draft child abuse and neglect

1. Child maltreatment
Ext. Sansanee Kiatwisarlchai
Ext. Phatthraporn Prapayon
Ext. Witchapong Phutrakul
Advisor Asst.Prof. Ramorn Yampratoom, MD

2. Outline
• Definition
• Types
• Physical abuse
• Sexual abuse
• Emotional or psychological abuse
• Neglect
• Risk factors
• Parent
• Child
• Society
• Signs of abuse
• Clue to diagnosis
• Differential diagnosis
• Consequences
• Prevention

3. Definition
• Child maltreatment = All forms of physical and/or
emotional ill-treatment, sexual abuse, neglect or other
exploitation, resulting in actual or potential harm to the
child’s health, survival, development or dignity in the
context of a relationship of responsibility, trust or power.

4. Types
• Physical abuse
• Sexual abuse
• Emotional or psychological abuse
• Neglect

5. Physical Abuse - Definition
• The intentional use of physical force against a child that
results in or has a high likelihood of resulting in harm for
the child’s health, survival, development or dignity.
• This includes hitting, kicking, shaking, biting, strangling, scalding,
burning, poisoning and suffocating.

6. Sexual Abuse - Definition
• The involvement of a child in sexual activity that he or she
does not fully comprehend, is unable to give informed
consent to, or for which the child is not developmentally
prepared, or else that violates the laws or social taboos of
society.

7. Emotional & Psychological abuse - Definiti
• The abuse involves both isolated incidents, as well as a
pattern of failure over time on the part of a parent or
caregiver to provide a developmentally appropriate and
supportive environment. Acts in this category may have a high
probability of damaging the child’s mental, physical, spiritual,
moral or social development.
• This includes the restriction of movement, patterns of belittling,
blaming, threatening, frightening, discriminating against or
ridiculing, and non-physical forms of rejection or hostile treatment.

8. Neglect - Definition
• This type includes both isolated incidents, as well as a
pattern of failure over time on the part of a parent or other
family member to provide for the development and well-
being of the child (where the parent is in a position to do
so) in one or more of the following areas, including health,
education, emotional development, nutrition, shelter and
safe living conditions.

9. Risk Factors of child maltreatment
1. Child
2. Parent or caregiver
3. Relationship
4. Community and societal factors
World health organization, Child maltreatment, 19 Sep 2022

10. Child
Characteristics of an individual child that may increase
the likelihood of being maltreated include:
• being either under four years old
• being unwanted, or failing to fulfil the expectations of
parents
• having special needs, crying persistently or having
abnormal physical features
• having an intellectual disability or neurological disorder

11. Parent or caregiver
• difficulty bonding with a newborn
• not nurturing the child
• maltreated as a child
• lacking awareness of child development or having
unrealistic expectations
• misusing alcohol or drugs, including during pregnancy
• having low self-esteem
• suffering from poor impulse control
• having a mental or neurological disorder
• being involved in criminal activity
• Financial difficulties

12. Relationship
• family breakdown or violence between other family
members
• being isolated in the community or lacking a support
network
• a breakdown of support in child rearing from the
extended family

13. Community and societal factors
• gender and social inequality
• lack of adequate housing or services to support families and
institutions
• high levels of unemployment or poverty
• the easy availability of alcohol and drugs
• inadequate policies and programs to prevent child maltreatment,
child pornography, child prostitution and child labor
• social and cultural norms that promote or glorify violence
towards others, support the use of corporal punishment,
demand rigid gender roles, or diminish the status of the child in
parent–child relationships
• social, economic, health and education policies that lead to poor
living standards, or to socioeconomic inequality or instability

14. Clues to diagnose child maltreatment
• The most important information leading to a diagnosis of
physical abuse is obtained through the medical history.
• The diagnosis of abuse should be pursued if there are injurie
to multiple areas, injuries in various stages of healing, or
suspicious injury patterns. Bruises, bites, burns, fractures,
abdominal trauma, and head trauma are the most common
physical findings.

15. • Suspicious injuries
• Posterior rib fractures
• Retinal hemorrhages
• Metaphysical or complex skull fractures in infants
• Long bone fractures in children younger than two years
• Scapular, spinous process, and sternal fractures
• Cigarette burns
• Subdural hemorrhages in infants
• Transverse fractures

17. Evaluation

18. Documentation
Obtain the following information if the history of an injury involves a fall:
• The initial position and location of the child before the fall
• The fall dynamics (distance, describe the fall)
• The final position and location of the child after the fall (how they landed,
landing surface)
The injury event should be further reconstructed with the following basic
questions:
• Who witnessed the injury?
• Where did the injury occur?
• When did the injury occur?
• How did the child act after the injury?
• What did the caregiver do after the injury?
• Obtain a basic developmental history (eg, What is the child able to do
physically? Roll over? Crawl? Walk? Climb?).

19. Documentation
• Diet history, as follows, is important in failure to
thrive (FTT):
• Birth weight and serial weights if available (growth
chart, chart review, parental memory)
• Twenty-four–hour diet history - What formula/food?
How is it prepared? How much? At what times?
• Past medical history should ideally include the
following:
• Birth history (gestational age, delivery method, birth
weight, any complications)
• Behavioral problems
• Previous traumatic events, illnesses, operations, ED
visits, evaluations by other medical specialists

20. Documentation
• A family history of bleeding disorders, hearing loss, and easily broken bones in young people should be
documented.
• A review of systems should be extensive and include easy bleeding, bruising, weight loss, and changes
in behavior.
• The minimum social history includes who lives with and cares for the child, and presence of other
siblings if they need to be protected/evaluated. Social work, CPS or other child abuse team members
will likely ask a more thorough social history such as domestic violence exposure, caregiver police
involvement, prior CPS involvement, substance or alcohol abuse, and mental health issues. [18]
• Key questions to guide interpretation of injuries are as follows:
• Does the description of how the injury occurred fit with this child’s developmental capabilities?
• Does the pattern of injury fit with the description given?
• Historical characteristics concerning abuse are as follows:
• Unexplained or vague injuries
• Injuries incompatible with the stated history
• A changing history recognizing that minor discrepancies in the history may have little or no significance
• Inappropriate delay in care (eg, waiting several hours to bring an unresponsive baby in for evaluation)

21. Differential diagnosis of
child physical abuse
• Bruises
• Fractures
• Burns

22. Differential diagnosis
Bruises
Injury localization on a child.
a Localizations typical of accidental falling. b Localizations typical of abuse.

23. Differential diagnosis
Bruises

24. Differential diagnosis
Bruises
Mongolian spots on a
light-skinned child

25. Differential diagnosis
Fractures
• Non-abusive trauma
• Osteogenesis imperfecta
• Pathologic fracture due to osteopenia caused by
limited mobility in children with cerebral palsy or
other neuromuscular disease
• Pathologic fractures from metabolic bone disease,
including rickets, vitamin C and copper deficiency,
cholestatic liver disease, or neoplasm

26. Differential diagnosis
Fractures
Scurvy - radiologic findings

27. Differential diagnosis
Burns
Phytophotodermatitis
Intentional burns
Unintentional pull
over scald

28. Differential diagnosis
Burns
Impetigo
Cigarette burns

29. Differential diagnosis
Sentinel injuries

30. Differential diagnosis

31. Consequences
1. Physical health consequences
2. Psychological consequences
3. Behavioral consequences
4. Societal consequences

32. Physical health consequences
Childhood maltreatment affect long-term health status
• Increasing risk for diabetes, lung disease, malnutrition, and vision
problems-and support the need for early health care prevention

33. Physical health consequences

34. Physical health consequences

35. Psychological consequences
• Difficulties learning and paying attention
• a risk factor for depression, anxiety, and other
psychiatric disorders throughout adulthood
• more likely to develop antisocial traits as they grow
up, which can lead to criminal behavior in
adulthood
• Posttraumatic stress

36. Behavioral Consequences
• Juvenile delinquency leading to adult criminality
• Alcohol and other drug use
• Future perpetration of maltreatment

37. Societal Consequences
• Society pays a price for child abuse and neglect in
both direct costs (e.g., hospitalizations, foster care
payments) and indirect costs (e.g., long-term care,
lost productivity at school, juvenile and criminal
justice systems costs).

38. Adverse childhood experiences pyramid

39. Prevention

40. Prevention

41. Prevention

42. Reference
• Preventing child maltreatment: a guide to taking action and
generating evidence /World Health Organization and
International Society for Prevention of Child Abuse and
Neglect, 2006
• McDonald KC. Child Abuse: Approach and Management.
Am Fam Physician 2007;75:221–8
• Krug EG et al., eds. World report on violence and health.
Geneva, World Health Organization, 2002.