Child Abuse

1
Child Abuse Neglect for Health Care Providers
2
Introduction

• Child abuse and neglect are widespread, found
  across all levels of socioeconomic status, all
  racial and ethnic (cultural) groups, and all
  religious affiliations.
• Healthcare providers are in a unique position to
  identify abuse and neglect.
• Moral and legal obligation to report abuse and
  neglect, whether suspected or confirmed.

3
Abuse Defined

• Abuse A patient has suffered physical or
  emotional injury inflicted by a caregiver (eg,
  parent, legal guardian, teacher, etc) that
  results in disability, disfigurement, mental
  distress, or risk of death.

4
Neglect Defined

• Neglect A childs physical, mental, or emotional
  condition has been endangered because the
  caregiver has not provided for the childs basic
  needs.

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The HCWs role

• Recognize signs/symptoms of abuse and neglect.
• Provide medical evaluation and treatment.
• Protect from further abuse.
• Report all cases of suspected abuse.
• Document all findings accurately, thoroughly, and
  legibly.

6
Recognizing Abuse/Neglect

• Importance of History
• Injury or illness inconsistent with history
• Critical to determine whether injury or illness
  could have been caused unintentionally or was
  inflicted
• Multiple visits to ED from same household or
  previous visits for family violence

7
Recognizing Right to Privacy

• Children have right to refuse
• Adolescents especially sensitive
• Do not examine unwilling child, especially if
  sexual abuse is suspected
• Give choices if possible

8
Recognizing Skin Injuries

• Most common and easily recognized sign of abuse
• Conduct complete, thorough skin examination
• Always look for cuts, scrapes, bruises, burns,
  bites, redness, swelling
• Describe systematically and consistently when
  documenting

9
Recognizing Bruises

• Note location(s)
• Infants rarely bruise accidentally
• Young, active children tend to incur bruises
  naturally on front of body (eg, knees, shins,
  elbows, forehead)
• Bruises in recognizable shape of object are
  suspect
• Multiple bruises in different stages of healing
  are suspect

10
Recognizing Burns

• Scald burns common
• Two general patterns immersion and splash
• Immersion burns characterized by clear lines of
  demarcation
• Examples Donut pattern burn on buttocks or
  stocking/glove pattern burns of arms or lower
  legs
• Accidental burns more often have splash marks as
  child withdraws from heat source

11
Recognizing Bites

• Adult human bite marks strongly suggest abuse
• In general, bite marks are multiple, random, well
  defined
• No one tooth mark stands out (differing from
  animal bites)

12
Recognizing Fractures

• Fractures discovered accidentally
• Skeletal injury inconsistent with history
• Multiple fractures in different stages of healing
• Accompanied by other injuries

13
Recognizing Falls

• Fall from standing position or low object (less
  than childs height) rarely results in serious
  injuries
• Fall from greater than childs height usually
  required to sustain serious injury

14
Recognizing Injuries to Face Head

• Unintentional injuries usually involve front of
  body
• Specific injuries to side of face, cheeks, ears
  suspicious of abuse
• Direct blow to mouth usually results in lip tear,
  possibly with broken jaw or teeth
• Considerable force required to cause severe head
  trauma

15
Recognizing Hair Loss

• Can be manifestation of child abuse
• May be self-inflicted to relieve stress
• Can be caused by dragging child by hair, using
  excessive force during brushing, or certain types
  of hair braiding
• Often blood at the surface or beneath scalp

16
Recognizing Shaken Baby Syndrome

• Most common in children less than 2 years old
• May be no evidence of external trauma
• Possible signs include decreased consciousness,
  seizures, vomiting, other signs of head injury,
  unusual cry
• Altered mental status may be only sign
• Recognizing the possibility should trigger
  suspicion of abuse

17
Recognizing Sexual Abuse

• Signs may include pain, bleeding, or discharge
  from urethra, vagina, or rectum
• Can also be insidious, chronic, hidden abuse
  occurring over weeks or months
• In these cases, signs may include nonspecific
  abdominal pain, vaginal inflammation, or painful
  urination
• Physical examination normal in most cases

18
Treating sexually abused patients

• Believe what the child says
• Use the childs own words and document statements
  in quotes
• Never examine unwilling child
• Do not remove childs clothing or examine
  genitals unless severe genital pain or gross
  genital bleeding
• Refer child to specialist for examination

19
Recognizing Emotional Abuse

• A component of all forms of child abuse
• Attack on childs development of self and social
  competence
• May not be done on conscious level
• Most cases mild, but early recognition important

20
Recognizing Emotional Abuse

• Ignoring the child
• Rejecting the childs needs and requests
• Isolating the child
• Verbally assaulting the child (eg, name-calling,
  harsh threats)
• Encouraging destructive, antisocial behavior
• Humiliating the child

21
Recognizing Neglect

• Most common form of child abuse
• Likely most under-recognized and under-reported
  form of child abuse
• Neglected children suffer greatly, often left
  with emotional scars

22
Recognizing Neglect

• Inadequate care, including inadequate provision
  of food, clothing, or shelter
• Inadequate medical attention, including delay in
  seeking care for known illness
• Example While child is having asthma attack,
  mother leaves home to go shopping.

23
Recognizing Neglect

• Signals to watch for
• Poor personal hygiene
• Unsanitary conditions
• Inadequate sleeping arrangements
• Lack of supervision
• Evidence of substance abuse
• Structural, fire, environmental hazards

24
Recognizing Munchausen Syndrome by Proxy

• Bizarre and rare form of child abuse
• Illness in child is repeatedly induced by parent
  or other caregiver, who denies knowledge of cause
• Symptoms subside when child is separated from
  parent or caregiver
• Child should not be left alone with parent or
  caregiver

25
Cultural Considerations

• Childrearing practices greatly influenced by
  culture
• Examples babies allowed to cry themselves to
  sleep, children sleeping in parents bed for
  several years
• Practice considered abuse in one culture may be
  norm in another
• Examples scarification of face, physical
  discipline

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Cultural Considerations

• Cultural differences may affect evaluation of
  case
• Important to be aware of other cultures in own
  community
• Families may not realize that certain practices
  are considered abuse in US

27
Folk Medicine Practices

• May mimic abuse
• Should not be reported as abuse (usually)
• Examples
• Coin rubbing rubbing a coin along the skin may
  produce bruise-like rash
• Cupping applying heated cup to skin and pulling
  off after suction develops causes circular
  bruises
• Moxibustion treatment related to acupuncture in
  which lighted objects placed on skin result in
  burns

28
Communicating with Caregivers

• The primary goal is to protect the child from
  further injury.
• Families likely to react negatively
• Best to discuss in a place where assistance is
  immediately available
• Police presence may be desirable

29
Reporting Abuse/Neglect

• Reports must be made when child abuse or neglect
  is suspected or there is reasonable cause to
  believe that child abuse or neglect has occurred
• Proof is NOT required

30
Reporting Abuse/Neglect

• Reasonable Cause When the pre-hospital provider
  HCW becomes aware of the possibility of neglect
  or abuse they have a duty to report

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Reporting Abuse/Neglect

• The reasons for reporting are
• to determine whether or not an investigation will
  ensue
• to determine whether or not abuse or neglect
  occurred
• to determine what happened and who is responsible
• to safeguard the child from future injury

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Legal Obligations

• Immediate notification to DCF required for
  parents of an infant who have requested
• deprivation of nutrition necessary to sustain
  life
• deprivation of medical or surgical interventions
  necessary to remedy or ameliorate a
  life-threatening condition (may not apply to
  terminally ill children if treatment would be
  ineffective)

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Legal Obligations

• Laws protect a person making a report in good
  faith, by making them immune from civil or
  criminal liability
• Failure to report or actions to prevent someone
  else from reporting is a misdemeanor with a fine
  of up to 500 or imprisonment of up to 1 year.
  Such individuals are also civilly liable for
  damages caused by their failure to report.