This document summarizes information presented at a seminar on child abuse. It discusses several key topics: 1) Types of child neglect including physical and emotional neglect and their signs and symptoms. Common injuries from physical abuse like bruises and fractures are also outlined. 2) Theoretical models for understanding the causes of child abuse including mental illness, environmental stress, social learning, and human ecological models. 3) Factors that can predispose to physical abuse including parental characteristics like violence and poverty, child characteristics like disabilities, and environmental stressors. 4) Clinical manifestations and findings suggestive of physical neglect and abuse. Suggestive behaviors in abused children are also described.

1. SEMINAR
ON
CHILD ABUSE
Mr. Ashish Noel
M.Sc.Nursing ( Paed)

3. CHILD ABSUE
 INTRODUCTION –
Child neglect is the most common form of
maltreatment. Neglect is generally defined as
the failure of a parent or other person legally
responsible for the child’s welfare to provide
for the child’s basic needs and an adequate
level of care.
(Nester, 1998 & Kaplan and Labruna, 1999)

4. TYPE OF NEGLECT –
 PHYSICAL NEGLECT – involves the
deprivation of necessities such as food,
clothing, shelter, supervision, medical care
& education.
 EMOTIONAL NEGLECT – refers to failure
to meet the child’s needs for affection,
attention and emotional nurturance.

5. PATHOPHYSIOLOGY
 The pathophysiology is the result of
injuries that may be due to beating,
twisting the extremities, punching,
scalding or burning with cigarettes.

6. SINGS AND SYMPTOMS
 Sign and symptoms consist
primarily of bruises,
scratches, burns,
hematomas and fractures of
long bones, ribs or skull as
well as discomfort and pain.
 Neglect, is the chronic failure
of adults to protect the child
from obvious physical danger
or to provide the care
needed.

9. ASSESSMENT
 History Taking
 Physical Examination
 X – Ray- stages of healing of several
bone lesions.
 The different diagnosis depends on
the particular injuries.

10. TREATMENT
- Appropriate medical, surgical and psychiatric treatment
should be promptly initiated.
- The law requires that a child suspected of being
abused or neglected be reported immediately to child
protective services (CPS).
- Suspected abuse child should not be discharged from
the clinic or office without consulting the country CPS.
- Hospitals caring for children should have a team of
professionals who are trained & skilled in child abuse
recognition, reporting and services. This team should
include a pediatrician, a hospital social worker, a
pediatric nurse, a psychologist or psychiatrist and a
data coordinator.
- Provide symptomatic treatment to the child.

11. Cont…….
 Provide more intensive surveillance and well
child case for the abused and neglected children.
 Abused children need good physical case and
love.
 Provide psychological support to the child and
parents.
 Provide the counseling to the parents regarding
to child rearing, positive parents behaviors and
involvement of parents in child's care activity.

12. PARENTS ANONYMOUS
 Self – help, non profit groups called parents
Anonymous have been organized across the
country.
 Ideally, each abusive individual should have a
normal adult who can assume the role of parent.
 The main objective is to establish a positive parent-
child relationship and to restore the parents self
confidence by changing old habits one step at a
time. These self help groups need the support and
encouragement of the nurses as a professional or
as a friend.

13. THEORETICAL PERSPECTIVES
ON CHILD ABUSE
 MENTAL ILLNESS MODEL –
 This explanation for bike abuse states that
parents who abuse their children are
mentally ill. The goal is to cure the parent,
who will them stop the abuse. This model
was developed very early in the
identification and treatment of abuse.

14.  ENVIRONMENTAL STRESS MODEL –
 In this model, two factors interact t precipitate abuse
a violent environment and stress. The violent
environment can be found either in society or the
family. Abusive parents ideologically belong to that
segment of society that approves of physical violence
against children in certain circumstances. According
to this theory, the violence has to be a result of child
behavior abuse for no reason is unacceptable. This
model is used to explain intergenerational abuse
those abuse as children were exposed to an
environment that tolerated and even sanctioned child
abuse as a method of problem solving.

15.  SOCIAL LEARNING MODEL –
 This model to explain how humans learn
behavior was developed by Bandura
(1973). Many human behaviors are
learned through observation as well as
through behavioral reinforcement. This
model of abuse is useful because it
includes cultural and family influences.

16.  SOCIAL PSYCHOLOGIC MODEL –
 This model was proposed by Kempe and Helfer (1972). For
abuse to occur, three variables must be present;
 A special parent,
 A special child and stress.
 The parent can be “special” in a number of ways, including being
immature having unrealistic expectations of the child, having poor
impulse control and failing to recognize and respect the child ah a
unique individual.
 The child can also be special in several ways; “wrong” sex,
physically or mentally disabled, “different” from the other children
in the family of tem chronic.
 This is important because of the frequent difference of perception
of stress between the two groups and the professional's limited
understanding of the parent's lifestyle and resources.

17.  HUMAN ECOLOGIC MODEL –
 This model to explain child abuse was developed by
Garbarino (1977). It says that abuse is a result of
interactions of the culture, the family, the parent, the
bike and stress. It identify the family ah the
dysfunctional system, with abuse being a
symptoms. This suggests that parents the abused
child and other children in the family interact in such
a way that abused occur occurs during periods of
stress.

18.  PSYCHOLOGIC - SOCIOLOGIC MODEL FOR
SEXUAL ABUSE –
 Finkelhor (1984) has presented a model specification
related to sexual abuse. It has 4 components,
developed from an individual and a socio cultural level.
 First, the perpetrator must be motivated to abuse a
child sexually.
 Second, necessary for sexual abuse to occur is the
overcoming of internal inhibitors.
 Third, external inhibitors must be overcome Mother's
ability to protect her children.
 Finally, the resistance of the child must be overcome.
Children can play a role in whether they are sexually
abuse.

19.  CYCLE OF CHILD ABUSE
 Many parents who abuse their children were
themselves victims of child abuse because
they unable to meet their parents needs.
These individuals, lacking love and security
as children, become lonely adults who,
when they are of an age to marry, seek a
loving parent figure to care for them.

20. PHYSICAL ABUSE
 The deliberate infliction of injuries on a
child, usually by the child's caregiver is
termed physical abuse. Minor physical
injury is responsible for more reported
cases of a treatment than major.

22. FACTORS PREDISPOSING
TO PHYSICAL ABUSE
 The exact cause of abuse is not
known but three major criteria
 Parental characteristics.
 Characteristics of child.
 Environmental characteristics.

23.  Parental Characteristic-
 Violence,
 Poverty,
 Parental history of abuse,
 Socially isolated,
 Low self esteem,
 Less adequate maternal functioning.

24.  Characteristic of Child -
 No. of children’s,
 Child's temperament,
 Position in the family,
 Additional physical needs if ill or disabled,
 Activity level or degree of sensitivity to
parental needs.
 Occasionally the abused child is ill e.g. it is
mate, unwanted, brain damaged, hyper
active or physically disabled.

25.  Environmental Characteristics -
 Chronic stress,
 Problem of divorce,
 Poverty,
 Unemployment,
 Poor housing,
 Frequent relocation,
 Alcoholism,
 Drug addiction.

26. CLINICAL MANIFESTATION -
 PHYSICAL NEGLECT -
SUGGESTIVE PHYSICAL FINDINGS –
 Failure of Thrive,
 Signs of mal nutrition such as thin extremities, abdominal
distension,
 Poor personal hygiene,
 Unclean and in appropriate dress,
 Evidence of poor health case, such as delayed immunization,
untreated infections, frequent colds,
 Frequent injuries from lack of supervision.
SUGGESTIVE BEHAVIORS-
 Dull and inactive; excessively passive or sleep,
 Self - stimulatory behaviors, such ah finger - sucking or rocking,
 Begging or stealing food,
 Absenteeism from school,
 Drug or alcohol addiction,


27.  PHYSICAL ABUSE –
 SUGGESTIVE PHYSICAL FINDINGS –
 Bruises and Welts -On faces, lips, mouth, back, buttocks, thighs
regular patterns descriptive of object used such as belt buckle, hand,
wise hanger, chain, wooden spoon, squeeze or pinch mark.
 Burns- on sole of feet, palms of hand, back or buttocks. Patterns
descriptive of object used, such as sound cigar or cigarette burns,
immersion in scalding water, rope burns on wrists.
 Absence of ' splash' marks and presence of symmetric burns.
 Stun gun injury: lesions circular, fairly uniform (up to 0.5 cm).
 Fractures and dislocations-
Skull, nose or facial structures.
Multiple new or old fractures in various stages of healing.
 Lacerations and abrasions-
On back of arms torso, face or external genitalia.
Descriptive marks such as from human bites or pulling hair out.
 Chemical-
UN explained repeated poisoning, especially drug overdose.

30. CONT…. SUGGESTIVE BEHAVIOUR –
 Wary of physical contact with
adults.
 Apparent fear of parents or
going home.
 Lying very still while surveying
environment.
 In appropriate reaction to
injury, such as failure to cry
from pain.
 Withdrawal behavior.
 Superficial relationship.
 Lack of reaction to frightening
events.

32. NURSING CARE OF PHYSICALLY
ABUSED CHILDREN
CHILD AND FAMILY ASSESSMENT –
 Use age - appropriate methods to assess development;
preverbal and young children respond to play therapy with
folks that represent family members.
 Provide age - appropriate support for the child during radio
logic and other diagnostic tests. - Document physical injuries.
 Document observations of child behavior that indicate
psychologic and emotional status.
 With other health care team members, complete the family
assessment.

33. PLANNING AND INITIATING CARE –
 Assess level of knowledge and skill of parent
regarding childcare and development.
 Identify one nurse as the child's primary care
giver.
 Develop a clearly defined plan of case to be
followed by all nurses.
 Involve older children in developing the plan for
their own care.
 Plan patient care to include parental participation.

34. INTER DISCIPLINARY PARTICIPATION IN CARE –
 Provide positive reinforcement for family / parent
strengths.
 Model healthy communication and parenting behavior.
 Inform parents that child protection services are being
notified. Without judging or accusing parents.
 Explain that the objective of involvement is to
strengthen family functioning and prevent future harm
to children.
 Support parents during initial interviews with child
protection workers.
 Assist parents in identifying strategies necessary to
prevent future always.

35. PREVENTION FROM PHYSICAL ABUSE
 The pediatrician's role in primary abuse prevention
includes identifying parents at high risk for being
unable to accept, love and properly discipline and
care for their offspring.
 The history obtained from all parents should include
information about pregnancy planning, pregnancy,
emotional and physical health, domestic violence and
attitudes about the child and child- rearing
experiences.
 Abuse and serious neglect may be prevented when
at- risk families receive intensive training and support
during pregnancy and after delivery.

37. PROGNOSIS –
 Early studies of abused children
returned to their parents without any
intervention indicate that about 5 are
subsequently killed and that 2 5 are
seriously re- injured with
comprehensive, intensive family
treatment, 8- 9 of families involved in
child mal treatment may be
rehabilitated to provide adequate care
for their children.

38. EMOTIONAL ABUSE AND NEGLECT
SUGGESTIVE PHYSICAL FINDINGS –
 Failure to thrive.
 Feeding disorders, such as rumination
 Enuresis
SUGGESTIVE BEHAVIORS –
 Self-stimulatory behavior such as biting, rocking.
 During infancy, lack of social smile and stranger anxiety.
 Withdrawal
 Unusual fearful ness
 Antisocial behavior, such as destructiveness, stealing, cruelty
 Lags in emotional and intellectual development, especially
language
 Suicide attempts.

41. SEXUAL ABUSE
 Sexual abuse includes any activity with a
child, before the age of legal consent that is
for the sexual gratification of an adult or a
significantly older child. Sexual abuse
includes oral - genital, genital - genital,
genital - recta l, hand - genital, hand - recta l
or hand breast contact; exposure of sexual
anatomy, forced viewing of sexual anatomy;
and showing of pornography to a child or
using a child in the production of
pornography.

42. DEFINITIONS –
 SEXUAL PLAY –
The other hand may be defined as viewing or
touching of the genitals, buttocks or chest by pre adolescent
children 4 separated by not more than 4 years, in which these has
been no force or coercion.
 INCEST –
Any physical sexual activity between family members;
alone relationship is not required causes can include step parents,
upper siblings, grand parents, aunts and uncles does not include
sexual relations between legally sanctioned parents such as
spouses. E.g. Brother-sister.
 MOLESTATION –
A vague term that includes “indecent
liberties”, such as touching, foundling, kissing, single or mutual
masturbations, or oral- genital contact.

43. CONT……..
 EXHIBITIONISM –
Indecent exposure, usually exposure of the genitals by an adult
to children or other adults.
 CHILD PORNOGRAPHY –
Arranging and photographing in any media sexual acts
involving children, either alone or with adults or animals, regardless
of consent by the child's legal guardian; also may denote distribution
of such material in any form with or with out profit.
 CHILD PROSTITUTION –
Involving children in sex acts for profit and usually with
changing partners.
 PEDOPHILIA –
Laterally means “Love of child” and does not denote a type of
sexual activity but the preference for pre pubertal children as the
means of achieving sexual excitement.

44. ETIOLOGY/ METHODS –
 Gifts or privileges.
 Misrepresents moral standards by telling the
child that it is 'okay’
 Emotionally and socially impoverished children
 Sex offender pressures the victim into secrecy
regarding the activity by describing it as a
secret between us.
 Child's fears
 Vulnerable children

45. CLINICAL MANIFESTATONS
SUGGESTIVE PHYSICAL FINDINGS –
 Bruises bleeding, lacerations or irritation of external
genitalia, anus, mouth or throat
 Torn, stained or bloody under clothing
 Pain on urination or pain, swelling and itching of genital
area
 Penile discharge
 Sexually transmitted disease, non specific vaginitis or
venereal warts
 Difficulty in walking or sitting
 Pregnancy in young adolescent
 Recurrent urinary tract infection

46. SUGGESTIVE BEHAVIORS
 Sudden emergence of sexually related problems, including
excessive or public masturbation, age - in appropriate sexual play,
promiscuity or overtly seductive behavior.
 With drawn, excessive day dreaming
 Poor relationships with peers
 Preoccupied with fantasies, especially in play
 Regressive behavior, such as bed- wetting or thumb – sucking
 Sudden onset of phobias or fears, particularly fears of the dark,
men, strangers or particular settings or situations (e.g. Undue fear
of leaving the house).
 Running away from house - Substance abuse - Rapidly declining
school performance
 Suicidal attempts or ideation.

47. INVESTIGATION –
Investigating the possibility of sexual abuse requires
supportive sensitive and detailed history taking.
 History Taking
 Physical Examination
 Laboratory Findings- It depends on the history and the
time since injury.
 Specimens of offender blood, hair and the victim's
mail clipping and clothing.
 Gonorrhea and chlamydia cultures should be obtained
from the mouth, anus and genitals.
 In the vagina, motile sperm can be found for 6 hr non
motile sperm exist for longer than 72 hrs.

48. TREATMENT –
 It is a criminal offense and is investigated by the police
 All victims of sexual abuse require psychological support.
 The consequences and appropriate therapy of sexual abuse vary,
depending on the type of abuse; the age and other physical and
emotional factors in the victim.
 The therapist may recommend that the victim of incest be returned
home he the perpetrator is out of the home.
 Medication to prevent pregnancy may be given to post menarchal
girls with in the previous 72 hr intercourse.
 Treatment with antibiotics is initiated to prevent sexually transmitted
diseases.
 The offending parents and spouse should be referred for psychiatric
or psychologic evaluation.

49. NURSING CARE OF SEXUALLY
ABUSED CHILDREN
 Nurse must be aware of the presenting symptoms that
frequently mask sexual abuse (abdominal pain, somatic
complaints with no identifiable cause).
 Nurse must be able to support a patient / after
disclosure.
 The nurse who understands the investigative
assessment procedure will be able to judge.
 Nurse suggestions about age – appropriate ways to
gather data can be valuable to the interviewer.
 The nurse provides support to the patient and family
and to record accurately child behavior and child –
parent interactions.

50. PREVENTION –
 The primary prevention of sexual abuse is related, in
part, to normal developmental education and sexual
behavior.
 Teaching children the proper names of all body parts,
including the names, function and significance of '
private parts' nipples, genitals and rectum
 Teach to children should be say 'NO'.
 Victim therapy should decrease the potential for re-
abuse.
 Routine family discussions of uncomfortable events.
 Written permission should be obtained from any
caregiver to allow a police screening for offenses.

51. PROGNOSIS –
 With early and adequate intervention,
victims may lead normal adult lives.
However, even with intervention, certain
adolescent victims may run away from
home and fall to adolescent prostitution,
violence, drug addiction and unprepared
parenthood. Others who remain at home
may manifest a variety of emotional
problems, including depression, suicidal
gestures, deterioration in school
performance and conversion reactions.

52. NURSING ROLES IN PREVENTION OF
CHILD ABUSE
The nursing role in prevention of child abuse and maltreatment is
addressed here by using 5 objectives as a framework –
 Increase public awareness of the nature and extent of efforts to
prevent child abuse.
 Increase knowledge of health professionals.
 Coordinate and improve the availability, accessibility and quality of
health services to families.
a. Advocacy for expanded health and social services for children
and families.
b. Identification and treatment of families at high risk for child abuse
and maltreatment.
 Develop data systems to monitor the incidence and prevalence of all
forms of child abuse.
 Research.

53. NURSING DIAGNOSIS –
 Fear / anxiety related to negative interpersonal
interaction, repeated maltreatment, powerlessness,
potential loss of parents.
 Impaired parenting related to child, caregiver or
situational characteristics that precipitate abusive
behavior.
 Risk for trauma related to characteristics of child,
caregiver and environment.
 Deficient knowledge about the child’s realistic
developmental abilities how to access external support
resources related to past inexperience with parenting.

54.  OTHER NSG DIAGNOSIS –
 Pain related to inflicted injury.
 Impaired skin integrity relate to inflicted
injuries.
 Altered nutrition less than body
requirements related to inadequate caloric
intake.