This document provides information to help medical professionals recognize and diagnose child abuse. It discusses statistics on child abuse, types of abuse, risk factors, and gives guidance on evaluating injuries commonly seen in abuse such as burns, bruises, fractures, and head trauma. Physical findings that suggest abuse include bruises in unusual locations, patterned bruises, immersion burns, fractures of certain bones, and injuries of different ages. An accurate history is important, as explanations that are vague or inconsistent with the child's ability may indicate abuse.
Violence against transgender individuals is severely underreported due to a lack of legal protections and data collection. Transgender people experience disproportionately high rates of physical and sexual assault, domestic violence, harassment, and murder. The psychological effects of this violence include suicidal ideation, PTSD, and depression. Transgender people of color and those engaging in sex work are especially vulnerable. Collecting data on violence is important to justify hate crime legislation but the lack of protections prevents data collection, creating a catch-22 situation.
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Intensity
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The document discusses gender dysphoria and transsexualism. It defines key terms like gender identity disorder and outlines the diagnostic criteria from the DSM-IV and ICD-10. It then discusses the different types of transsexuals, prevalence rates around the world, and proposed biological and psychological causes. The path to transition is described including counseling, real life experience, hormone therapy, and various surgical procedures. Assessment and treatment of voice in male-to-female transsexuals pre and post hormones is the focus of the presentation.
This document is a presentation by Dr. Steven Brown for the 4th Annual Transgender Medical Symposium in Fort Lauderdale, Florida. It discusses hormones and their effects on the body, the development of secondary sex characteristics, and considerations for providing hormone therapy to transgender patients. It covers topics like informed consent processes, evaluating patients for hormone therapy, monitoring treatment effects and side effects, and addressing psychosocial factors.
Unconsummated marriage: Causes , Assessment and ManagementMitra Molaeinezhad
The document discusses consummation and unconsummated marriage. It defines consummation as the first act of sexual intercourse between a married couple. Unconsummated marriage is defined as the inability to successfully engage in sexual intercourse at the beginning of marriage, especially in the first few nights. Common causes of unconsummated marriage include vaginismus, erectile dysfunction, lack of sex education, and relationship factors. The document then describes the development and validation of the Multidimensional Vaginal Penetration Disorder Questionnaire (MVPDQ), a self-report questionnaire for assessing women with lifelong vaginismus. The MVPDQ measures 9 dimensions of vaginal penetration disorder.
Eugenics, behavioural genetics and genetic disorderssandeshGM
This document discusses eugenics, behavioural genetics, and genetic disorders. It defines eugenics as practices that aim to improve the genetic quality of humans. It discusses the origins and types of eugenics such as positive and negative eugenics. The document also defines behavioural genetics as examining genetic and environmental influences on behavior through studies like twin studies. It discusses research findings on genetic influences on behavior. Finally, it defines and provides examples of different types of genetic disorders like single gene disorders, multifactorial disorders, and X-linked, Y-linked, and mitochondrial disorders.
Tim Redmond: Bb LectureParaphillas and paraphillic disordersTRedmond27
This document discusses paraphilias and paraphilic disorders. Paraphilias are atypical sexual interests that are not inherently disordered unless they cause distress or impairment. Paraphilic disorders involve paraphilic behaviors that consume excessive time and cause problems. Major paraphilic disorders include exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, and voyeurism. The document outlines these disorders and notes prevalence rates. It also discusses child molestation, diagnosing sex offenders, atypical paraphilias, rape prevalence and types. The next lecture will cover causes and prevention of paraphilic disorders.
Marsha P. Johnson was a pioneering transgender activist known for participating in the 1969 Stonewall riots and co-founding the Street Transvestite Action Revolutionaries. In the 1970s and 1980s, Johnson advocated for transgender rights and provided support to transgender youth. Johnson's death in 1992 was initially ruled a suicide but was later reopened as a possible homicide.
This document provides an overview of genetic counseling. It defines genetics and genetic counseling, lists their objectives and components. It describes pedigree charting and the roles of the genetic counselor in providing information, estimating risk, and transmitting information to clients. Examples are given of different inheritance patterns and genetic disorders. The role of nurses in genetic counseling is outlined as receiving clients, obtaining family histories, providing support and information, encouraging questions, and maintaining privacy.
Violence against transgender individuals is severely underreported due to a lack of legal protections and data collection. Transgender people experience disproportionately high rates of physical and sexual assault, domestic violence, harassment, and murder. The psychological effects of this violence include suicidal ideation, PTSD, and depression. Transgender people of color and those engaging in sex work are especially vulnerable. Collecting data on violence is important to justify hate crime legislation but the lack of protections prevents data collection, creating a catch-22 situation.
Pitch
Resonance
Rate
Intensity
Quality
The document discusses gender dysphoria and transsexualism. It defines key terms like gender identity disorder and outlines the diagnostic criteria from the DSM-IV and ICD-10. It then discusses the different types of transsexuals, prevalence rates around the world, and proposed biological and psychological causes. The path to transition is described including counseling, real life experience, hormone therapy, and various surgical procedures. Assessment and treatment of voice in male-to-female transsexuals pre and post hormones is the focus of the presentation.
This document is a presentation by Dr. Steven Brown for the 4th Annual Transgender Medical Symposium in Fort Lauderdale, Florida. It discusses hormones and their effects on the body, the development of secondary sex characteristics, and considerations for providing hormone therapy to transgender patients. It covers topics like informed consent processes, evaluating patients for hormone therapy, monitoring treatment effects and side effects, and addressing psychosocial factors.
Unconsummated marriage: Causes , Assessment and ManagementMitra Molaeinezhad
The document discusses consummation and unconsummated marriage. It defines consummation as the first act of sexual intercourse between a married couple. Unconsummated marriage is defined as the inability to successfully engage in sexual intercourse at the beginning of marriage, especially in the first few nights. Common causes of unconsummated marriage include vaginismus, erectile dysfunction, lack of sex education, and relationship factors. The document then describes the development and validation of the Multidimensional Vaginal Penetration Disorder Questionnaire (MVPDQ), a self-report questionnaire for assessing women with lifelong vaginismus. The MVPDQ measures 9 dimensions of vaginal penetration disorder.
Eugenics, behavioural genetics and genetic disorderssandeshGM
This document discusses eugenics, behavioural genetics, and genetic disorders. It defines eugenics as practices that aim to improve the genetic quality of humans. It discusses the origins and types of eugenics such as positive and negative eugenics. The document also defines behavioural genetics as examining genetic and environmental influences on behavior through studies like twin studies. It discusses research findings on genetic influences on behavior. Finally, it defines and provides examples of different types of genetic disorders like single gene disorders, multifactorial disorders, and X-linked, Y-linked, and mitochondrial disorders.
Tim Redmond: Bb LectureParaphillas and paraphillic disordersTRedmond27
This document discusses paraphilias and paraphilic disorders. Paraphilias are atypical sexual interests that are not inherently disordered unless they cause distress or impairment. Paraphilic disorders involve paraphilic behaviors that consume excessive time and cause problems. Major paraphilic disorders include exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, and voyeurism. The document outlines these disorders and notes prevalence rates. It also discusses child molestation, diagnosing sex offenders, atypical paraphilias, rape prevalence and types. The next lecture will cover causes and prevention of paraphilic disorders.
Marsha P. Johnson was a pioneering transgender activist known for participating in the 1969 Stonewall riots and co-founding the Street Transvestite Action Revolutionaries. In the 1970s and 1980s, Johnson advocated for transgender rights and provided support to transgender youth. Johnson's death in 1992 was initially ruled a suicide but was later reopened as a possible homicide.
This document provides an overview of genetic counseling. It defines genetics and genetic counseling, lists their objectives and components. It describes pedigree charting and the roles of the genetic counselor in providing information, estimating risk, and transmitting information to clients. Examples are given of different inheritance patterns and genetic disorders. The role of nurses in genetic counseling is outlined as receiving clients, obtaining family histories, providing support and information, encouraging questions, and maintaining privacy.
This document summarizes key aspects of child development from a biological perspective. It discusses the interplay between nature and nurture, including evidence from twin, adoption and feral studies. Genetic foundations are explored, including chromosomes, DNA, genes and inheritance. Common genetic conditions are described. The document also notes reproductive challenges and choices such as diagnostic tests, infertility treatments and adoption. Key frameworks for understanding genetic influences on development are presented.
The document discusses a presentation by the Jean Nidetch Women's Center and P.A.A.V.E. on sexual assault, domestic violence, and alcohol-facilitated sexual assault. It defines key terms, provides statistics on sexual assault prevalence, and discusses issues like consent, effects on victims, and the role of alcohol in sexual assaults. The presentation aims to raise awareness of these issues and provide information on local resources for victims of interpersonal violence.
Frotteuristic disorder, or frotteurism, is a paraphilia characterized by unwanted rubbing against others in public spaces to achieve sexual arousal. Individuals must experience these urges for at least 6 months and feel clinically significant distress. Most perpetrators are males aged 15-25 years old, and treatment includes psychotherapy and behavioral therapy.
Is “Unconsummated Marriage” Still an Appropriate Term? A Snapshot of Reality CrimsonPublishers-PRM
The most shared definition of Unconsummated Marriage (UM) refers to "the failure to perform successful sexual intercourse at the beginning of the marriage. UM usually occurs in the first few nights of marriage and so it is frequently referred to as "honeymoon impotence” or "wedding night impotence”. In the Middle-Eastern (MES) and Western (WS) societies, sexuality follows different patterns in terms of meaning and rules. Moreover the evolution of societies all around the world created new contexts and kinds of relationship. This could hamper a correct taxonomy of such sexual dysfunction where a social variable seems crucial.
Aim: To analyze and review data on UM all around the world, to understand if in different societies it refers to the same situation.
Method: A review of published literature on UM from 1970 to date, was conducted.
Results: Substantial difference emerged from MES to WS. In MES, sexuality is allowable only in marriage, while in WS sexuality and relationship are not strongly linked. This could suggest that the term "marriage” is unable to cover the phenomenon in such different countries. Moreover, the average time before the consultation, causal attribution and prevalence are very different in Western and Middle Eastern countries.
Conclusion: We found that the term "first attempts dysfunction” could be better used to describe male, female or both difficulties related to ignorance about sexuality or state/performance anxiety. On the other hand over the individual category of sexual dysfunctions, we suggest a new term as "Unconsummated relationship”, where individual difficulties toward sexuality are involved creating a couple's dysfunction.
The diagnosis of a genetic condition can profoundly impact a family in several ways. Families often experience grief, guilt, depression, and fear after learning of their child's diagnosis. They may also face social stigma and difficulties selecting partners or maintaining relationships. Additionally, genetic conditions can cause psychological, physical, cognitive, and economic burdens as families struggle with care costs and lost income. However, receiving conclusive test results that rule out a suspected genetic disorder can provide families with relief.
The document discusses workshops and advocacy provided by the Jean Nidetch Women's Center and P.A.A.V.E. on topics related to violence prevention and breast cancer awareness. It provides definitions and statistics on sexual assault, domestic violence, and alcohol-facilitated sexual assault. It discusses issues of consent, the effects of intoxication on one's ability to consent, and the long-term impacts victims may experience. Resources for victims of interpersonal violence are listed.
Lawsuit information over the birth defect side effects alleged caused by prenatal Zofran use by mothers and the latest litigation information. Top attorneys are investigating fetal injury claims, and this brief presentation lays out the most important points of the case.
This document discusses the importance and applications of genetic counseling in modern obstetrics. It outlines several key points:
1. Genetic counseling should be provided to all pregnant women to help them understand risks of various genetic disorders and recurrence rates to help make informed decisions.
2. Common indications for genetic counseling include advanced maternal age, abnormal screening tests, family history of genetic disorders, and previous children with genetic conditions.
3. Genetic counseling helps evaluate risks of conditions like chromosomal abnormalities, birth defects, genetic diseases based on family history and test results. It allows discussing options like prenatal diagnosis.
4. Emerging tools like non-invasive prenatal testing are improving detection rates of conditions like Down
Unmasking the Gender Factor in Gay Men's Health: Sex Now Survey 2010CBRC
This document discusses conducting a survey to better understand the determinants of health disparities among gay men. It notes that factors beyond sexual orientation, like gender, marginalization, and social stress, may help explain higher rates of issues like depression, HIV, and STIs in gay populations. The survey aims to examine how intersecting systems of oppression and privilege relate to these health outcomes. It also seeks to understand masculinities and gender norms, and their relationship to transmission risk and health indicators. The goal is to identify specific social inequities that contribute to health disparities in gay communities and help inform public health interventions.
This document defines human trafficking and discusses the role of healthcare providers. It begins by defining trafficking as involving force, fraud or coercion for the purpose of exploitation. Trafficking can involve labor or sex. Healthcare providers may encounter trafficking victims since around 28-50% of victims will see a provider while still captive. The document recommends screening patients privately for signs of trafficking such as untreated infections, injuries or confusion/fear. The Affordable Care Act supports screening and treatment that can help identify and support victims.
Changing the Detrimental Narrative that Underlies Armenia's Legal Response to...Gabriel Armas-Cardona
Presentation on sex selective abortion (a.k.a. pre-natal sex selection) for the 2017 Conference on Empowerment of Girls and Women in Armenia.
The purpose of this presentation is to change the popular narrative. The issue of sex-selective abortion has been used as a powerful tool to promote paternalistic policies that harm women in the guise of protecting them. This presentation aims to present those harms and propose an alternative narrative that respects women's reproductive rights.
Charts from UNFPA publication Prevalence of and Reasons for Sex-selective Abortion in Armenia (2012).
This document discusses genetics and genetic disorders. It begins by defining genetics as the study of genes, genetic variation, and heredity. It then provides information on several genetic disorders including Huntington's disease, Down syndrome, cystic fibrosis, and Barth syndrome. For Huntington's disease specifically, it details the signs and symptoms, diagnosis through genetic testing, management through various treatments, and differential diagnosis compared to other conditions. It also provides details on the causes and diagnosis of Down syndrome.
The document discusses the stages of human development from fertilization through birth. It describes how a zygote is formed through the joining of an egg and sperm, and the early embryonic development of major organs over the first 8 weeks. The fetal stage from 8 weeks until birth is a period of rapid growth and differentiation, with the fetus increasing 20 times in length and developing functioning organs. The document also notes some potential problems in pregnancy like infertility, miscarriage, abortion, and threats to development from environmental factors and a mother's health behaviors during pregnancy.
This document discusses sexual abuse of people with intellectual disabilities. It defines intellectual disability as significant limitations in both intellectual functioning and adaptive behavior. People with intellectual disabilities are at higher risk of sexual abuse due to factors like lack of communication, education on appropriate touching, and caregivers not receiving proper background checks. Symptoms of sexual abuse can include physical injuries as well as long-term psychological and behavioral effects like depression, anxiety, and sexually inappropriate behaviors. The document also notes that children with intellectual disabilities are four times more likely to experience sexual abuse than others.
The document summarizes the Tokyo Declaration of 1975, which outlines international guidelines for physicians concerning torture and cruel treatment. It states that doctors should refuse to enable or participate in torture. Prisoners who refuse food against medical advice should not be force-fed. The declaration aims to prevent any misuse of medical knowledge that could harm human life or dignity. It defines torture and lists eight principles physicians must follow, such as maintaining confidentiality and not using medical data to facilitate interrogation.
This document discusses non-accidental trauma (NAT) or physical abuse in pediatric patients. It notes that certain fractures have a high association with NAT, including femur fractures in children under 1 year old and humeral shaft fractures in children under 3 years old. While fracture type alone is not specific, multiple fractures in different stages of healing is highly suggestive of NAT. A complete evaluation for suspected NAT includes a thorough history, physical exam, skeletal survey and involvement of child protection services if abuse is suspected. Proper documentation of findings is important for legal purposes if abuse is confirmed.
The document discusses different types of burn injuries including thermal, chemical, smoke inhalation, and electrical burns. It describes the pathophysiology and clinical manifestations in the emergent and acute phases after a burn. Key aspects are fluid and electrolyte shifts leading to shock in the emergent phase and wound healing through debridement, grafting, and rehabilitation in the acute phase. Complications include infection and contractures.
The document discusses the analysis of wounds from a forensic perspective. It describes how a pathologist can determine details about wounds like type, dimensions, and location. It also discusses analyzing specifics of different wound types like bruises, abrasions, incised wounds, and stab wounds. Details like shape, size, depth, and other characteristics can provide information about the weapon and force used. Analysis of wounds is important forensic evidence that can provide details about crimes and injuries.
Social Media 101 - An Introduction to Social MediaLisa Myers
This document provides an overview of social media and how to use it effectively for business purposes. It discusses that social media is about people, not technology. It emphasizes listening first, then engaging to build long-term relationships through various types of content creation and sharing. When using social media like blogs, Twitter, viral campaigns or other channels, the key is to focus on relevant content for your target audience and to actively spread and monitor engagement. Measurement and ongoing analysis are also important aspects of an effective social media strategy.
The document explains how to extract fifth roots mentally in 3 steps:
1. Split the number into the left and right portions based on the comma. Determine the fifth root of the left portion to get the tens place value.
2. The ones place value is the same as the rightmost digit.
3. Combine the tens and ones place values to get the full fifth root.
Examples are provided to illustrate the process.
This document summarizes key aspects of child development from a biological perspective. It discusses the interplay between nature and nurture, including evidence from twin, adoption and feral studies. Genetic foundations are explored, including chromosomes, DNA, genes and inheritance. Common genetic conditions are described. The document also notes reproductive challenges and choices such as diagnostic tests, infertility treatments and adoption. Key frameworks for understanding genetic influences on development are presented.
The document discusses a presentation by the Jean Nidetch Women's Center and P.A.A.V.E. on sexual assault, domestic violence, and alcohol-facilitated sexual assault. It defines key terms, provides statistics on sexual assault prevalence, and discusses issues like consent, effects on victims, and the role of alcohol in sexual assaults. The presentation aims to raise awareness of these issues and provide information on local resources for victims of interpersonal violence.
Frotteuristic disorder, or frotteurism, is a paraphilia characterized by unwanted rubbing against others in public spaces to achieve sexual arousal. Individuals must experience these urges for at least 6 months and feel clinically significant distress. Most perpetrators are males aged 15-25 years old, and treatment includes psychotherapy and behavioral therapy.
Is “Unconsummated Marriage” Still an Appropriate Term? A Snapshot of Reality CrimsonPublishers-PRM
The most shared definition of Unconsummated Marriage (UM) refers to "the failure to perform successful sexual intercourse at the beginning of the marriage. UM usually occurs in the first few nights of marriage and so it is frequently referred to as "honeymoon impotence” or "wedding night impotence”. In the Middle-Eastern (MES) and Western (WS) societies, sexuality follows different patterns in terms of meaning and rules. Moreover the evolution of societies all around the world created new contexts and kinds of relationship. This could hamper a correct taxonomy of such sexual dysfunction where a social variable seems crucial.
Aim: To analyze and review data on UM all around the world, to understand if in different societies it refers to the same situation.
Method: A review of published literature on UM from 1970 to date, was conducted.
Results: Substantial difference emerged from MES to WS. In MES, sexuality is allowable only in marriage, while in WS sexuality and relationship are not strongly linked. This could suggest that the term "marriage” is unable to cover the phenomenon in such different countries. Moreover, the average time before the consultation, causal attribution and prevalence are very different in Western and Middle Eastern countries.
Conclusion: We found that the term "first attempts dysfunction” could be better used to describe male, female or both difficulties related to ignorance about sexuality or state/performance anxiety. On the other hand over the individual category of sexual dysfunctions, we suggest a new term as "Unconsummated relationship”, where individual difficulties toward sexuality are involved creating a couple's dysfunction.
The diagnosis of a genetic condition can profoundly impact a family in several ways. Families often experience grief, guilt, depression, and fear after learning of their child's diagnosis. They may also face social stigma and difficulties selecting partners or maintaining relationships. Additionally, genetic conditions can cause psychological, physical, cognitive, and economic burdens as families struggle with care costs and lost income. However, receiving conclusive test results that rule out a suspected genetic disorder can provide families with relief.
The document discusses workshops and advocacy provided by the Jean Nidetch Women's Center and P.A.A.V.E. on topics related to violence prevention and breast cancer awareness. It provides definitions and statistics on sexual assault, domestic violence, and alcohol-facilitated sexual assault. It discusses issues of consent, the effects of intoxication on one's ability to consent, and the long-term impacts victims may experience. Resources for victims of interpersonal violence are listed.
Lawsuit information over the birth defect side effects alleged caused by prenatal Zofran use by mothers and the latest litigation information. Top attorneys are investigating fetal injury claims, and this brief presentation lays out the most important points of the case.
This document discusses the importance and applications of genetic counseling in modern obstetrics. It outlines several key points:
1. Genetic counseling should be provided to all pregnant women to help them understand risks of various genetic disorders and recurrence rates to help make informed decisions.
2. Common indications for genetic counseling include advanced maternal age, abnormal screening tests, family history of genetic disorders, and previous children with genetic conditions.
3. Genetic counseling helps evaluate risks of conditions like chromosomal abnormalities, birth defects, genetic diseases based on family history and test results. It allows discussing options like prenatal diagnosis.
4. Emerging tools like non-invasive prenatal testing are improving detection rates of conditions like Down
Unmasking the Gender Factor in Gay Men's Health: Sex Now Survey 2010CBRC
This document discusses conducting a survey to better understand the determinants of health disparities among gay men. It notes that factors beyond sexual orientation, like gender, marginalization, and social stress, may help explain higher rates of issues like depression, HIV, and STIs in gay populations. The survey aims to examine how intersecting systems of oppression and privilege relate to these health outcomes. It also seeks to understand masculinities and gender norms, and their relationship to transmission risk and health indicators. The goal is to identify specific social inequities that contribute to health disparities in gay communities and help inform public health interventions.
This document defines human trafficking and discusses the role of healthcare providers. It begins by defining trafficking as involving force, fraud or coercion for the purpose of exploitation. Trafficking can involve labor or sex. Healthcare providers may encounter trafficking victims since around 28-50% of victims will see a provider while still captive. The document recommends screening patients privately for signs of trafficking such as untreated infections, injuries or confusion/fear. The Affordable Care Act supports screening and treatment that can help identify and support victims.
Changing the Detrimental Narrative that Underlies Armenia's Legal Response to...Gabriel Armas-Cardona
Presentation on sex selective abortion (a.k.a. pre-natal sex selection) for the 2017 Conference on Empowerment of Girls and Women in Armenia.
The purpose of this presentation is to change the popular narrative. The issue of sex-selective abortion has been used as a powerful tool to promote paternalistic policies that harm women in the guise of protecting them. This presentation aims to present those harms and propose an alternative narrative that respects women's reproductive rights.
Charts from UNFPA publication Prevalence of and Reasons for Sex-selective Abortion in Armenia (2012).
This document discusses genetics and genetic disorders. It begins by defining genetics as the study of genes, genetic variation, and heredity. It then provides information on several genetic disorders including Huntington's disease, Down syndrome, cystic fibrosis, and Barth syndrome. For Huntington's disease specifically, it details the signs and symptoms, diagnosis through genetic testing, management through various treatments, and differential diagnosis compared to other conditions. It also provides details on the causes and diagnosis of Down syndrome.
The document discusses the stages of human development from fertilization through birth. It describes how a zygote is formed through the joining of an egg and sperm, and the early embryonic development of major organs over the first 8 weeks. The fetal stage from 8 weeks until birth is a period of rapid growth and differentiation, with the fetus increasing 20 times in length and developing functioning organs. The document also notes some potential problems in pregnancy like infertility, miscarriage, abortion, and threats to development from environmental factors and a mother's health behaviors during pregnancy.
This document discusses sexual abuse of people with intellectual disabilities. It defines intellectual disability as significant limitations in both intellectual functioning and adaptive behavior. People with intellectual disabilities are at higher risk of sexual abuse due to factors like lack of communication, education on appropriate touching, and caregivers not receiving proper background checks. Symptoms of sexual abuse can include physical injuries as well as long-term psychological and behavioral effects like depression, anxiety, and sexually inappropriate behaviors. The document also notes that children with intellectual disabilities are four times more likely to experience sexual abuse than others.
The document summarizes the Tokyo Declaration of 1975, which outlines international guidelines for physicians concerning torture and cruel treatment. It states that doctors should refuse to enable or participate in torture. Prisoners who refuse food against medical advice should not be force-fed. The declaration aims to prevent any misuse of medical knowledge that could harm human life or dignity. It defines torture and lists eight principles physicians must follow, such as maintaining confidentiality and not using medical data to facilitate interrogation.
This document discusses non-accidental trauma (NAT) or physical abuse in pediatric patients. It notes that certain fractures have a high association with NAT, including femur fractures in children under 1 year old and humeral shaft fractures in children under 3 years old. While fracture type alone is not specific, multiple fractures in different stages of healing is highly suggestive of NAT. A complete evaluation for suspected NAT includes a thorough history, physical exam, skeletal survey and involvement of child protection services if abuse is suspected. Proper documentation of findings is important for legal purposes if abuse is confirmed.
The document discusses different types of burn injuries including thermal, chemical, smoke inhalation, and electrical burns. It describes the pathophysiology and clinical manifestations in the emergent and acute phases after a burn. Key aspects are fluid and electrolyte shifts leading to shock in the emergent phase and wound healing through debridement, grafting, and rehabilitation in the acute phase. Complications include infection and contractures.
The document discusses the analysis of wounds from a forensic perspective. It describes how a pathologist can determine details about wounds like type, dimensions, and location. It also discusses analyzing specifics of different wound types like bruises, abrasions, incised wounds, and stab wounds. Details like shape, size, depth, and other characteristics can provide information about the weapon and force used. Analysis of wounds is important forensic evidence that can provide details about crimes and injuries.
Social Media 101 - An Introduction to Social MediaLisa Myers
This document provides an overview of social media and how to use it effectively for business purposes. It discusses that social media is about people, not technology. It emphasizes listening first, then engaging to build long-term relationships through various types of content creation and sharing. When using social media like blogs, Twitter, viral campaigns or other channels, the key is to focus on relevant content for your target audience and to actively spread and monitor engagement. Measurement and ongoing analysis are also important aspects of an effective social media strategy.
The document explains how to extract fifth roots mentally in 3 steps:
1. Split the number into the left and right portions based on the comma. Determine the fifth root of the left portion to get the tens place value.
2. The ones place value is the same as the rightmost digit.
3. Combine the tens and ones place values to get the full fifth root.
Examples are provided to illustrate the process.
The document defines and provides examples of different types of arguments including deductive, inductive, and everyday arguments. It explains that an argument consists of one or more reasons leading to a conclusion and discusses indicator words that can help identify the conclusion. Examples are given of debates, court cases, academic inquiries, and negotiations to illustrate different contexts where arguments are used.
El documento habla brevemente sobre coches fantásticos en la televisión, mencionando el primer coche fantástico como un héroe televisivo y el nuevo Mustang GT superando al antiguo, preguntando cuál será el próximo coche fantástico estrella y si será el mencionado al final.
On November 10, 2011, I co-keynoted "The Connected Network" at the Arts Marketing Association's Digital Marketing Day, sharing a number of social media case studies from my tenure as Marketing Director at The New York Public Library.
Este documento describe las normas de seguridad en el taller de tecnología. Estas normas tienen como objetivo prevenir accidentes y evitar lesiones. Entre las normas se encuentran trabajar de forma ordenada y silenciosa, no usar herramientas sin saber cómo funcionan, protegerse adecuadamente y reciclar materiales. También incluyen moverse con cuidado en el taller y limpiarlo antes de salir.
Solving Business Problems for Our Clients, Each Step of the WayKevin Hoffman
This was a presentation that Happy Cog East made to PhillyCHI on Wednesday, September 23 2009. It was a series of 10 minute talks regarding each step of a project process at our boutique web design firm. http://www.happycog.com http://phillychi.acm.org
We present a new method and the associated workflow for estimating market shares of future products based exclusively on pre-introduction data, such as syndicated studies conducted prior to product launch. Our approach provides a highly practical, fast and economical alternative to conducting new primary research.
Blogs can be dangerous if personal information is shared, as they are a public space not meant for private details. However, blogs can be used safely by not including personal information, staying polite, deleting inappropriate comments, and ensuring all posts and pages are appropriate for public viewing.
The document discusses human performance technology and surveys conducted with performance improvement professionals. It can be summarized as:
1) A survey was conducted with 30 participants from the Michigan International Society for Performance Improvement to understand emerging issues and priorities in the field.
2) Both emerging and experienced professionals saw making strong business cases, collecting good data to make decisions, and leveraging web technologies as important.
3) While emerging and experienced professionals may agree, the future direction depends most on emerging talents who will influence the field. Understanding where it is headed and which new areas to explore is important.
The document discusses the history and evolution of downtown Ferndale from the 1920s to present day. It summarizes the decline in the 1970s-1990s and subsequent revitalization efforts beginning in 2001 through programs like the National Trust Main Street Center. Statistics show $57.5 million reinvested since 2000, reduced vacancy rates, and job and property value growth. The document outlines the DDA's role and impact through business assistance, physical improvements, promotions, and community building. It proposes amendments to the development plan including projects around development, streetscapes, and traffic/parking to continue revitalizing downtown Ferndale.
Nestholma is a venture accelerator that helps startups and large corporations collaborate. It uses a proven accelerator model to invest in startups and provide hands-on support. The program combines mentorship, workshops, and networking events to help startups validate ideas, develop products, and access potential partners and customers from partner corporations. It aims to create scalable new businesses by leveraging the startups' agility and the corporations' resources and industry expertise.
Linkages between Child Abuse and Asthma - Presentation to WVAC - May 14, 2013Jim McKay
This document discusses the link between childhood trauma, including abuse and neglect, and the development of asthma. It summarizes several studies that found the risk of asthma is doubled in children who experienced physical or sexual abuse. The studies also linked experiences of violence and stress in childhood to epigenetic changes and higher rates of adult-onset asthma. The document emphasizes the importance of screening children with asthma for abuse and considering abuse in children with asthma. It provides information on warning signs of abuse and outlines mandated reporting responsibilities in West Virginia.
This document discusses child abuse and the role of EMS providers. It begins with definitions of child abuse and outlines the four main categories: neglect, physical abuse, sexual abuse, and emotional abuse. Statistics on child abuse in the US, Idaho, Oregon, and Washington are provided. Risk factors for victims and perpetrators are described. Common injuries associated with different types of abuse are illustrated and explained. The document stresses that all EMS providers are mandatory reporters of suspected child abuse in their states and outlines reporting procedures and protections for reporters. The goal is to help EMS providers recognize and appropriately respond to suspected abuse.
This document provides an overview of child abuse and neglect. It defines different types of child abuse like physical abuse, sexual abuse, emotional abuse, and neglect. It also discusses factors contributing to child abuse, statistics on abuse, clinical assessment of abuse, signs of abuse, and legal requirements for reporting suspected abuse. The goal is to educate dental professionals on properly identifying, documenting, treating, and reporting suspected cases of child abuse.
This document discusses child abuse from an EMS perspective. It begins by outlining the four major categories of child abuse: neglect, physical abuse, sexual abuse, and emotional abuse. It then provides statistics on child abuse in the US and Idaho. The document discusses signs of abuse, characteristics of victims and perpetrators, specific types of injuries to watch for, cultural practices that can mimic abuse, and requirements for reporting suspected abuse.
This document discusses the need for more research on male offenders who seriously physically abuse or kill children. It notes that while both men and women commit such offenses, the majority are committed by men. More research has examined female rather than male offenders. The document calls for identifying the psychological profiles and risk factors of different types of male offenders, such as biological fathers who systematically cause harm versus unrelated adults in the home. Understanding these offender types could help professionals investigating such cases, which often involve uncooperative parents providing contradicting explanations for a child's injuries.
2015 Eastern OR Conference Child MaltreatmentRobert Cole
This document provides information from a presentation on child abuse for EMS providers. It defines the different types of child abuse, including physical, sexual, emotional and neglect. It discusses statistics on child abuse in the US and several Western states. It provides details on signs and symptoms of different types of physical abuse and instructions for EMS providers on recognizing, documenting and reporting suspected child abuse. The presentation emphasizes that all EMS providers are mandatory reporters and have a legal duty to report suspected abuse.
This document provides an overview of child abuse and neglect. It defines different types of abuse, including physical abuse, sexual abuse, physical neglect, and emotional abuse/neglect. It discusses characteristics of abusers and abused children. The document presents statistics on the prevalence of different types of abuse from studies in the US and India. It also outlines signs, symptoms and evidence of different types of physical abuse like fractures, shaken baby syndrome, and battered baby syndrome. The conclusion discusses several studies that have examined injuries in abused children, with many finding injuries to the head and face.
This document discusses child abuse as a global problem that occurs in various forms and is rooted in cultural, economic, and social practices. It defines different types of child abuse, including physical, sexual, emotional abuse and neglect. Risk factors for child abuse are outlined. The document also discusses the health consequences of child abuse, indicators that family doctors can identify, and common features of successful child abuse prevention programs.
The document discusses police duties and responsibilities during the COVID-19 pandemic. It notes that police must perform their regular duties while also ensuring their own safety and enforcing public health measures. Specific responsibilities mentioned include breaking up gatherings, using media to inform the public, and distributing rations while maintaining social distancing. The document provides guidance on how police can effectively communicate with the public and address crimes during the pandemic.
PRINCIPLES AND PRACTICE OFChild and AdolescentForensic lvi.docxstilliegeorgiana
PRINCIPLES AND PRACTICE OF
Child and Adolescent
Forensic lvi ntal Health
Edited by
Elissa R Benedek, M.D.
Peter Ash, M.D.
Charles L. Scott, M.D.
Washington, DC
London, England
Chapter ] 6
Reliability and Suggestibility
of Children's Statements
From Science to Practice
Sarah Kulkofsky, Ph.D.
Kamala London, Ph.D.
n spring 1985, a 4-year-old student at the Wee Cale
Nursery School was having his temperature taken
with a rectal thermometm when he commented,
"That's what my teacher does to me at nap time at
school." The child's comment led to an mvestlgation
of Kelly Michaels, a young teacher at the nursery
school All children at the nursery school wele lepeat-
edly questioned about potential abuse by their parents
(who were informed about sexual abuse suspmlons in
the school), by investigators, and in individual and
gtoup therapy sessions. The chfldlen eventually made
a number of horrendous and sometimes bizalre alle-
gations, including that they were raped with spoons,
knives, and Lego blocks; that Kelly Michaels fmced
them to lick peanut butter off her naked body; that she
forced them to eat feces and drink urine; and that she
forced them to play games in the nude. Despite the
fact that there was no physmal evidence m the case
and that Kelly Michaels passed a polygraph test, she
was indicted on 299 charges and, after an 11-month
trial, was sentenced to 47 years m prison. She served 5
years m prison before her case was overturned on ap-
peal, largely as a result of the unreliability of the chil-
dren's testimony, which was elicited in a highly sug-
gestive manner.
In the United States, more than 4 million cases of
child maltreatment ale investigated each year (Pipe et
al. 2007) Histormally, children rarely provided uncor-
roborated testimony in legal settings. However, be-
cause of society's greater recognition of the prevalence
and problems associated with child maltreatment,
partmulmly with child sexual abuse (CSA), several ju-
dicial leforms were enacted starting in the 1970s and
1980s that brought more children at younger ages into
the courts. It is estimated that more than 100,000
childlen m the United States testify annually m crim-
inal and civil proceedings (Cecl and Bruck 1993).
As children began flooding the legal system, con-
cerns were raised about their ability to provide com-
plete and accmate accounts about past events. Many
of these concmns were raised in lesponse to some
high-profile sexual abuse cases, such as those revolv-
ing Kelly Michaels, as well as similar cases involving
Gerald and Cheryl Amlrault and the McMartm Pre-
school. These cases were characterized by bizarre alle-
gations of abuse made by multiple children as well as
by aggressive and overzealous interviewing tech-
niques. When many of these cases started to come to
light, very little research existed regarding the reliabil-
ity of children's statements or appropriate interview-
217
21 8 Principles and Practice of Child and Adolesc ...
PRINCIPLES AND PRACTICE OFChild and AdolescentForensic lvi.docxkeilenettie
PRINCIPLES AND PRACTICE OF
Child and Adolescent
Forensic lvi ntal Health
Edited by
Elissa R Benedek, M.D.
Peter Ash, M.D.
Charles L. Scott, M.D.
Washington, DC
London, England
Chapter ] 6
Reliability and Suggestibility
of Children's Statements
From Science to Practice
Sarah Kulkofsky, Ph.D.
Kamala London, Ph.D.
n spring 1985, a 4-year-old student at the Wee Cale
Nursery School was having his temperature taken
with a rectal thermometm when he commented,
"That's what my teacher does to me at nap time at
school." The child's comment led to an mvestlgation
of Kelly Michaels, a young teacher at the nursery
school All children at the nursery school wele lepeat-
edly questioned about potential abuse by their parents
(who were informed about sexual abuse suspmlons in
the school), by investigators, and in individual and
gtoup therapy sessions. The chfldlen eventually made
a number of horrendous and sometimes bizalre alle-
gations, including that they were raped with spoons,
knives, and Lego blocks; that Kelly Michaels fmced
them to lick peanut butter off her naked body; that she
forced them to eat feces and drink urine; and that she
forced them to play games in the nude. Despite the
fact that there was no physmal evidence m the case
and that Kelly Michaels passed a polygraph test, she
was indicted on 299 charges and, after an 11-month
trial, was sentenced to 47 years m prison. She served 5
years m prison before her case was overturned on ap-
peal, largely as a result of the unreliability of the chil-
dren's testimony, which was elicited in a highly sug-
gestive manner.
In the United States, more than 4 million cases of
child maltreatment ale investigated each year (Pipe et
al. 2007) Histormally, children rarely provided uncor-
roborated testimony in legal settings. However, be-
cause of society's greater recognition of the prevalence
and problems associated with child maltreatment,
partmulmly with child sexual abuse (CSA), several ju-
dicial leforms were enacted starting in the 1970s and
1980s that brought more children at younger ages into
the courts. It is estimated that more than 100,000
childlen m the United States testify annually m crim-
inal and civil proceedings (Cecl and Bruck 1993).
As children began flooding the legal system, con-
cerns were raised about their ability to provide com-
plete and accmate accounts about past events. Many
of these concmns were raised in lesponse to some
high-profile sexual abuse cases, such as those revolv-
ing Kelly Michaels, as well as similar cases involving
Gerald and Cheryl Amlrault and the McMartm Pre-
school. These cases were characterized by bizarre alle-
gations of abuse made by multiple children as well as
by aggressive and overzealous interviewing tech-
niques. When many of these cases started to come to
light, very little research existed regarding the reliabil-
ity of children's statements or appropriate interview-
217
21 8 Principles and Practice of Child and Adolesc ...
This document provides an overview of child abuse. It begins with definitions of physical, sexual, and emotional abuse as well as neglect. Statistics on child abuse victims in the US from 2008-2012 are presented. Younger children, especially infants, are most at risk of abuse. The effects of different types of abuse are discussed, including physical and psychological impacts. Prevention programs and challenges in identifying abuse are also examined.
Child abuse is the physical, sexual or emotional maltreatment or neglect of a child or children.[1] In the United States, the Centers for Disease Control and Prevention (CDC) and the Department for Children And Families (DCF) define child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.[2] Child abuse can occur in a child's home, or in the organizations, schools or communities the child interacts with. There are four major categories of child abuse: neglect, physical abuse, psychological or emotional abuse, and sexual abuse.
In Western countries, preventing child abuse is considered a high priority, and detailed laws and policies exist to address this issue. Different jurisdictions have developed their own definitions of what constitutes child abuse for the purposes of removing a child from his/her family and/or prosecuting a criminal charge. According to the Journal of Child Abuse and Neglect, child abuse is "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, an act or failure to act which presents an imminent risk of serious harm".[3]
However, Douglas J. Besharov, the first Director of the U.S. Center on Child Abuse and Neglect, states "the existing laws are often vague and overly broad"[4] and there is a "lack of consensus among professionals and Child Protective Services (CPS) personnel about what the terms abuse and neglect mean".[5] Susan Orr, former head of the United States Children's Bureau U.S. Department of Health and Services Administration for Children and Families, 2001–2007, states that "much that is now defined as child abuse and neglect does not merit governmental interference".
This document discusses child sexual abuse, including definitions, prevalence, dynamics, impacts on children, and common myths. Some key points:
- Child sexual abuse includes any sexual act involving a child. Most abusers are known to the child.
- Rates of child sexual abuse are high, with estimates that 1 in 4 girls and 1 in 6-7 boys will experience abuse by age 18. However, many cases go unreported.
- Children often experience secrecy, helplessness, delayed disclosure, and may recant or reaffirm allegations later due to various pressures. Their responses depend highly on individual circumstances.
In Oklahoma, a child is reported abused or neglected every ten seconds. In 2008, over 11,000 children were confirmed victims of abuse or neglect in the state. Neglect, which includes failure to provide basic needs, is the highest form of child maltreatment in Oklahoma. Substance abuse by caregivers is a major contributing factor to neglect cases. Child abuse and neglect can have long-term negative health impacts, with survivors at greater risk for problems like low academic achievement, drug use, and criminal behavior.
In Oklahoma, a child is reported abused or neglected every ten seconds. In 2008, over 11,000 children were confirmed victims of abuse or neglect in the state. Neglect, which includes failure to provide basic needs, is the highest form of child maltreatment in Oklahoma. Substance abuse by caregivers is a major contributing factor to neglect cases. Child abuse and neglect can have long-term negative health impacts, with survivors at greater risk for problems like low academic achievement, drug use, and criminal behavior.
Most of the people are not knowing about child abuse, some people are knowing but not much about laws in India about child abuse are still unknown. So here I am trying to share some information about child abuse with some statistical info and laws in India for child abuse.
The document discusses incest and moral degradation. It defines incest as sexual relations between nuclear family members and moral degradation as misconduct that is considered bad or wrong. Incest is categorized into consanguinal, affinial, and quasi-relative types. The effects of incest can include psychological and behavioral issues for the victim as well as genetic defects in children born from incestuous relationships. Laws around incest vary globally, with some countries prohibiting it and others not. The document analyzes whether incest is considered immoral and a crime based on religious, cultural, and legal perspectives in different places.
How to Manage Reception Report in Odoo 17Celine George
A business may deal with both sales and purchases occasionally. They buy things from vendors and then sell them to their customers. Such dealings can be confusing at times. Because multiple clients may inquire about the same product at the same time, after purchasing those products, customers must be assigned to them. Odoo has a tool called Reception Report that can be used to complete this assignment. By enabling this, a reception report comes automatically after confirming a receipt, from which we can assign products to orders.
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...TechSoup
Whether you're new to SEO or looking to refine your existing strategies, this webinar will provide you with actionable insights and practical tips to elevate your nonprofit's online presence.
Temple of Asclepius in Thrace. Excavation resultsKrassimira Luka
The temple and the sanctuary around were dedicated to Asklepios Zmidrenus. This name has been known since 1875 when an inscription dedicated to him was discovered in Rome. The inscription is dated in 227 AD and was left by soldiers originating from the city of Philippopolis (modern Plovdiv).
65. Father of Gang-Tattooed Child Arrested Boy was restrained during painful process: police By JESSICA GREENE Updated 9:58 AM PDT, Fri, May 15, 2009 Related Topics: Fresno | Crime | Gan g Violenc e 16 Commen ts Post a Comment PRINT EMAIL Fresno PD Fr esno police re leased this picture of the boy's tattoed hip area. The law finally caught up with an alleged gang member who police say held down his 7-year-old son while a fellow gang-banger tattooed the boy's belly with the group's insignia. Enlarge Photo Police say 26-year-old Enrique Gonzales held down his 7-year-old son while another gang member tattoed the group's insignia on his belly. Fresno cops arrested Enrique Gonzalez , 26, at hotel in the S ierra foothills and booked him for investig ation of mayhem, child abuse, false imprisonment, battery, participating in a criminal street gang and committing a crime for the benefit of a gang, Police Chief Jerry Dyer said. Gonzales, a member of Fresno's largest street gang, the Bulldogs, held down his son while another gang member painfully marked the boy's belly with the group's insignia -- a paw print, police said. The boy's mother reported the incident in April, police said. When police searched the hotel room where they arrested Gonzales, they found a picture of him and the boy, along with another child who also had gang graffiti on their bodies, the Fresno Bee reported . Related Stories • 7-Year-Old Held Down for Gang Tatt: Police The alleged tattooer, 20-year-old Travis Gorman , was arrested not long after the incident and charged with six felonies. H e pleaded not guilty last month and is being held under a $700,000 bond. Famil y members tol d police the boy is traumatized by the incident. Copyright Associated Press / NBC Bay Area
74. Time to Burn by Water Temperature in Adults from Moritz AR and Henriques FC. Studies of thermal injury. Am J Pathol. 1947; 23:695-720 Degrees Centigrade Degrees Fahrenheit Time (Seconds) 65 149 1 60 140 2 55 131 12 50 122 120 45 113 10800
Put a photo here as a jumping off point for talking about how ED physicians know what to look for, but fail to do so, and talk about how it is a change in approach and behavior that is really necessary--not so much education regarding what to look for.
Definition is from the Federal Child Abuse Prevention and Treatment Act (CAPTA), (42 U.S.C.A. 5106g), as amended by the Keeping Children and Families Safe Act of 2003.
AAP policy states 152,000 in 2004, based on U.S. Dept of HHS, Administration on Child, Youth, and Families. “Child Maltreatment 2004” Washington, DC, US Gov Printing Office; 2006. Check out this discrepancy. Question: Are the percentages by race related to how those groups are represented in the general population, or is there a difference by race in the actual incidence of abuse?
Statistics are broken down by relationship to the child, female vs. male, and age. Note that only about 14% of abuse is committed by non-relatives. This is related to many factors, including the fact that 64% of what constitutes child abuse is neglect, and that parents and other relatives are simply the ones caring for the majority of children. Of those maltreating children, 7% committed sexual abuse, while 60% committed neglect. Of the perpetrators who were parents, 91.5% were the biological parent of the victim. Note the difference in demographics between abusers and killers.
So is there a definition of Fatality secondary to abuse? NCANDS is the National Child Abuse and Neglect Data System, a federal government agency. 2006 is the most recent year for which the statistics are published. Incidence is undoubtedly higher--number of SIDS deaths that may be related to occult abuse; proximate cause reported as something else but secondary to acute or chronic abuse.
So what age do you have to be to die of child abuse? Need to find the bimodal peaks for ages Young children are the most vulnerable because of their dependency, small size, and inability to defend themselves. They are most at risk during episodes of colic and during toilet training. Adolescents are vulnerable for reasons obvious to any parent of an adolescent.
1) As we’ve already seen, younger children are the most likely to be abused. While there is a peak in the adolescent years, these children are more able to defend themselves, and more able to articulate a history. 2) Children with emotional problems are obviously more challenging--though it is difficult to state which comes first, the emotional problems or the abuse. 3) Children with health problems are also more challenging--for example, a child with chronic respiratory issues may have feeding problems, which leads to more fussiness, which is more frustrating for the caregiver. 4) Children with developmental delays can be exceedingly frustrating--think about how difficult it is to deal with a toddler, then imagine that the toddler phase never ends.
1) Younger age brings with it less life experience--caregivers with unrealistic expectations of child development are more likely to abuse. 2) Children in homes with annual incomes of less than 15K per year have 3X the number of fatalities, 7X the number of serious inflicted injuries, and 5X the number of moderate inflicted injuries compared with those in homes with income >15K/year (AAP evaluation guidelines #12) 3) There is no single profile of a perpetrator of fatal child abuse, although certain characteristics reappear in many studies. Frequently, the perpetrator is a young adult in his or her mid-20s, without a high school diploma, living at or below the poverty level, depressed, and who may have difficulty coping with stressful situations. In many instances, the perpetrator has experienced violence first-hand. Most fatalities from physical abuse are caused by fathers and other male caretakers. Mothers are most often held responsible for deaths resulting from child neglect 4) Note the contrast: a large % of abuse-related fatalities are caused by an unrelated (male) caregiver: remember that 86% of abuse is committed by relatives. When abuse is significant enough to be fatal, it is more likely to be committed by someone not related to the child. How does this compare to sexual abuse?--Need statistics on % of SA committed by relatives. However, the most violent sexual assaults are usually committed by non-relatives (often strangers, but not always). A study by Levine et al. found that the majority of fatalities were perpetrated by parents--neglect by mothers and abuse by fathers.
Of note with these families were problems associated with the safety and risk assessments that were made and the interventions that were undertaken when the families were initially referred to ACS on allegations of child maltreatment. Of particular concern was the lack of attention to the interaction of multiple risk factors in these families’ lives that elevated the risk of harm to children and the inattention to patterns of multiple reports of child maltreatment. In many of the cases, domestic violence, a factor that is strongly associated with child maltreatment, was present along with parental substance abuse. In some of the same cases, the families were the subjects of numerous child maltreatment reports before the child died. Roughly one-third of families in which fatal child maltreatment occurred had had prior contact with child protective services (Alfaro, 1988), as cited in Levine, Freeman, & Compaan, 1994). Another study found that well over three-fourths of the families had never come to the attention of the state’s child protective services agency
In Carole Jenny’s article, “Analysis of missed cases of abusive head trauma,” from JAMA 1999; 281: 621-626, In one study of abuse victims younger than 24 months, 75% had evidence of previous trauma or history of a previous injury (#21 in AAP Evaluation of Suspected Child Physical Abuse) Another study (#22 in same article) it was stated that child abuse may recur 35% of the time without appropriate detection and intervention Child abuse injuries, particularly TBIs, may result in significant long term disabilities, including learning deficits, ADD/ADHD, behavioral problems, seizures, spasticity, blindness, paralysis, and MR. (#23 and #24)
In one anonymous survey of 1435 mothers, it was found that 2.6% of children under 2 years were shaken by their mothers as a means of discipline (#19 AAP Eval guidelines) In addition, many abusers are ignorant of normal infant development. Many perceive their baby’s crying as excessive when it is in fact in the normal range (#17); many have unrealistic expectations of what infants and toddlers do--”I changed his diaper and he peed on me ON PURPOSE.” The rate of abuse is 2 times higher among children with disabilities than children without disabilities (#15) Child abuse is almost 5 times more common in families with identified spouse abuse (#20) Caregivers who are depressed or have other psychiatric illness are more likely to abuse children in their care.
1) History of trauma or previous hospitalization may provide a clue to a history of abuse 2) Congenital conditions may put the child at the increased risk experienced by those with illnesses or disabilities 3) Chronic illnesses--same as above; also may give a clue as to conditions that mimic abuse or cause injury with lower level of trauma 4) Family history (esp of bleeding, bone disorders, and metabolic or genetic disorders). Social history includes questions about any history of abuse in this child, siblings, or caregivers. (Point out here that we will get to some ways to ask these sorts of questions without causing offense)
ROS: It isn’t just a point system for reimbursement Ask parents about: Behavior changes--a child who is being abused may become anxious, depressed, withdrawn, or aggressive Regressive behaviors--thumb-sucking, bedwetting, fear of the dark Changes in eating--weight gain or loss Sleeping changes--frequent nightmares, trouble falling asleep, appearing tired Changes in school performance--poor concentration, excessive absences Risk-taking behaviors--drugs, alcohol, weapons
Use patient’s words: “He kicked me in the balls” rather than: patient states he was kicked in the scrotum. The latter does not hold up well in court, as it allows the defense attorney to question physician’s credibility. History is critical.
You cannot adequately assess any small child for any condition without fully undressing him. If the presenting problem is medical, and you do not undress the child, you will miss rashes. Whatever the presenting problem, you will miss such things as bruises and scrapes, and evidence of neglect such as diaper rash. Neglect is often accompanied by FTT. Though you may not have any basis for comparison, it is still helpful to know where the child falls on the growth chart. I realize this is a tall order for an ED--but if you want to do everything you can to pick up subtle cases of abuse, this is the sort of thing that must be done. Please document the child’s demeanor. Some children display strong non-verbal cues of anxiety and reluctance when answering questions regarding potential abuse, either because they are protective of their abuser, or because they fear the consequences of “telling.” Others may appear openly fearful of their abuser.
These are listed in order of decreasing frequency In the authors’ estimation, 4 out of 5 deaths of children in the missed AHT group might have been prevented by earlier recognition. 28% were known to have been reinjured because of the delay in diagnosis; 41% had medical complications related to the delay.
Head trauma is the leading cause of child abuse fatalities. Children with head trauma may have SDH, SAH, multiple SDH of varying ages. The absence of symptoms should not necessarily reassure, since infants with intracranial injuries may have no symptoms or nonspecific symptoms. Open fontanel(s) allow for expansion of the brain secondary to bleeding or edema without neurologic symptoms. Skull fractures can occur from accidents or inflicted injury. Short falls commonly result in skull fractures, but not serious intracranial injury. They are usually associated with scalp bruising or swelling. Talk here about literature on head injury from short falls.
Skull fractures: Linear skull fx come from falls of many heights, including short falls. (Duhaime Pediatrics 1992; other articles--need citations here). Depressed skull fractures, basilar, and bilateral fractures are more likely to come from falls greater than 4 feet Epidural hematomas can occur with short falls, but no other type of ICH is associated with short falls. Focal SAH or focal parenchymal contusions are associated with more significant falls MVA associated with a high incidence of SDH or diffuse SAH/contusions
Studies of the biomechanics of brain injury have established that forces applied to the head that result in a rotation of the brain about its center of gravity cause diffuse brain injuries. It is this type of movement that is responsible for the diffuse axonal injury and subdural hematoma seen, for example, in cases of motor vehicle accidents that result in severe disability or death. In contrast, forces that result in a translation, or straight-line, movement of the center of gravity are generally less injurious to the brain, with the effects largely determined by the specific focal contact forces. 6 The type and severity of the injury are determined both by the type of deceleration and by its magnitude. In infants and young children, household falls causing head injuries mainly involve low-velocity translational forces; rotational (or angular) deceleration is distinctly uncommon. 3 T he term “whiplash shaken-baby syndrome” was coined by Caffey to explain the constellation of SDH and SAH, traction-type metaphyseal fractures, and retinal hemorrhages. It was based on evidence that the mechanism of injury described above, rotational deceleration, is associated with SDH. Most often these injuries occur when a child is shaken, then the head strikes a surface. If the surface is soft, the force of the impact is widely dissipated and may not be associated with visible signs of surface trauma, even though the brain itself decelerates rapidly. It is the sudden angular deceleration experienced by the brain and blood vessels of the brain, not the specific contact forces applied to the surface of the head, that results in the intracranial injury. So the term “shaking-impact syndrome” may reflect more accurately than “shaken-baby syndrome” the usual mechanism responsible for these injuries. Whether intentional shaking by a caregiver by itself can cause the constellation of findings associated with the syndrome is still a subject of some debate. What is clear is that activities of daily living, such as routine play, infant swings, or falls from a low height are not sufficient to cause the syndrome.
Patient Presentation A 6-month-old female was transferred to the emergency room of a children’s hospital for treatment of a femur fracture. Her mother was carrying her down some stairs and fell landing on the infant. The mother could not give more details of how she was carrying the infant before the fall, how many stairs she fell down, nor the final position of the infant or herself. The past medical history showed her to be a full-term infant who had received regular health supervision visits. The family history was negative for genetic or skeletal disease. The social history showed two other siblings living with their biological mother and father who are not married. The mother denies any history of alcohol, drugs or violence. The review of systems was negative. The pertinent physical exam showed an alert infant in a leg immobilizer who smiles. Vital signs were normal. Head circumference was 25%, weight and length could not be done accurately due to the immobilizer. She appeared developmentally appropriate. Her examination was normal including head, eyes, abdomen, genitalia and skin. The radiologic evaluation on the radiographs from the outside hospital showed a transverse femur fracture of the diaphysis that was angulated but not shortened. The diagnosis of a transverse femur fracture was made. The patient’s clinical course was that she was taken to the operating room where a spica cast was placed. The following day, an evaluation for possible child abuse was conducted and showed a normal head computed tomography examination, normal skeletal survey, normal ophthalmological evaluation and initial screening laboratories were negative. The Department of Human Resources was contacted and discharged the infant to a temporary foster care placement along with her siblings. The Department of Human Resources and the courts determined after further investigation that she had been abused. She was later placed in permanent foster care and was awaiting adoption. Her femur fracture healed with no residual problems.
There is no particular pattern of femur fractures that is pathognomonic for child abuse, therefore all femur fractures could be suspicious. Several early studies found spiral fractures to be the most common fracture type, therefore many clinicians may still believe that spiral fracture are indicative of abuse. Spiral fractures may be caused by other mechanisms. More recent reports such as the one above, show transverse fractures to be most common overall and more common in child abuse. Therefore clinicians should consider abuse potentially in any child with a femur fracture and in particular with transverse fractures which may be overlooked. In a study by Pierce and colleagues, the following elements were used to evaluate the plausibility of a femur fracture being accidental versus inflicted: Caregiver history of the fall - could the caregiver describe the elements of the initial position, fall dynamics, and final position. A caregiver who could not give these or fewer elements was more suspicious Fracture and the possible biomechanical mechanism - did the possible biomechanics match the type of fracture Time to seeking care - immediate versus delayed with or without signs of injury. Delayed care with more obvious signs of injury was more suspicious Additional findings or injuries on initial exam - more additional injuries increases suspicion They pointed out in their study at that initially the caregiver histories did not seem unusual, but additional questioning often found more vague answers that were without detail, and that the fewer the specific elements that the caregiver could describe, the more suspicious the case was. Spiral fractures in this study only occurred in walking patients and where the leg was reported to be folded or twisted under the patient’s body. If the leg was reported to be pinned under a caregiver’s body, the fractures were commonly transverse or oblique. Immediately seeking care, or a delay with a subtle or well aligned fracture was not suspicous for child abuse. Any additional injuries to the child were suspicous for child abuse.
Physicians are often called upon by child protection agencies to estimate the cause and age of bruises, in an attempt to determine whether a bruise was accidental or inflicted, and if inflicted, to identify the perpertrator(s), to determine whether multiple episodes of trauma occurred, and to ensure the child’s safety.
Bruising of the skin develops after the application of blunt force sufficient to disrupt blood vessels, resulting in blood extravasation (blood leaking out) and accumulation in the dermal layers. A bruise may not become apparent for hours or even days after injury, depending on the depth of the vessels disrupted. A large, flat surface may dilate superficial blood vessels, resulting in temporary erythema (redness). With more force to the same area, blood vessels under the skin will rupture. If bone (which is unyielding) is close to the surface, the skin is more likely to be crushed between the striking object and the bone, with more visible and extensive tissue damage which appears quickly. In one study of infants younger than 12 months of age, all bruises were found on the front of the body over bony prominences. Conversely, the same force applied by the same object to the buttocks may take longer to appear (the injured tissue is deeper--fat has few blood vessels) and may be less visible. A blow of similar force to the same body area, but from a smaller object, is likely to cause more concentrated, more serious, and deeper damage.
Hands are the number one implement used to strike children. In a study published in Child Abuse and Neglect, 33% of the bruising injuries were inflicted by a hand. It is also a common target organ--meaning that it is a part of the body struck with the greatest frequency. Hands may be used to propel, drop, push, pull, or drag children--so the marks may differ depending on the mechanism The hand as a weapon was followed by belts and straps and a variety of household objects.
The first of these, CBC, PT/INR, PTT, and von Willebrands panel, are perfectly reasonable tests to order without consulting hematology. Knowing the level of platelets at the time of injury can be important in countering the often-used defense argument that platelets were low due to some viral injury, and that the child had a transient coagulopathy that rendered him more susceptible to bruising from a minor injury. Many of the more sophisticated tests can wait for the consult, since things like Factor VIII deficiency don’t come and go. Closure time is a study of platelet function which has come to replace the bleeding time test). The link listed here gives a description of the test, for those of us who trained in the time of the bleeding test (I was at the tail end of that, but still trained before the closure time, which sounds more like “Last Call” at the bar to me.
More than half the people I ask, in the course of a standard review of systems in the ED, say that they bruise easily. I have reached the point where I do not ask the question that way. Instead I ask “Do your gums bleed when you brush your teeth gently?” Of course I don’t ask this question of people who have obviously not brushed their teeth in years. I also ask “How often do you find bruises on yourself and have no idea where they came from?” So the majority of adults seem to think they bruise easily, and many parents believe the same thing about their children. An abusive caregiver will also use this to try to explain unexplained bruises on the child. Having said that, there do exist some conditions which will cause a child to bruise easily. They are rare.
Oriental Cupping is an ancient Chinese method that uses cups from a cupping set to create a suction (or a partial vacuum) on the skin. This helps in activating the underlying tissues. When the cup is left in place on the skin for a few minutes, blood stasis is formed and localized healing can take place much easier. Cupping therapy has been further developed as a means to open the 'Meridians' of the body. Meridians are the conduits in the body through which energy flows to every part of the body and through every organ and tissue. There are five meridians on the back that, when opened, allow invigorating energy to travel the whole length of the body. It has been found that cupping is probably the best way of opening those meridians. Cupping has also been found to affect the body up to four inches into the tissues, causing tissues to release toxins, activate the lymphatic system, clear colon blockages, help activate and clear the veins, arteries and capillaries, activate the skin, clear stretch marks and improve varicose veins. Cupping is the best deep tissue massage available. Cupping, the technique, is very useful and very safe and can be easily learned and incorporated into your family health practices.
Coining is a common healing practice used among Asian patients within the United States. Traditionally, coining is used for conditions associated with "wind illness". It is also used with a wide variety of febrile illnesses as well as stress related symptoms in adults such as headaches, muscle aches and pain, low energy. The practice produces linear petechiae and ecchymosis on the chest and back which resolve over several days. The lesions seen in coining are produced by rubbing a warm oil or Tiger Balm on the skin and firmly abrading the skin with a coin or special instrument as is illustrated in this photo. Patients report variable degrees of comfort with coining. Some describe it as soothing like a massage and others as painful.
A bruise is caused by blood that has escaped from damaged capillaries into the interstitial tissues. It is the process of hemoglobin degradation and its expression through the “window” of the skin that determins the color of a bruise. Other factors, such as ambient light and skin color, may affect the apparent color of a bruise. Comparing the clinically estimated age of a bruise to the described age is critical to many child abuse assessments. Practitioners are often asked by child protection and law enforcement agencies and the courts to offer opinions about the age of a child’s bruise to assess the credibility of the history and to aid in perpetrator identification. Depth, location and skin complexion affect the time of appearance and the color of a bruise. A superficial bruise may discolor the skin immediately, whereas deep bruising may take days to appear. When a particular color appears also varies in part according to injury depth. Yellow seems to develop more quickly in superficial bruises, so that if a child has been bruised both deeply and superficially at the same time in nearby locations, the bruises may be different colors and may seem to have occurred at different times. Location: Periorbital and genital bruises (where tissue is loose and blood vessels are poorly supported) will appear sooner than extremity bruises. Skin color: Light-complexioned children may seem to bruise from relatively minor impacts, whereas bruises in dark-complexioned children may be masked by their skin color. The chronicity of bruising may affect the aging process. Bruises in chronically injured animals healed on average 2 days sooner than bruises in acutely injured control animals. If this is also true of humans, it suggests that a chronically injured child may heal more quickly than an acutely injured one.
It should be noted here that blows to some body surfaces may well not cause an external mark, but cause significant internal injury. In particular, blows to the abdomen from a hand, fist, or instrument, may not cause any bruising, as the skin of the abdomen collapses and the bowel is injured. This is especially likely at the ligament of Treitz, where the bowel is bound to the spine. The chest may be crushed by a knee or a caregiver’s arm, fracturing the ribs and leaving no marks on the skin. Therefore, it is prudent always to consider what organs lie underneath the marks from a blow. Blunt trauma to the scalp with brain injury, but no swelling or bruising of the scalp, may produce marks on the inner surface of the scalp when it is reflected at autopsy. This is probably related to the properties discussed earlier--the tissue adjacent to the hard skull receives more vascular damage than that on the outside, which is adjacent to the instrument inflicting the injury. Abrasions of the eyelids, scalp bruising, and mouth contusions may result from intentional smothering. These physical findings would, of course, raise the suspicion of intentional injury in a child whose death might otherwise be attributed to SIDS. A slap leaves a readily identified mark and is most commonly seen on the face or buttocks. If the buttocks have been struck repeatedly by the hand, the marks may overlap or coalesce, making it more difficult to recognize the hand as the source of trauma. Older children are more likely to be struck with instruments and are more able to escape an instrument, resulting in grab marks from being held, sometimes around the neck. They may also be tied to restrain their movements. Any geometrical mark should raise suspicion for inflicted injury. Likewise, symmetrical or mirrored marks are unusual. If a child strikes the nose or forehead, it is possible for bilateral ecchymosis to occur. It would, however, be unusual for subconjunctival hemorrhages to occur from a blow to the nose or forehead (be careful in infants, though--they do manage to stick their wobbly little fingers in their eyes and a unilateral subconjunctival hemorrhage is not necessarily indicative of abuse). Basal skull fractures may also result in a panda-like blue discoloration around the eyes. A child with bruises about both eyes, with or without subconj hemorrhages, and no injury to the forehead or nose is like to have been struck on two occasions.
In one study published in Pediatrics, researchers studied 50 children with accidental bruises who presented to an emergency department. The dates of the bruises were known. History-blinded emergency pediatricians, other physicians, and trainees of all stripes independently examined the bruised are and recorded injury characteristics and age estimation, and ranked the characteristics that influenced their estimates. The factors most often used to estimate the age of the bruises were color, tenderness and swelling. However, none of these factors was significantly correlated with history. These findings have been replicated in a number of studies, using both live patients and photographs.
Langlois and Gresham authored the only published study of the visual aging of bruises in 1991. They tried to determine how accurately the age of a bruise can be estimated by looking at its color. 369 photos were taken of the bruises of 89 inpatients, staff, and patientsin an ED. Only bruises with known ages and origins were photographed. Each photograph was accompanied by a color chart to assure accurate color reproduction. The data on color and age were then analyzed statistically. They concluded the following: At the present time there is no way to date a bruise accurately. Of course the practitioner must continue to describe the size, shape, location, and color of each bruise accurately. This is best done by written description and drawings along with careful photographic documentation. Recognize the limitations of available light and technique and how they may affect the representation of color. A standard color wheel should be used in the photograph to help minimize any distortion caused by these factors.
After a few days, hemoglobin breaks down into other chemicals, which have colors other than red-blue. It is the bilirubin, a breakdown product of hemoglobin, that is measured. In spectrometry, a white light, which contains all the colors of the rainbow, is shined towrads the bruise. The light that reflects from the skin in measured with a spectrometer. More precisely, the spectrometer measures how much of the different colors are reflected back. From the reflected light, the amount of blood in the bruise and the oxygen in the blood can be measured.
Burns comprise a significant number of injuries in abuse, representing 10% of all severe child abuse--and I think severe is an important word here. I cannot say that burns comprise 10% of what I see (and I am grateful for that). Most people find that their stomachs turn when thinking about intentionally inflicting a burn on anyone, much less a child. The pain we know a child must suffer while intentionally being burned is particularly horrific. When considered as a cause of child abuse deaths, burns are exceeded only by head injury and abdominal injury. Looked at from a different angle, burns due to abuse make up 10-25% of severe burns in children--those burns requiring hospitalization. The absence of other injuries does not rule out child abuse, since 80% of deliberately inflicted burns are not associated with other ttrauma
The physical conditions required to burn skin are: adequate exposure to elevated temperatures to transfer energy to the skin. Thus, high temperatures require short exposure times, and low temperatures require longer exposure times. This becomes important in such injuries as tap water burns. I have not been able to get my hands on this article, since it was written in 1947. This chart is cited by many child abuse articles and texts, but I don’t know the methods by which they determined these numbers. The study by Moritz and Henriques is one of the classics, and their data continue to be used in the assessment of the time required to cause a first degree burn. It can be expected that children’s skin will burn in less time. I am not aware of any studies of burning times in children. It seems fairly obvious that this would be an unethical study.
The typical accidental scald burn is a splash burn, which results when a liquid falls onto a child or is pulled or thrown toward him or her. In the case of a spill the burn will have a classic “arrowhead” shape, with the widest and deepest part of the burn at the top (or the point of first contact). The pattern both narrows and becomes less deep because the liquid cools as it flows down the body. Thick liquids such as grease, oils or syrups maintain their heat for longer periods and can be at a higher temperature than the boiling point of water, and thus they may result in a more extensive burn pattern. If the child was wearing clothing at the time of the injury, the pattern may be altered. This is why it is important to determine whether clothing was worn and, if possible, to retain the actual clothing. Depending on the material, the water may have been against the skin longer, which would result in a deeper injury and pattern. A fleece sleeper, for instance, will change the course of the water and hold the temperature longer in one area as opposed to a thin, cotton T-shirt.
Some questions to ask in the investigation of a scalding injury include: Where were the caretakers at the time of the accident? How many persons were home at the time? How tall is the child? How far can she reach? Can the child walk, and are the child’s coordination and development consistent with his or her age? How much liquid was in the pan, and how much does it weigh? What is the height to the handle of the pan when it is sitting on the stove (or other surface)? Does the child habitually play in the kitchen? Near the stove? Does she climb on the cabinets or table? It is unusual for a child to incur a scald burn on her back accidentally, but not impossible. Factors other than the location of the burn must be considered before concluding the injury was intentional. Deliberate burning by throwing a hot liquid on a child is usually done either as punishment for playing near a hot object, or in anger. However, children sometimes get caught in the crossfire between two fighting adults, and then then accused of having spilled the liquid accidentally.
Scald burns with sharp margins should suggest the possibility of abuse by immersion in a hot liquid. This pattern of burn results from the caregiver holding the child in the water, whereas an accidental immersion often results in splash patterns as the child tries to escape the water. The typical pattern of inflicted scald burn is an immersion burn with sharply demarcated borders and a uniform intensity of burn. On the extremities a stocking/glove pattern (with or without buttock involvement) should cause suspicion. When looking at the burn pattern it is important to remember that diapers are protective, and that anything that excludes the water from the skin surface will spare that area. However, hot water that flows under or soaks clothing may cause a more severe burn in that insulated area. In immersion burns, folds are often spared and any body area that is pressed against the container holding the water may be spared. Therefore, if a child is held in a sitting position in a bathtub of hot water there may be a “doughtnut” shaped buttock burn with central sparing. Immersion burns are often inflicted as punishment for toileting accidents.
Immersion by holding child upside down in hot water
Cigarette burns: Consider the location--back or buttocks unlikely to have been caused by walking into a lighted cigarette. Burns about the face and eyes can occucur accidentally if the child walks or runs into the adult’s lighted cigarette held at waist height. Single vs. multiple: Multiple cigarette burns are distinctively characteristic of intentional injury, and of course even more so if they are of different ages. Configuration: Accidental burns are usually more shallow, irregular, and less well defined than deliberate burns. Intentional cigarette burns tend to be circular, 7-10 mm in diameter, and are often 3rd degree burns It should be remembered that most unintentional contact burns to the hand could be expected to occur on the palms or palmar surfaces of the fingers as the child attempted to touch or grab the object. It is unusual for a child to explore an article with the back of the hand. Sharply demarcated burns on the dorsum of the hand should suggest an abusive etiology. Purposely inflicted “branding” type injuries usually mirror the objects that caused the burn and are much deeper than the burns caused by accidentally touching these objects.
Scalded skin syndrome, as its name implies, looks very much like a scald-type burn. A history of infection, often with fever and leukocytosis, and rapid extension of the affected area generally allows rapid differentiation from a thermal burn. Erysipelas, with its sharp red margins, might bring to mind a contact burn. However, the lesions also have rapidly extending leading edges. There is no blistering.I Impetigo, especially in its early stages, when one or two lesions are present, may mimic a cigarette burn. The crusted lesion of impetigo can usually be removed with soap and water, leaving behind almost normal skin. Phytophotodermatitis Skin reactions are caused by furocoumarin chemicals in the plant and exposure to Ultraviolet A sunlight. Blisters form in a few hours after contact with the plant and sunlight. Hyperpigmented skin develops in the affected area after the blisters have healed and may last for months.
We all like to have protocols--PIOPED studies with resulting diagnostic criteria, studies that can be ordered and that are diagnostic. I hate to be cynical, but it is pretty clear to me that we all try harder when the wolf of litigation is nipping at our calves. Physicians are nice people-and we are people who think about the consequences of bad behavior, want to avoid those consequences, and therefore adjust our behavior accordingly. People who abuse children do not have the same set of norms for behavior, and consequences do not mean the same thing to them.