Child Maltreatment

3 factors that influence the potential for abuse

 Parental characteristics

 Characteristics of the child

 Environmental characteristics

family and environmental characteristics for child maltreatment

 Single parent (or primary caregiving role with little help)

 IPV

 Unemployment/financial stressors

 Isolation

 Poverty/limited resources

 Change in the primary caregiving role

 Number of people living in the household

 Major life changes

caregiver characteristics - risk factors

 Unrealistic expectations for the child’s behavior

 Immature parent

 Poor coping skills

 Substance abuse

 Caregiver abused as a child

 Prior CPS (child protective services) involvement

 Depression

 Low self esteem

child characteristics - risk factors

 0-3 years old

 Colic

 Physical /developmental disabilities

 Emotional/behavioral difficulties

 Prolonged or chronic illness

 Hyperactivity

 Resemblance to abusive person from past relationship

 Unwanted child

neglect definition

failure of parent/caregive to meet a child’s basic needs

types of neglect (4)

 Physical (food,shelter,lack of supervision)

 Medical (Failure to provide necessary medical or mental health treatment)

 Educational (failure to educate a child or attend special education needs)

 Emotional (inattention to a child's emotional needs)

contributing factors in 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”

consequences of global neglect

 Developmental Delay

 Neuropathlogic consequences

 Poor socialization

 Parentification

 Multiple minor scarring injuries

 Death or serious injury during inappropriate supervision

 When combined with physical/sexual abuse a high percentage will develop personality disorders associated with criminal and abusive behaviors as adults

when to consider possibility of neglect - child

 Is frequently absent from school

 Begs or steals food or money

 Lacks needed medical or dental care, immunizations, or glasses

 Is consistently dirty and has severe body odor

 Lacks sufficient clothing for the weather

 Abuses alcohol or other drugs

 States that there is no one at home to provide care

 Has not received help for physical or medical problems brought to the parents’ attention

when to consider the possibility of neglect in caregiver

 Appears to be indifferent to the child

 Denies the existence of—or blames the child for— the child’s problems in school or at home

 Seems apathetic or depressed

 Behaves irrationally or in a bizarre manner

 Is abusing alcohol or other drugs

physical abuse definition

nonaccidental physical injury to a child caused by a parent, caregiver, or other person responsible for a child

major signs of physical abuse (6)

 Bruising (#1 sign)

 Fractures

 Burns

 Abdominal injuries

 Abrasions (typically nonspecific )

 Lacerations

triggering situations

 Crying baby (Colic)

 Feeding issues

 Toilet training

 Child’s misbehavior

 Argument/family conflict

 Parental stressors outside of the home

red flags

 Physical evidence of abuse or neglect, including previous injuries

 No history provided to explain physical findings

 Injury not consistent with history or developmental level

 Delay in seeking medical attention

 History changes, “conflicting stories”

 Parents blame the child or sibling

 Seek medical attention far from home

 Reaction to injury is inappropriate

behavior characteristics of abused children

 Wary of adults

 Vacant stare or is always watchful, as though preparing for something bad to happen

 Is overly compliant, passive, or withdrawn (Little movement or crying with painful procedures)

 Does not turn to parent for support

 Constantly tries to please parent and to assess parental reaction

 Role reversal

 Aggressiveness toward animals or smaller children

 Shows sudden changes in behavior or school performance

 Has learning problems (or difficulty concentrating) that cannot be attributed to specific physical or psychological causes

 Comes to school or other activities early, stays late, and does not want to go home

behavior characteristics of abusive caregivers

 Shows little concern for the child

 Denies the existence of—or blames the child for—the child's problems in school or at home

 Asks teachers or other caregivers to use harsh physical discipline if the child misbehaves

 Sees the child as entirely bad, worthless, or burdensome

 Demands a level of physical or academic performance the child cannot achieve

 Looks primarily to the child for care, attention, and satisfaction of emotional needs

what is the most common direct sign of physical abuse to be missed?

bruising

TEN 4 FACESp

look at slide!!

developmentally appropriate bruising

 It can be normal for mobile children to bruise overlying bony areas of the body

 Shins

 Knees

 Elbows

 Forehead

serious abd injuries from abuse

 Ruptured Liver or Spleen

 Intestinal Perforation

 Pancreatic Injury

 Kidney Injury

immersion burns

 Clear delineation between burned and unburned areas

 Sparing in flexion creases or where pressure has prevented the fluid from contacting skin

 Absence of “splash” marks

contact burns

may result in severe burn injury dt prolonged transfer of heat from an object to the skin

other types of burns

• chemical

• pattern burns - irons, heater, cigarettes

• rope burns

cigarette burns

 9-10 mm in diameter

 Circular

 Sharp edges

 Typically see several

 3rd degree centrally, 2nd degree & elevated peripherally

abuse fracture characteristics

 Majority of fractures in child < 1 year are from abuse

 High percentage of fractures < 3-yo = abuse

 Common areas include femur, humerus, tibia, radius, skull, spine, ribs, ulna, fibula, nose, or facial bones

 Multiple fractures especially those with different stages of healing

 Unexplained fractures

rib fractures

 Posterior rib fractures are caused by violent squeezing of the chest

 Back is unsupported, so that ribs bend back over the sides of the backbone

 Posterior fractures are not a result of direct impact (fall)

 Highly specific for physical abuse

metaphyseal fractures

 “Corner fractures”

 Highly specific for abuse in otherwise healthy infants

 Very unusual in accidental injury, OI, birth

 Involves shearing force applied across a joint

 Implies twisting, yanking, flailing of extremity

infants are more likely than any other age group to suffer which forms of abuse or neglect?

 Fatal abuse

 Abusive head trauma

 Abusive fractures

 Munchausen's Syndrome by Proxy

 Global neglect with failure to thrive

featurse predisposing infants to serious absue

 Dependency

 Isolation

 Lack of Language

 Size

***The trigger for most abuse in infancy is crying, especially prolonged crying

number 1 cause of mortality/morbidity related to child abuse

PAHT

pediatric abusive head trauma (PAHT) definition

• injuries to the head and spine of a chidl that occur as a result of abuse

• global brain injury caused by rotational/angular forces

• shaken baby, inflicted head injury, shaken impact syndrome

mechanisms of injury PAHT

• shaking

• impact

• crush

• combo

prevalence of PAHT (ages)

 PAHT usually occurs in children younger than 1 year of age, but has been found in school aged children older as well.

 Average age of PAHT is 6mo old

 Peak age of fatal PAHT is 1-2mo

 It is the most common cause of death from brain injury in children less than one year of age

what can PAHT cause

 Subdural hematomas and or other intracranial bleeds, +/- retinal hemorrhage, scalp bruising, skull fracture…but it’s the injury to the brain tissue itself that causes death and disability

 Symptoms occur immediately following the abusive act, however, can be highly variable ranging from somnolence/stopping crying to loss of consciousness, apnea or cardiac arres

PAHT infant anatomy risk factors

 Disproportionately larger head to body

 Weak neck muscles

 “Smoother” skull

 Immature brain, less myelination

 More space extra-axial space

 Infant brain is 25% more water than adults

 Think underset gelatin

how does shaking cause the injury

head in motion = torn bridging vessel = SDH

evidence of impact in PAHT

 If impact is involved, may see skull fracture, scalp bruise, or scalp swelling - but not necessarily

 Impact on a soft surface can leave no evidence of impact

 Never be falsely reassured by the absence of bruising

PAHT injury types

 Closed Head Injury

 Open Head injury; skull fractures

 Subdural hematoma

 Death

 Irreversible Brain Damage

 Vision impairment

 Spinal Cord or Central nervous System injury

 Loss of speech & hearing

 Problems with memory and attention

 Learning Disabilities

 Cerebral Palsy

PAHT s/s

 Altered mental status

 Persistently irritable, difficult toconsole

 Breathing abnormalities

 Increased head size compared to previous measurements (especially dramatic increases)

 Bulging or tense fontanelle

 Bruises, poor feeding

 Seizures or posturing

 Unequal pupils, high pitched cry

 Retinal Hemorrhages

 Pale, mottled, cold, clammy skin

 Vomiting, behavior changes

 OR relatively normal exam

PAHT common associated symptoms (4)

 Retinal Hemorrhages

 Skeletal fractures: skull, metaphyseal, rib, long bones, etc.

 Bruising of the skin (black eyes)

 Internal abdominal injury (won’t necessarily see bruising!)

perpetrator characterisitcs

 Male

 Age less than 30 years

 Education less than high school

 Illiteracy

 Depression

 Social Isolation

 Substance Abuse

 Low self esteem

 Poor impulse control

risk factors of the child

 Male gender

 Colic

 Prematurity

 Low birth Weight

 Drug/nicotine/alcohol exposure or withdrawal syndrome

 Special needs or medically fragile

 Infants with NAS, or being a child who cries frequently

 Being one of a multiple birth

strategies on how to cope iwth triggers for abuse

 Period of purple crying

 Dr Harvey Karp's five S’s

 Walk away and call for help

 Make sure basic needs are met (change diaper, feed baby)

 Check for signs of illness

 Rock or walk with infant

 Bring baby outside for fresh air/stroller ride

 Sing or talk to baby

 Offer a pacifier

 Call the doctor

period of PURPLE crying

• P - peak of crying

• U - unexpected

• R - resists soothing

• P - pain-like face

• L - longlasting

• E - evening

Dr. Harvey Karp’s five S’s

• swaddling

• side/stomach position

• sucking

• shushing

• swinging

common mistakes in identifying abuse

 Non-specific signs and symptoms attributed to benign causes

 Diagnose injury as accidental

 Subtle physical exam clues missed

 Contaminate the history (don’t be a history teacher)

 Nice people gig -

 Give the “benefit of the doubt” to the adult instead of the baby”

what to document when you notice bruising

 Color,shape, location, and size of bruising

• pain, bone tenderness, swelling

• health + hygiene

• developmental level of child

 What the child or parent says happened

 A list of all questions you asked

nurse’s role in noticing bruising

• stay calm and ask non-leading questions

• document what you see, hear, and ask

• make a report

characteristics of sexual abuse (perpetrator)

 Male

 Well known to the child

 All social levels

 Often in positions where they work closely with children

 Abuse is repetitive

 Use coaxing & threats

characteristics of sexual abuse victims

• little physical evidence

• seldom ever make abuse up!!

• sexual knowledge beyond developmentally appropriate

• antisocial

• behavioral changes

physical evidence of sexual abuse

 Bruises, bleeding, irritation of external genitalia

 Torn, stained, bloody underclothing

 Pain on urination, swelling, itching, recurrent UTIs

 STDs

 Difficulty walking or setting

behavioral changes in sexual abuse victims

 Signs of stress or anxiety

 New or existing sexual curiosity

 Constant masturbation

 Seductive behavior

 Fear of strangers

 New unwillingness to visit other homes

munchausen syndrome by proxy (MSP)

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.

MSP perpetrator characteristics

 Being a parent, usually a mother

 Sometimes being a healthcare professional or having medical knowledge.

 Being very friendly and cooperative with the healthcare providers.

 Appearing to be quite concerned — some might seem overly concerned

— about their child or designated patient.

 Suggests certain tests or procedures

 Possibly also suffering from factitious disorder imposed on self. This is a related disorder in which the caregiver repeatedly acts as if he or she has a physical or mental illness when he or she has caused the symptoms

MSP child characteristics

 < 6 years old

 Uncooperative

 Anxious

 Fearful

 Negative

 Isolation

MSP common presentations (s/s)

 Apnea- suffocation, drugs, poisoning

 Seizures- Drugs, poisoning, asphyxiation

 Bleeding- Adding blood to urine, vomit, etc.; opening IV lines

 Fevers, blood infections- Injection of feces, saliva, contaminated water into the child

 Vomiting- Poisoning with drugs that cause vomiting

 Diarrhea- Poisoning with laxatives, salt, mineral oil

when to suspect MSP

 Unexplained prolonged, recurrent, or extremely rare illness

 Discrepancies between clinical findings and history

 Unresponsive to treatment, S/S occurring only in parent’s presence.

 Knowledgeable parent who refuses to leave the child’s room

 Parent very interested in interacting with medical staff

 Family members with similar symptoms