neglect on the developing brain may cause this.

18. Management
• Physical abuse
■ Platelet count and coagulation screen in presence of any bruising
■ Skeletal survey as required (should be done in children below 2 years of
age)
■ Photographs of injuries
■ Others as indicated :-
• e.g. head injuries - CT SCAN for suspected shaken baby
syndrome
• Ultrasound for intra-abdominal injuries -free fluid & hematomas
• X-rays for fractures (only if clinically indicated in children >2 years
old)

19. • Others
■ Proper documentation in text and diagram
■ Take photographs, if possible
■ Photos must be labeled according to the number in roll of film or
filed according to name and date in digital form
■ Examine other siblings or children in home, as relevant
■ Direct observation of child-parent/guardian interaction

20. Acute sexual assault or abuse
• Examination for sexual abuse
■ In most cases, there is no urgency in examination
■ Calm the parents by keeping them informed
■ Arrange appointment with trained doctor. Avoid repeated vaginal
examinations
■ Doctor should inform the child the reason an examination is
required and what it entails, according to the child’s developmental
level

21. • Urgent examinations
■ Urgent treatment needed for the child when :-
• there is obvious physical trauma or suspected internal trauma
• there are signs or symptoms of systemic illness or local signs and
symptoms especially significant genital discharge or bleeding or ano-
genital pain
■ Acute sexual assault/last incident within 72 hours before presentation
• As forensic evidence may be present for only a matter of hours
■ It is appropriate for the primary care doctor (in context of vaginal
bleeding/ acute trauma) to do limited examination to determine urgency of
referral followed by an examination by the specialist BUT only one medical
report from the hospital is to be submitted

22. • Examination under anesthesia
■ If child is distraught and examination considered essential to
further protect the child
■ Painful injuries e.g. vaginal wall tear
■ Risk of sexually transmitted diseases and child unable to allow
adequate swabbing
■ Strong possibility that forensic swabs would be useful and child
unable to comply
■ If there is a suspected foreign body

23. Management of Sexual Abuse of Adolescents
•
1. Examination done by O&G doctor as soon as possible if < 72 hours after
incident.
2. Medical treatment initiated if indicated. e.g. abrasion or laceration
wound - dressing or pain relief.
3. Prophylaxis indicated :-
(i) Emergency contraception - Medically and legally warranted.
(ii) Antibiotics for high risk group Increased risk of infection in
rape compared to consensual sex
(iii) HIV Prophylaxis - Is indicated if assailant is probable
HIV+(high risk of infection)
(iv) If suicidal risk or symptom of depression is present - make a
referral to a psychiatrist

24. Prevention
■ If the child has not been abused but there is cause for concern (e.g.
poor coping ability of parents), preventative interventions may be
provided by:
• Public health nurses
• Medical social workers
• Mental health workers
• Community agency (government or NGO)

25. Support
■ Explain to family their critical role in providing healing for their child.
Be aware that this is at a time when they may be dealing with their
own feelings of denial, guilt, anger or humiliation
■ Consideration should be given to making contact with supportive
parent or person identified by child (as in cases where the child is
brought in by JKM officer from school)
■ Parents/ caregivers should be informed as early as possible about
referral to JKM or police report
• Before this, consider the safety of child, impact on family and
identification of suspected abuser

26. Refer To Child Psychiatrist
■ Some children may require a referral to a child psychiatrist as
determined by the paediatrician
■ In the sexual abuse of very young children, parents may need to be
referred if they themselves are anxious or depressed
■ If there is a history of dysfunctional family or if parents/ guardian
have poor coping or parenting skills
■ Suspected perpetrators who are children
■ In some custody cases