Week 9: Child Maltreatment

Is child abuse common?

Yes, it more common than some diseases such as leukemia, CF, diabetes, and meningitis

What are the three main categories of child maltreatment?

Physical Abuse, Sexual Abuse, and Neglect

What are the types of child neglect?

Physical, medical, environmental, emotional, nutritional, supervisory, and educational

What are some reasons people abuse children?

Exact cause unknown but can be related to parental characteristics, child characteristics, and environmental characteristics

What are family and environmental risk factors for child maltreatment?

Single parent, intimate-partner violence, unemployment, financial stress, poverty, limited resources, change in the primary caregiver, number of people living in the household (more people= higher risk), major life changes

What are caregiver risk factors that increase the likelihood of child maltreatment?

Unrealistic expectations for the child’s behavior, immature parent (young), poor coping skills, substance abuse, caregiver abused as a child, prior CPS involvement, depression, low self-esteem

What is colic?

Crying ALL of the time; inconsolable

What are child characteristics that increase the risk of child maltreatment?

0-3years old because they are 100% dependent on the caregiver, colic, any disabilities, chronic illness, hyperactivity, resemblance to abuse person from past relationship, unwanted child

What is neglect?

The failure of a parent or caregiver to meet a child’s basic needs (physical, medical, educational, and emotional)

What are contributing factors of neglect?

Ignorance of the child’s needs, lack of resources, poor parenting skills, failure to recognize emotional nurturing as an essential need of children, “this is all they know”

What are signs in a child that would indicate the possibility of neglect?

Is frequently absent from school, begs or steals food or money, lacks needed medical/dental care/immunizations/glasses, is consistently dirty, lacks sufficient clothing for the weather, abuses alcohol or drugs, states that there is no one at home to provide care

What are signs in a parent/caregiver that could possibly indicate neglect?

Appears to be indifferent to the child, denies existence of or blames the child for the child’s problems at home and school, seems apathetic or depressed, behaves irrationally or odd, is abusing alcohol and/or drugs

What is physical abuse?

No accidental physical injury to a child caused by a parent or caregiver

What is the number one sign of physical abuse?

Bruising

What are the signs of physical abuse?

Bruising, fractures, burns, abdominal injuries, abrasions, lacerations

What are triggering situations that may result in a parent or caregiver physically abusing a child?

Colic, feeding issues, toilet training, child’s misbehavior (tantrums), argument/family conflict, parental stressors outside of the home (money, job, etc.)

What is the number one triggering situations that leads to physical abuse of a child?

Colic

Why is it so challenging to recognize abuse?

Abuse is not black and white; there are no injuries that are always or never caused by abuse; there are common patterns of abuse and behaviors seen at various ages

What are “red flags” that would make you question if physical abuse was occurring for a child?

Physical evidence, no Hx to explain physical findings, injury inconsistent with Hx or developmental level, delay in seeking medical attention, Hx changes between caregivers, parents blame the child or siblings, seek medical attention far from home, reaction to injury is inappropriate (too concerned or not concerned enough)

Why is it a red flag for physical abuse when the caregivers blame the child or siblings for the physical injuries?

Children don’t typically have enough strength or force to create a bruise or broken bone

What is considered normal bruising?

No bruising before they can move around (4-6months), Bruising on bony prominences (>6months), no bruising on squishy parts or back of the body (stomach)

What are behavior characteristics of abused children?

Wary of adults or clingy to healthcare workers, always watchful as though preparing for something bad to happen, is overly compliant or withdrawn (little movement or crying during painful procedures), does not turn to parent for support, constantly tries to please the parent and assess the parent’s reaction, aggressiveness toward animals or smaller children, sudden changes in behavior or school performance (older children), has learning problems, comes to school or activities early, stays late, and does not want to go home

What are behavior characteristics for abusive caregivers?

Shows little concern for the child, asks teachers to use harsh physical discipline if the child misbehaves, sees the child as entirely bad/worthless/burdensome, demands a level of physical or academic performance the child cannot achieve, looks primarily to the child for care

Is a bruise an injury?

Yes! Absolutely!

What is the TEN-4-FACESp tool? What is it used for?

Tool that is used when bruising is concerning for abuse in children less than 4 years

What does the TEN stand for in the TEN-4-FACESp tool?

Torso (chest, back, bottom), Ears (highly protected area), neck; this is extremely concerning and requires immediate follow-up

What does the 4 stand for in the TEN-4-FACESp tool?

Infants 4 months of age and younger

What does the F in FACES stand for in the TEN-4-FACESp tool?

Frenulum (thin band of tissue that connects lips to gums or tongue to floor of the mouth) damaged or broken due to forcing things in the mouth such as a bottle;

What does the FACES stand for in the TEN-4-FACESp tool?

Frenulum, angle of the jaw, cheeks, eyelids, subconjunctival hemorrhage

What does the p stand for in the TENS-4-FACESp tool?

Patterned injury (cord, belt, handprint)

What is developmentally appropriate bruising?

It is normal for mobile children to bruise overlying bony areas of the body such as the shins, elbows, knees, and forehead; seatbelt pattern associated with a car accident

What disorder looks similar to bruising from abuse?

Congenital Dermal Melanocytosis

Do you see external signs of abdominal injuries?

May or may not see external injury (bruising)

What are signs of immersion burns?

Clear delineation between burned and unburned areas, spared skin in creases or where pressure has prevented the fluid from contacting the skin, absence of splash marks

What are types of burns?

Contact burns (prolonged transfer of head from an object to the skin), immersion burns, chemical burns, pattern burns (irons, heater grates, cigarettes), rope burns

What are characteristics of cigarette burns?

9-10mm circles, sharp edges, typically see several, found on soles of feet/ palms of hands/ hidden areas

What age range do fractures typically indicate abuse?

<3 years old because it is not developmentally appropriate for them to have fractures

What types of fractures typically indicate abuse?

Multiple fractures especially those with different stages of healing, unexplained fractures; common areas include femur, humerus, tibia, radius, skull, spine, ribs, ulna, fibula, nose, or facial bones

Why are rib fractures really concerning?

Posterior rib fractures are caused by violent squeezing of the chest, not direct impact from something like a fall; highly specific for physical abuse

What are metaphysical fractures?

Spiral fractures that involve shearing force applied across a joint by twisting, taking, flailing of the extremity; very unusual accidental injury that is highly specific for abuse

Why are infants at a greater risk for abuse?

Dependency, isolation, lack of language, and size

What is the age with the highest risk for Pediatric Abusive Head Trauma (PAHT)?

1-2 months old

What is the average range for the risk of Pediatric Abusive head Trauma?

6 months

What is Pediatric Abusive Head Trauma (PAHT)?

Global brain injury that was caused by shaking, impact, or both that typically happens more than once

Why are infants more affected by PAHT than older children and adults?

Disproportionately larger head to the body, weak neck muscles, smoother skull, immature brain, more extra-axial space, infant brain has 25% more water than adults

What are some different injuries that PAHT can cause?

Close or open head injury, subdural hematoma, death, irreversible brain damage, vision impairment, CNS injury, loss of speech and hearing, memory and attention problems, learning disabilities, and cerebral palsy

What are s/s of PAHT?

Altered mental status (really sleepy, not feeding well), irritability, difficult to console, breathing abnormalities (apnea), increased ICP, bulging/tense fontanelle, bruises, poor feeding, seizures or posturing, unequal pupils, high pitched cry, retinal hemorrhages, pale/cold/clammy skin, vomiting, behavior changes, poor head control; could have a completely normal exam

What some common symptoms that could be associated with PAHT?

Retinal hemorrhages, skeletal fractures (skull, ribs, long bones), bruising of the skin (black eyes), internal abdominal injury; OR NOTHING

What are the typical perpetrator characteristics of PAHT?

Male, age <30yrs, education less than high school, illiteracy, depression, social isolation, substance abuse, low self esteem, poor impulse control

What are the typical child characteristics of PAHT?

Male gender, colic, prematurity, low birth weight, drug/nicotine/alcohol exposure or withdrawal syndrome, special needs, being one of a multiple birth (twin or triplet)

What are nursing responsibilities for PAHT?

Prevention, recognition, reporting

What is the nurses role in prevention of PAHT?

Education about coping with triggers for abuse (crying), walking away and calling for help, make sure basic needs are met, check for signs of illness, rock or walk with infant, bring baby outside for fresh air, sing or talk to baby, offer a pacifier, call the doctor, Period of Purple, Dr. Harvey Karp’s 5 S’s

What does the Period of Purple Crying teaching tool?

Peak of crying, Unexpected crying, Resists to soothing, Pain-like face, Long lasting, Evening crying

What are Dr. Harvey Karp’s 5 S’s?

Swaddling, shushing, swinging, sucking, and side/stomach position

What is the nurses role in identifying/recognizing PAHT?

Look for skin findings on physical exam, know the TEN-4-FACESp tool, know developmentally appropriate skin findings, when talking with family and patient be understanding and stay open minded, stay objective, examine bruises closely and decide if they match the story and if it is feasible

What are red flags of PAHT?

No or vague explanation of the injury, a detail changes (caregivers should know), an explanation that is not consistent with the injury, an explanation is inconsistent with the child’s physical or developmental abilities, different witnesses provide different explanations of the injury

What are common mistakes that cause people to miss or ignore the signs of PAHT or abuse?

Diagnosing the injury as accidental, subtle exam clues are missed, just because the family seems nice doesn’t mean they can’t be abusive, giving the benefit of the doubt

What are things that a nurse should document if PAHT or abuse is suspected?

What you see, hear, and ask; color/shape/location/size of bruising, what the child and parent say happened, a list of all the questions you asked, any pain or tenderness, overall health and hygiene, developmental level of the child

What should a nurse do for a child who is suspected to have PAHT or abuse?

Meet the physical needs, provide a role model for parenting, provide support, document fully and objectively, report

What are characteristics of a sexual abuser?

Male, well-known to the child (from school, family, extracurricular activities), often in positions where they work closely with children, abuse is repetitive, use of coaxing and threats

What are characteristics of sexual abuse victims?

Little physical evidence, if they tell you believe them because they rarely make it up, possess sexual knowledge beyond with is developmentally appropriate, antisocial behavior, behavioral changes such as stress, anxiety, sexual curiosity, constant masturbation, seductive behavior, or fear of strangers

What are nursing interventions for sexual abuse?

Always believe the victim, provide a safe space, and do not promise to keep secrets but can promise to keep them safe

What is Munchausen Syndrome by Proxy?

Disorder in which the caretaker of a child either makes up fake symptoms or causes real symptoms to make it appear that the child is injured or ill

What are perpetrator characteristics of Munchausen Syndrome by Proxy?

Being a parent, being a healthcare professional or having medical knowledge, being very friendly and cooperative, appearing overly concerned, suggesting certain tests or procedures

What are child characteristics of Munchausen Syndrome by Proxy?

<6yrs old, uncooperative, anxious, fearful, negative, isolation (mom is best friend, homeschooled, no additional friends)

What are common “illnesses” that children experiencing Munchausen Syndrome by Proxy present with?

Apnea, seizures, bleeding, fevers, blood infections, vomiting, diarrhea

When should we suspect Munchausen Syndrome by Proxy?

Unexplained prolonged, recurrent, or extremely rare illnesses, discrepancies between clinical findings and history, unresponsive to treatment, s/s only occurring in parents presence, parent refuses to leave the child’s room

When is spanking considered abuse?

When it has left a mark or is done with an object