Child abuse (Victim Service Division) PowerPoint Presentation

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“So long as little children are allowed to suffer, there is no true love in this world” Duncan

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Child Abuse In 1999, the WHO Consultation on Child Abuse Prevention compared definitions of abuse from 58 countries and drafted the following definition: ‘‘Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.’’

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Definition of Child Abuse “The physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate that the child’s health or welfare is harmed or threatened.” Child Welfare Act

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Another Definition “Any behavior directed toward a child that endangers or impairs a child’s physical or emotional health and development”

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Types of Child Abuse physical abuse sexual abuse emotional abuse neglect

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Health Consequences of Child Abuse

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Health Consequences of Child Abuse(cont.)

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Child Maltreatment Approximately 60% of referrals are made by professionals Teachers represent the largest referral source at 17% If NO intervention: 50% chance of repeated abuse 10% chance of mortality

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Who are at Risk -Abuse most common in children < 1 yr. old -Girls more frequently abused at older age vs. boys

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Three Major Components of Child Abuse Child + Care Giver + Stress = Child Abuse

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Role of First Responders in Child Abuse Protect Suspect Inspect Collect Respect

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Protect... Patient/family and team safety are paramount. Protect the life of the patient as well as as much evidence as possible.

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\\ Suspect... Does the history fit what you are seeing- either injury or illness? Is this a repeat patient or family member of a repeat patient? Is there a history of family violence?

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Collect... Collect as much evidence as possible, including… physical and trace evidence information

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Respect... Respect the right to refuse Respect diversity Respect privacy

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Responsibilities to Report... Who must report… Deciding to report… A report of suspected child abuse is a responsible attempt to protect a child.

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Physical Abuse Physical abuse is any non-accidental injury to a child under the age of 18 by a parent or caretaker. These injuries may include beatings, shaking, burns, human bites, strangulation, or immersion in scalding water or others, with resulting bruises and welts, fractures, scars, burns, internal injuries or any other injuries.

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Bruising Cutaneous injuries are the single most common presentation of physical child abuse Bruises are the most common type of injury in abused children

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Definitions Bruise (contusion): Bleeding beneath the intact skin at the site of blunt impact trauma Loop marks Slap marks Ecchymosis: Blood that has dissected through tissue planes to become visible externally Battle’s sign Petechiae Hematoma: Blood that has extravasated from the vascular system into the body Subdural hematoma Intra-abdominal bleeding

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Can bruises be dated? Importance of color: Red/blue/purple is associated with recent bruising Yellow/brown and green is associated with older healing (yellow greater than 18hours) BUT – any of these colors can be observed in a bruise at any time before it fully resolves

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Assessment of the age of a bruise in children is inaccurate and has NO scientific basis

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Bruising and Age/Development Bruising is rare in infants/precruisers and becomes increasingly more common as children age and develop If bruising is seen in a non-ambulatory child, consideration should be given to abuse or some other underlying condition

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Where is the bruise? Accidental Shins Elbows Lower arms Forehead Vertex of chin Ankles Hips Abuse Upper anterior thighs Trunk (torso, chest, back) Upper arms Face and ears Neck and cheeks Hands and fees Buttocks/genitalia

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Bony prominences tend to be bruised unintentionally in mobile cruisers or ambulatory children Soft tissue areas tend to be bruised from abusive mechanisms

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Bruising: Investigative Recommendations 1. Recognize patterns 2. Examine the entire body 3. Photodocument everything 4. Keep an open mind 5. Scene investigations are critical

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Corporal Punishment Corporal punishment of children --- in the form of hitting, punching, kicking or beating --- is socially and legally accepted in most countries. In many, it is a significant phenomenon in schools and other institutions and in penal systems for young offenders.

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Burns

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Epidemiology of Burns Pediatric burns cause: - Over ¼ million injuries/year req. medical attn. - Over 15,000 hospitalizaions/year - Over 10,000 cases of severe disability/year - 1,100 deaths per year Third leading cause of mortality in children less than 5 years of age

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Burns Caused by Abuse/Neglect In the U.S., scald burns from tap water are the most common abusive burn Abuse related burns carry higher morbidity than accidental burns Boys 2-3 times more likely to sustain abusive burns Mean age between 2-4 years

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Burns: The Medical Evaluation Any red flags in the history? How severe is the burn? Is this really a burn? Does the burn have a pattern? Does the pattern match the history we have been provided?

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How severe is the burn? Severity of a burn is based on: Thickness of the skin Varies by age, gender, and location on body Infant skin is often ½ thickness of adult skin Classifications: Superficial (1st degree) Partial thickness (2nd degree) Full thickness (3rd degree

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Liquid Burns and Patterns Scalding is the most frequent form of burn abuse More than 80% of abusive burns from tap water Patterns: Immersion (stocking/glove or doughnut) Drip or skin-sparing patterns

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Cigarette Burns Intentional: Firm contact produces a sharp circular pattern Approx. 5-10mm diameter Exposed areas (hands, feet, head) Accidental: typically causes only superficial “brush” burns

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Abusive Head Trauma Battered child syndrome Whiplash shaken infant syndrome Shaken baby syndrome Impact head unjuries ALL equal Abusive Head Injury/ Inflicted Head Trauma

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Scope of the Problem A leading cause of morbidity and mortality in infants and children Abuse is the most common cause of head injury in children less than 1 year of age The most common cause of death in children who are abused

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Mechanism of Injury Shearing force and impact to brain inside of bony skull Most often involved children less than 1 year of age. WHY?

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Clinical Presentations “Serious” Apnea Lethargy Seizures Increased or decreased tone Impaired consciousness “Less serious: Poor feeding Irritability Vomiting

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Classic Injuries 1) Cranial Injuries Injury may occur at multiple levels Most often subdural hemorrhage – seen in 90% Cerebral edema (brain swelling)

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Classic Injuries 2) Retinal hemorrhage Bleeding in one or more layers of the eye Seen in 65-95% of cases of abusive head inj. Often asymmetric or one-sided Requires trained professional to diagnose PATHOGNOMONIC of traumatic head injury

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Classic Injuries 3) Skeletal Injury Rib Fractures Classic metaphyseal lesions Skull fractures

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Suspicious Fractures /

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Falls / In most cases, falls cause a minor injury. If a child is reported to have had a routine fall but has what appear to be severe injuries, the inconsistency of the history with the injury indicates child abuse.

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Head, Facial, Oral Injuries Head is a common area of injury. Approx. 50 % of physical abuse patients have head or facial injuries. Injuries to the sides of the face, ears, cheeks, and temple area are highly suspicious for abuse. Mouth/lip/teeth injuries

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Human Bites / Strongly suggest abuse Easily overlooked Location of bite marks on infants differ from sites on older children

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Neglect 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. Neglect is thus distinguished from circumstances of poverty in that neglect can occur only in cases where reasonable resources are available to the family or caregiver.

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Definition of Failure-to-Thrive From the AAP 2005: “A significantly prolonged cessation of appropriate weight gain compared with recognized norms for age and gender after having achieved a stable pattern.”

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Incidence of Failure-to Thrive Starvation affects > 3 million children worldwide While neglect is the most common form of child maltreatment, it is unclear what percentage of these cases represent nutritional neglect Up to 10% of low-income American children have failure to thrive.

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Causes of Failure to Thrive Organic (medical) Inadequate intake Increased metabolic rate Maldigestion/absorption Prematurity Developmental delay Congenital anomalies Non-organic (social causes) Food withheld Inappropriate diet Inappropriate preparation

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Risk Factors for Failure to Thrive Poverty Unusual health and nutrition beliefs Social Isolation Substance abuse Violence or domestic abuse Mental health issues Poor parenting skills Infant – Caregiver attachment issues

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When is Obesity Neglect? When all 3 conditions are present: 1. There is a high likelihood of serious harm 2. A reasonable likelihood that intervention will help 3. There are no other alternatives.

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PSYCHOLOGICAL MALTREATMENTDefinition Psychological Neglect - the consistent failure of a parent or caretaker to provide a child with appropriate support, attention, and affection. Psychological Abuse - a chronic pattern of behaviors such as belittling, humiliating, and ridiculing a child.

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Emotional Abuse Emotional abuse includes the failure of a caregiver to provide an appropriate and supportive environment, and includes acts that have an adverse effect on the emotional health and development of a child. Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other nonphysical forms of hostile treatment.

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CHILD SEXUAL ABUSEDefinition Child sexual abuse is the exploitation of a child or adolescent for the sexual gratification of another person.

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Sodomy Oral-genital stimulation Verbal stimulation Exhibitionism SEXUALLY ABUSIVE BEHAVIORS Voyeurism Fondling Child prostitution Child pornography Intercourse

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Recognizing Abuse Injuries / Skin Injuries Human Bite Marks Hair Loss Falls Head, facial, oral injuries Shaken baby Syndrome

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Indicators of Child Abuse (Discovered by Family Doctor)

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Confounding Factors / Normal childhood development Conditions that may be confused with abuse Unintentional vs intentional injury

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Questions??