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Child abuse

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Child abuse

  1. 1. Reference : 1. Nelson textbook of pediatrics 2. A study on child abuse in india 2007 Dr Ruturaj Deshmukh DNB Resident Choithram Hospital & Research Centre, Indore www.dnbpediatrics.com
  2. 2. www.dnbpediatrics.com
  3. 3. “So long as little children are allowed to suffer, there is no true love in this world” Duncan www.dnbpediatrics.com
  4. 4.  “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.” (nelson)  “Child abuse constitutes all forms of physical and/or emotional ill treatment resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power”. (WHO) www.dnbpediatrics.com
  5. 5. -Abuse most common in children < 1 yr. old -Girls more frequently abused at older age vs. boys www.dnbpediatrics.com
  6. 6.  Every fifth child in the world lives in India  Every third malnourished child in the world lives in India  Every second Indian child is underweight  Three out of four children in India are anaemic  Decline in female/male ratio is maximum in 0-6 years: 914 females per 1000 males  Birth registration is just 62% (RGI-2004)  Retention rate at Primary level is 71.01% (Elementary Education in India Progress towards UEE NUEPA Flash  Statistics DISE 2005-2006)  Girls' enrolment in schools at primary level is 47.79% (Elementary Education in India Progress towards UEE  NUEPA Flash Statistics DISE 2005-2006)  1104 lakh child labour in the country (SRO 2000) www.dnbpediatrics.com
  7. 7.  physical abuse  sexual abuse  emotional abuse  neglect www.dnbpediatrics.com
  8. 8. “Physical abuse is any non-accidental injury to a child under the age of 18 by a parent or caretaker. ” These includes- beatings, shaking, burns, human bites, strangulation, or immersion in scalding water or others, Which may results in: 1. Bruises and welts 2. fractures 3. Scars 4. burns 5. Internal injuries or any other injuries. www.dnbpediatrics.com
  9. 9. (1) bruising in a preambulatory infant , (2) bruising of padded and less exposed areas (buttocks, cheeks, under the chin, genitalia), (3) patterned bruising or burns conforming to shape of an object or ligatures around the wrists (4) multiple bruises, especially if clearly of different ages. Before confirming it we must rule out: (1) birthmarks and Mongolian spots (2) blood dyscrasias or connective tissue disorders (hemophilia,Ehlers- Danlos). (3) Henoch-Schonlein purpura (4) coagulopathy (5) Cultural practices www.dnbpediatrics.com
  10. 10. www.dnbpediatrics.com
  11. 11. Bruises www.dnbpediatrics.com
  12. 12.  characteristic pattern- “1 or 2 opposing arches with multiple bruises.”  child bites: < 8 yr primary teeth typically have a distance of less than 2.5 cm between the canines.  Animal bites: usually have narrower arches than human bites and are often deep.  Self-inflicted bites are on accessible areas, particularly the hands.  Adult bites: canine distance >2.5 cm and has broader arch.  Multiple bites by another child suggest inadequate supervision and neglect. www.dnbpediatrics.com
  13. 13.  When to suspect abuse: ◦ Multiple fractures in various stages of healing. ◦ classic metaphyseal lesions ◦ posterior rib fractures, ◦ fractures of the scapula, sternum, and spinous processes, especially in young children.  Non abused #: ◦ Clavicle, femoral, supracondylar humeral, and distal extremity fractures in children older than 2 yr are most likely noninflicted unless they are multiple or accompanied by other signs of abuse Differential diagnosis includes conditions that increase susceptibility to fractures, such as osteopenia and osteogenesis imperfecta, metabolic and nutritional disorders (e.g., scurvy, rickets), renal osteodystrophy, osteomyelitis, congenital syphilis, and neoplasia www.dnbpediatrics.com
  14. 14. www.dnbpediatrics.com
  15. 15. A, Metaphyseal fracture of the distal tibia in a 3 mo old infant admitted to the hospital with severe head injury www.dnbpediatrics.com
  16. 16.  When to suspect as abuse: ◦ it shows clear delineation between the burned and healthy skin ◦ has uniform depth. ◦ mainly sock or glove distribution ◦ absent Splash marks. ◦ Symmetrical burns (especially suggestive of abuse as are burns of the buttocks and perineum). ◦ pattern Burn (hot objects such as curling irons, radiators, steam irons, metal grids,hot knives, and cigarettes.) www.dnbpediatrics.com
  17. 17. www.dnbpediatrics.com
  18. 18. Burns www.dnbpediatrics.com
  19. 19. 1. ‘‘battered child syndrome’’: serious physical abuse repeated and devastating injury to the skin, skeletal system or nervous system causing multiple fractures of different ages, head trauma and severe visceral trauma, with evidence of repeated infliction. 2. “The shaken infant”: (mainly < 1yr of age) Intracranial haemorrhages, retinal haemorrhages and chip fractures of the child’s extremities result from very rapid shaking of an infant www.dnbpediatrics.com
  20. 20.  Neglect refers to the failure of a parent to provide for the development of the child – where the parent is in a position to do so – in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions.  When to suspect : • Begs for or hoards food • States frequent/continual absence of parent or guardian • Frequently dirty or not bathed • Has unattended physical problems • Shows extreme dependence or detachment • Frequently hungry or inappropriately dressed • Engages in delinquent behavior, such as like stealing www.dnbpediatrics.com
  21. 21. CHILD SEXUAL ABUSE: Child sexual abuse is the exploitation of a child or adolescent for the sexual gratification of another person. IT INCLUDS: Oral-genital stimulation Sodomy Verbal stimulation Exhibitionism Voyeurism Fondlin Child prostitution Child pornography Intercourse www.dnbpediatrics.com
  22. 22.  Difficulty walking or sitting  Demonstrates unusual sexual knowledge/behavior above developmental level  Shows extreme compliance or defiance  Sudden reluctance to change near others (for activities such as gym)  Reported nightmares or bedwetting  Sudden change in appetite  Suddenly avoids a certain adult(s)  Experiences pain when urinating  Signs of eating disorders www.dnbpediatrics.com
  23. 23. Indicators of Child Abuse (Discovered by Family Doctor) Type of Abuse Physical Indicators Behavioral Indicators Physical Unexplained bruises, welts, burns, fractures, or bald patches on scalp Wary of adult contact, frightened of parents or afraid to go home, withdrawn or aggressive, moves uncomfortably, wears inappropriate clothing for weather Sexual Difficulty walking or sitting; torn or stained/blood underclothes; pain, itching, bruises, swelling in genital area; frequent urinary or yeast infections Advanced sexual knowledge, promiscuity, sudden school difficulties, self-imposed social isolation, avoidance of physical contact or closeness, depression Emotional Speech or communicative disorder, delayed physical development, exacerbation of existing conditions, substance abuse Habit disorders, antisocial or destructive behaviors, neurotic traits, behavior extremes, developmental delays Neglect Consistent hunger, poor hygiene, inappropriate dress, unattended medical problems, underweight, failure to thrive Self-destructive behaviors, begging or stealing food, constant fatigue, assuming adult responsibilities or concerns, frequently absent or tardy, states no caretaker in home www.dnbpediatrics.com
  24. 24. Do Immediately tell the child you believe them. Tell them they were right to tell you, and were brave to do so. • Acknowledge that it is difficult talk about this • Tell the child that they are not responsible and did not deserve it • Ensure that the child feels safe following disclosure DON’T • Panic or show that you are shocked. REMAIN CALM! • Never give the impression that you might blame the child. Don’t ask: “Why did you let him?”, “what were you doing there anyways?” or “why didn’t you tell me before?”. • Don’t promise that you won’t tell anyone if the child asks you to keep it a secret • Don’t ask intrusive questions. Listen but don’t push for more answers.
  25. 25.  Consultation with a physician expert in child maltreatment is recommended.  A thorough history should be obtained from the parent(s) optimally via separate interviews.  children should be interviewed separately, in a developmentally appropriate manner.  A thorough physical examination is necessary.  Careful documentation of the history and physical is essential. • For abuse: What is the evidence for concluding abuse? Have other diagnoses been ruled out? What is the likely mechanism of the injury? When did the injury likely occur? • For neglect: Do the circumstances indicate that the child's needs have not been adequately met? Is there evidence of actual harm? Is there evidence of potential harm and on what basis? What is the nature of the neglect? Is there a pattern of neglect • What is contributing to the maltreatment? Consider the factors listed under the section on etiology. www.dnbpediatrics.com
  26. 26.  Treat any medical problems. Help ensure the child's safety, often in conjunction with CPS; this is a priority.  Avoid blaming. It is natural to feel anger or pain towards parents of maltreated children, but they need support and deserve respect  Know your national and state laws and/or local CPS policies on reporting child maltreatment  Address contributory factors, prioritizing those most important and amenable to being remedied  Establish specific objectives, with measurable outcomes. Similarly, advice should be specific and limited to a few reasonable steps. A written contract can be very helpful. • Engage the family in developing the plan, solicit their input and agreement. • Build on strengths; there are always some. These provide a valuable way to engage parents. www.dnbpediatrics.com
  27. 27. • Encourage informal supports (e.g., family, friends; invite fathers to office visits). This is where most people get their support, not from professionals. Consider support available through a family's religious affiliation. • Consider children's specific needs. Too often, maltreated children do not receive direct services. • Be knowledgeable about community resources, and facilitate appropriate referrals. • Provide support, follow-up, review of progress, and adjust the plan if needed. • Recognize that maltreatment often requires long-term intervention with ongoing support and monitoring. www.dnbpediatrics.com
  28. 28. Guardian and Wards Act, 1890  Factories Act ,1954  Hindu Adoption and Maintenance Act, 1956  Probation of Offenders Act, 1958  Bombay Prevention of Begging Act, 1959  Orphanages and Other Charitable Homes (Supervision and Control) Act, 1960  Bonded Labour System (Abolition) Act, 1976  Immoral Traffic Prevention Act, 1986  Child Labour (Prohibition and Regulation) Act,1986  Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act, 1987  Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994  Persons with Disabilities (Equal Protection of Rights and Full Participation) Act, 2000  Juvenile Justice (Care and Protection of Children) Act, 2000  Commission for Protection of the Rights of the Child Act, 2005 www.dnbpediatrics.com
  29. 29.  Infanticide (Section 315)  Abetment of Suicide: Abetment to commit suicide of minor (Section 305)  Exposure and Abandonment: Crime against children by parents or others to expose or to leave them with the intention of abandonment (Section 317)  Kidnapping and Abduction: Kidnapping for extortion (Section 360) Kidnapping from lawful guardianship (Section 361) Kidnapping for ransom (Section 363 read with Section 384), Kidnapping for camel racing etc. (Section 363) Kidnapping for begging (Section 363-A) Kidnapping to compel for marriage (Section 366) Kidnapping for slavery etc. (Section 367) Kidnapping for stealing from its person: under 10 years of age only (Section 369)  Procurement of minor girls by inducement or by force to seduce or have illicit intercourse (Section 366-A) . Selling of girls for prostitution (Section 372) h) Buying of girls for prostitution (Section 373)  Rape (Section 376)  Unnatural Sex (Section 377). www.dnbpediatrics.com
  30. 30. SCHEMES AND PROGRAMMES ON CHILD PROTECTION  A Programme for Juvenile Justice for children in need of care and protection and children in conflict with law. The Government of India provides financial assistance to the State Governments/UT Administrations for establishment and maintenance of various homes, salary of staff, food, clothing, etc. for children in need of care and protection and juveniles in conflict with law. Financial assistance is based on proposals submitted by States on a 50-50 cost sharing basis.  An Integrated Programme for Street Children without homes and family ties. Under the scheme NGOs are supported to run 24 hours drop-in shelters and provide food, clothing, shelter, non-formal education, recreation, counselling, guidance and referral services for children. The other components of the scheme include enrolment in schools, vocational training, occupational placement, mobilizing preventive health services and reducing the incidence of drug and substance abuse, HIV/AIDS etc.  CHILDLINE Service for children in distress, especially children in need of care and protection so as to provide them medical services, shelter, rescue from abuse, counseling, repatriation and rehabilitation. Under this initiative, a telephone helpline, number 1098, runs in 74 urban and semi-urban centres in the country.  Shishu Greha Scheme for care and protection of orphans/abandoned/destitute infants or children up to 6 years and promote in-country adoption for rehabilitating them. www.dnbpediatrics.com
  31. 31.  .  Rajiv Gandhi National Creche Scheme for the Children of Working Mothers in the age group of 0- 6 years. The scheme provides for comprehensive day-care services including facilities like food, shelter, medical, recreation, etc. to children below 6 years of age.  Pilot Project to Combat the Trafficking of women and Children for Commercial Sexual Exploitation in Source and Destination Areas for providing care and protection to trafficked and sexually abused women and children. Components of the scheme include networking with law enforcement agencies, rescue operation, temporary shelter for the victims, repatriation to hometown and legal services.  National Child Labour Project (NCLP) for the rehabilitation of child labour. Under the scheme, Project Societies at the district level are fully funded for opening up of Special Schools/Rehabilitation Centres for the rehabilitation of child labourers. These Special Schools/Rehabilitation Centers provide non-formal education, vocational training, supplementary nutrition and stipend to children withdrawn from employment.  INDO-US Child Labour Project (INDUS): The Ministry of Labour, Government of India and the US Department of Labour have initiated a project aimed at eliminating child labour in 10 hazardous sectors across 21 districts in five States namely, Maharashtra, Madhya Pradesh, Tamil Nadu, Uttar Pradesh and NCT of Delhi. www.dnbpediatrics.com
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