Child abuse can take many forms including physical, sexual, and emotional abuse as well as neglect. It is a widespread problem in India with over half of children experiencing some form of abuse. Physical abuse and sexual abuse are particularly common. Proper identification, documentation of injuries, collection of forensic evidence, and multidisciplinary management are important to address this issue. Prevention through education, community support, and strong legal protections can help reduce the incidence of child abuse.

1. 7th CNE National Workshop on "Current trends in Forensic Nursing & Toxicology at JIPMER"
"Child abuse – Types, assessment and
management - Case based discussion
& demonstration"
Prof Dr. Smriti Arora
Principal
CENER, AIIMS Rishikesh
21 Sept 2023

2. Introduction
• "Safety and security don't just happen, they are the result of
collective consensus and public investment. We owe our children, the
most vulnerable citizens in our society, a life free of violence and
fear." Nelson Mandela

3. Statistics
• Population of India- 1.3 billion, rich cultural diversity
• According to a study conducted by the National Commission for
Protection of Child Rights (NCPCR), nearly 55% of children in India
experienced some kind of abuse.
(TOI)

4. • Physical abuse is one of the most common forms of child abuse in
India, with around 25% of children having experienced it at some
point. The most common types are hitting and slapping, burning, and
beating.
• 16% of children have been sexually abused in some way, including
rape or other forms of unwanted sexual contact.
• Unfortunately, mental harassment is also on the rise, with 11% of
children claiming to have been victims of emotional or verbal abuse
by their caregivers.

5. Causes of child abuse
• Substance abuse
• Socioeconomic status
• Previous H/O abuse
• Broken homes
• No. of children
• Gender
• Improper parenting skills
• Unplanned children
• Mental illness
• Caregiver frustration
• Child with disabilities

6. Government Initiatives to Combat Child Abuse
• India has one of the toughest laws in the world. The Protection of Children from Sexual Offenses
(POCSO) Act, 2012, is a comprehensive legislation that deals with all aspects of child sexual abuse.
• It is aimed at protecting children from all forms of sexual abuse, including rape, molestation, and
sodomy.
• 24-hour helpline (1098) for reporting child abuse - launched in 2013
• the government has also set up special courts to deal with child abuse cases. These courts are
equipped with all the latest technology and tools to help speed up the trial process and ensure
that justice is served swiftly and effectively.
• National Commission for Protection of Child Rights (NCPCR) or the State Commission for
Protection of Child Rights (SCPCR) for further assistance.
• Child Welfare Committee can help protect the rights of the abused child and provide him/her
with legal representation.

7. Types of child abuse
Physical
abuse
Emotional
abuse
Sexual
abuse
Neglect

9. • Behavioural cues
• Excessive crying or developmental delay, Fear and anxiety,
Sleeping problems, Regressive behaviour, Social withdrawal.

10. Physical abuse
• Human bite mark , Poor weight gain, Malnutrition, Lacerations, abrasions or
scars, Bruising or petechiae, Burn or scald injuries
• Injury inconsistent with the history provided
• Injuries at various stages of healing, such as multiple fractures
• Patterned bruising, such as grab or squeeze marks, slap marks, spank marks,
human bite marks, and marks consistent with implements (eg, loop marks,
belt marks, etc.)
• Patterned contact burns in clear shape of the hot object (eg, fork, clothing
iron, curling iron, cigarette lighter, etc.)
• Forced immersion burn pattern with sharp demarcation, stocking and glove
distribution, and sparing of flexed protected areas
• Localized burns to genitals, buttocks, and perineum (especially during the
child's toilet-training phase)
• Unreasonable and excessive delay in seeking treatment
• Intracranial hemorrhage, especially subdural hemorrhage, in the absence of
a known underlying medical condition

11. Sexual abuse
• subjecting the child to inappropriate exposure to sexual acts or
materials or passive use of the child as sexual stimuli and/or actual
sexual contacts. (showing sex organs, fondling, oral sex, penetration,
pornography, prostitution)
• Online sexual abuse- showing images, sexting
• genital symptoms, foreign bodies in the vagina or anus, presence of
infection, Pregnancy

12. Emotional abuse
• involves constant belittling, shaming, humiliating a child,
making negative comparisons to others, frequent yelling,
threatening, or bullying of the child, rejecting and
ignoring the child as punishment, having limited physical
contact with the child (e.g., no hugs, kisses, or other
signs of affection), exposing the child to violence or
abuse of others or any other demeaning acts.
• All these factors can lead to interference with the child's
normal social or psychological development leaving the
child with lifelong psychological scars.

13. Neglect
• Child neglect, when an able caregiver fails to provide basic needs,
adequate food, clothing, hygiene, supervision shelter, supervision,
medical care, or support to the child.

14. Management
• Emergency Departments (ED) play a pivotal role in identifying child maltreatment as ED may
represent a frequent entrypoint to health care for patients. Therefore, healthcare personnel in
emergency setting may be the first hospital contact and opportunity for recognizing abuse.
• Basic principles in working with children and adolescents exposed to
maltreatment
1. The principle of the best interests of the child or adolescent
• Protect and promote safety
• Provide sensitive care
• Protect and promote privacy and confidentiality
• Respect autonomy
2. The principle of evolving capacities of the child or adolescent
• providing information according to the child’s age and developmental stage
and capacity;
• always seeking informed consent or assent, even from young children

15. Management- multidisciplinary approach
• Take history- a good medical and social history helps to unravel the
problem. Talk to child at his cognitive level, involve play to elicit
information, provide privacy, establish rapport with child
• Whenever a child is injured, a complete history regarding the
circumstances surrounding the injury, as well the injury itself, is essential.
• As with any medical history, the provider should aim to obtain a history
of present illness, past medical history, and review of systems.
• Remain neutral while asking questions, no leading questions
✓Cause of injury, type of abuse, preventive and curative measures

16. Basic questions to address the history of
present illness include the following:
• When was the child last seen completely well (no symptoms, no caregiver concern whatsoever)?
• What was the date and time of the injury and when was it first noted, and how does it relate to the time of
presentation?
• Where did the injury occur?
• Who witnessed the injury?
• What was happening prior to the injury?
• How did the child respond to the injury?
• What did the child do after the injury (i.e, did the child resume normal activity)?
• What did the caregiver do after the injury?
• How long after the injury did the caregiver wait until seeking care for the child and how reasonable was that
time?
• What prompted the caregiver to seek care?
• What symptoms was the child exhibiting, and what, if any, remedies did the caregiver attempt?
• Inquire about specific details related to the injury, such as distance and landing surface (if a fall) and
temperature of water (if scald burn), among others.

17. In cases of maltreatment, the history is often inaccurate and
misleading. The following historical elements should raise
concerns for possible physical abuse:
• Details change, or additional scenarios are suggested, as additional trauma is identified
or as the cause of the trauma is questioned
• Details are inconsistent among caregivers
• Caregivers provide implausible details not congruent with the trauma observed on
examination
• Caregivers describe minor trauma, but the child displays major injury on examination
• Injury described as self-inflicted is not possible given the age and developmental abilities
of the child
• Caregivers demonstrate a significant and unreasonable delay in seeking treatment for
the child
• Serious injury is attributed to a younger sibling or playmate

18. Physical examination
• The child should be prepared prior to performing the physical examination (Laraque etal.,
2006).
• Everything being done should be explained to the child prior to doing it. The child should
be told that if at any time the examination is painful to tell the forensic nurse examiner.
• The child should be allowed to maintain control of his or her body.
• It is also important to allow the child to examine all equipment that will be used during
the examination.
• Allow a support person to be present during the examination as decided by the child
https://www.researchgate.net/publication/329566548_Child_Abuse_Examination_Diagnosis_and_Treatment_b
y_the_Pediatric_Forensic_Nurse_Examiner#fullTextFileContent

19. Sexual Assault Examination
• The sexual assault examination is very involved. Important evidence can and should be
carefully collected by the forensic nurse examiner.
• Some of the evidence collected in this examination include: the victim’s clothing, debris,
dried secretions on the skin, oral swabs and smears, vaginal/penile swabs and smears,
rectal swabs and smears, genital swab, pubic hair combings and reference hair, head hair
combings and reference hair, saliva sample, blood sample, fingernail scrapings and
clippings, and nasal mucous (Laraque, DeMattia, & Low,2006).
• Other evidence may be present and should also be collected, such as condoms or
tampons.
• All lesions and visual evidence of trauma should be thoroughly documented and
photographed.
• Testing for sexually transmitted infections should also be done (Gomes, 2014)

20. • The oral cavity is an area frequently associated with sexual assault
(Kellogg, 2005).
• Petechiae and unexplained injury to the palate may be indicative of
forced oral sex. The buccal mucosa and tongue should be swabbed
for any semen or other foreign material. Testing for sexually
transmitted infections may also be indicated

21. Role of forensic pediatric nurse
• Observe parent child relationship
• Meticulous history
• Perform physical examination including genitals
• Investigations- blood tests, X rays, cultures
• Collecting and preserving forensic evidence
• Document signs of abuse, photodocumentation
• Provide first-line support – The LIVES CC approach for children,
adolescents, and their caregivers (Listen, Inquire, Validate, Enhance Safety,
Support, Child and adolescent friendly, Caregiver support)
• Educating parents and community

22. Management
• Medical care
• Psychosocial care
• Surgical care
• Informing law enforcing officials

23. Prevention of child abuse
• It is important to educate child about "safe" and "unsafe"
touch.
• Create a circle of trust where child knows to whom to
reach out to (parents, teachers and guardians).
• Most importantly, identify signs of abuse and act
responsibly.

24. Case study -1
• An 8-year old girl and her sibling had lost her mother and their father was not
willing to take responsibility of his own children and used to send them to his
relative’s places.
• Once he sent both children to their maternal aunt’s home. During an outreach
of CHILDLINE team, the team was informed that the girl was very sick and
appeared traumatised.
• She was admitted to the local hospital. The girl was diagnosed with
malnutrition and weakness by doctors. They also noticed some burn marks on
her private parts during examination. The team felt that the girl wanted to
share something but was reluctant and fearful.
• Kemoli AM, Mavindu M. Child abuse: A classic case report with literature review. Contemp Clin Dent. 2014 Apr;5(2):256-9. doi:
10.4103/0976-237X.132380. PMID: 24963259; PMCID: PMC4067796

25. • The CHILDLINE team approached the local police station, Child Welfare
Committee (CWC) and the DCPO for intervention. But despite the efforts, both
siblings refused to speak. CHILDLINE team wrote to CWC to provide a chance to
counsel the girl child and then a CHILDLINE team counsellor spent a few days
with her.
• After a few sessions focussing on building the girl’s confidence, she gradually
began to confide and finally shared her trauma.
• She revealed that her maternal aunt used to burn various parts of her body,
especially private parts, with a matchstick. She used to threaten the siblings
that she would kill them if they will inform this to anyone.
• CHILDLINE team shared the details with the CWC and took the girl to the local
police station to lodge an FIR against her maternal aunt. Police took immediate
action and arrested the aunt.
• The siblings were placed in a Children’s Home by the CWC. Both children are
learning to live a fearless life.

26. Case study 2
• Name - Peter, a 12-year-old boy, accompanied by his maternal aunt, presented at the local
university Dental Hospital (Pediatric Dental Clinic) in Kenya in October 2012
• Complaints- a large, painful left facial swelling related to the left upper incisors. He had been
referred from a local rural hospital where he had been taken by the same aunt, for treatment of
the swelling. The swelling had occurred only 2 days prior to visiting the local hospital, and 4 days
before presenting himself at the University Dental Hospital. Enquiry about the causes of the
swelling provided unclear answers.
• Family history- indicated that the young boy was a first-born among three siblings (9-year-old girl,
5-year-old boy), and that their single parent (mother) had been deceased for 6 years due to HIV-
related complications. The three children had moved to live with their maternal grandparents and
their seven sons.
• The patient had no adverse past medical history and had never consulted a dentist previous to
the present problem. The boy was in grade seven in a local primary school and had the aspiration
of becoming a medical doctor in future. It was not possible to establish from the aunt or the boy
the situation of the patient's other siblings.

27. Physical examination
• a young boy with a normal gait, sickly, unkempt, rather withdrawn,
and small for his age. He had asymmetrical face due to the swelling
involving his left submandibular region and spreading upwards to the
inferior orbital margin, febrile (39.1°C), a marked submandibular
lymphadenopathy on the left side, the skin overlying the swelling was
warm, shiny and fluctuant, and the lips were dry and incompetent (2
cm) .
• the temporomandibular joint movements were normal. The patient
was also found to have a big, healing scar on the dorsal surface of the
left foot, the cause of which was also unclear

28. Investigations
• Radiographs, dental X rays
• A diet and nutrition assessment, full blood count, stool microscopic
analysis for ova and cyst and bacterial culture and sensitivity were
also undertaken.
• Result- root fracture, neutrophilia, sepsis, anemia
• Diagnosis- child abuse

29. Management
• Objective- to eliminate the pain, infection, improve the general and oral health, restore carious teeth,
improve esthetic and report the child abuse and neglect to the relevant authorities.
• In the initial phase of treatment - the patient was admitted for 4 days and placed on dexamethasone 8 mg
stat, cefuroxime 750 mg 3 times a day, metronidazole 500 mg 3 times a day, diclofenac 50 mg tablets
alternating 4 hourly with oral paracetamol 1000 mg 3 times a day, to run for 5 days.
• Patient was also placed on chlorhexidine mouthwash 10 ml twice daily for 7 days and ranferon (hematinics)
10 ml to be used twice a day for 1 month.
• The second phase of treatment- incision and drainage of the abscess, followed by the splinting of the mobile
teeth in the upper dental arch using semi-rigid splint of 0.6 mm stainless steel round wire for 4 weeks. Root
canal treatment of 11, 21, 12, and 22 followed thereafter.
• Referral was made to the child support center in the main referral hospital, plus the patient was placed on
future recalls to determine whether the patient would have overcome the problem and the oral health was
maintained in good condition.

30. Complications of child abuse
• All types of child abuse and neglect leave the affected child with long-lasting scars
that may be physical or psychological
• emotional scars leave the child with life-long effects, damage the child's sense of
self, the ability to build healthy relationships and function at home, work or
school.
• This situation can in turn result in the child turning to alcohol or drugs to numb
the painful feelings.
• exposure by the child to violence during childhood can increase vulnerability of
that child to mental and physical health problems like anxiety disorder,
depression, etc., and make victims more likely to become perpetrators of violence
later in life.

31. Prevention
• Report
• Teach child about good touch bad touch
• Good parenting skills

34. Bare Acts related to children
• Juvenile Justice (Care and Protection of Children) Model
Amendment Rules, 2022
• The Protection of Children from Sexual Offences Rules, 2020
• Right of Children to Free and Compulsory Education Rules ,
2010
• Commissions for Protection of Child Rights (Amendment) Act
2006

36. Summary
• Nearly 3 in 4 children - or 300 million children - aged 2–4 years regularly suffer physical punishment and/or
psychological violence at the hands of parents and caregivers
• One in 5 women and 1 in 13 men report having been sexually abused as a child aged 0-17 years.
• 120 million girls and young women under 20 years of age have suffered some form of forced sexual contact.
• Consequences of child maltreatment include impaired lifelong physical and mental health, and the social
and occupational outcomes can ultimately slow a country's economic and social development.
• Child maltreatment is often hidden. Only a fraction of child victims of maltreatment ever gets support from
health professionals.
• A child who is abused is more likely to abuse others as an adult so that violence is passed down from one
generation to the next. It is therefore critical to break this cycle of violence, and in so doing create positive
multi-generational impacts.
• Preventing child maltreatment before it starts is possible and requires a multisectoral approach.
• Effective prevention approaches include supporting parents and teaching positive parenting skills, and
enhancing laws to prohibit violent punishment.
• Ongoing care of children and families can reduce the risk of maltreatment reoccurring and can minimize its
consequences.

37. Summary
• Advanced practice forensic nurses play an important role in the stopping of child abuse.
• Forensic nurse examiners can adequately identify signs of abuse, report this to the
proper agencies, and testify on the child’s behalf.
• This, in and of itself, will reduce the risk of further abuse and death in the child.
• Other advanced practice nurses may develop prevention strategies to help prevent the
child abuse from ever occurring.
• Still other advanced practice nurses may assist in setting policies and laws related to child
abuse.
• Whatever role the advanced practice nurse plays, the children’s best interest should
remain at the forefront

38. THANK YOU

39. References
• https://www.who.int/news-room/fact-sheets/detail/child-maltreatment
• https://timesofindia.indiatimes.com/readersblog/personal-blog-of-suhaib-rafi-
mir/protecting-our-children-a-look-at-current-indian-laws-on-child-abuse-50378/