child maltreatment

child maltreatment

child abuse has been defined by the child’ abuse prevention and treatment act (CAPTA) as “any recent act or failure to act on the part of a parent or caregiver, which results in death, serious physical or emotional harm, sexual abuse, or exploitation; or an act or failure to act which presents imminent risk of serious harm”

mandatory reporting

state laws vary per state; know laws for your state of residence and licensure

health care practitioner, educator, human service worker or a law enforcement officer are required by law to report any suspected child abuse or neglect

reporting does not require proof that child abuse or neglect has occurred

failed to make a report of suspected abuse or neglect of a child, the local department must file a complaint with the appropriate licensing board or employer of the mandated reporter

“good faith” report is immune from civil liability and criminal penalty

parental factors predisposing to abuse

younger parents

single parent families

unrelated partners

substance abuse

low self esteem

poor parenting skills

cyclic nature; kids who were abused are likely to abuse their kids; unconscious learned behaviors

child characteristics

birth to 1 year of age

disabled child

premature infant

^ all have higher needs → increases parental stress
these kids also can’t express/talk to tell they are being abused

environmental factors predisposing abuse

both lower and upper class

family crises with chronic stress

crowded living conditions

childcare by unrelated caregivers

social isolation

poor support systems

physical neglect

failure to provide basic needs and adequate care (food, clothing, shelter, medical care, supervision)

emotional neglect

failure to meet needs for affection, attention, and emotional nurturance

ex: ignoring crying, leaving them at home alone

physical findings of neglect

growth failure

signs of malnutrition

poor personal hygiene

inappropriate dress

poor health care

frequent injuries due to lack of supervision

signs of neglect: behaviors

dull and inactive affect

self-stimulatory behaviors

begging or stealing food

absenteeism from school

substance abuse

vandalism or shoplifting

emotional abuse (or neglect)

destroy or impair child’s self esteem

rejecting, isolating, terrorizing, ignoring, corrupting, verbally assaulting, or over pressuring the child

physical abuse

deliberate infliction of physical injury on a child by parent or caregiver

abusive head trauma

munchausen syndrome by proxy

cause often unknown

sexual abuse

“the use, persuasion, or coercion of any child to engage in sexually explicit conduct (or any stimulation of such conduct) or producing visual depiction of such conduct, or rape, molestation, prostitution, or incest with children”

increasing numbers but this may be due to increased reporting

increasing prosecution

increasing penalties

increasing media attention

signs of emotional abuse

is excessively withdrawn, fearful, or anxious about doing something wrong

demonstrates extremes in behaviors; extremely compliant or extremely demanding; extremely passive or extremely aggressive

does not seem to be attached to the parent or caregiver

demonstrates a noticeable decline in cognitive abilities

predisposing factors of physical abuse

parental: social isolation, teenager and/or single parent, loneliness, low self esteem, “abused child” theory is unsupported by research

child: temperament, position, disability, activity level, a difficult labor/delivery

environmental: chronic stress, poverty

shaken baby syndrome

also “inflicted traumatic head injury”, “neuro-inflicted brain injury”

violent shaking of infants and young children

intracranial bleeding (subdural and subarachnoid)

retinal hemorrhages

fractures of ribs and long bones

most often there are no signs of external injury

abusive head trauma presenting symptoms

irritability

poor feeding

listless

vomiting

seizures; late sign

developmental delays

cerebral palsy

visual impairment

munchausen syndrome by proxy

caregiver fabricates signs and symptoms of illness in child (the proxy) to gain attention from medical staff

child may undergo needless and painful procedures and treatments

signs of physical abuse

has frequent injuries or unexplained bruises, welts or cuts or explanation is incongruent to the injury

have injuries that appear to have a pattern such as marks from a hand or belt

attempts to hide body parts that previously were exposed without concern (arms, legs, neck)

has unusual, unexplained burn marks, bite marks, multiple fractures of differing ages

pt’s affect is inappropriate in relation to the extent of injury

shy away from touch, flinches at sudden movements, or is afraid to go home

red flags in signs of physical abuse

history is incompatible with the degree of injury

explanation of how injury occurred is vague, or the parent or guardian is reluctant to provide information

the pt is brought in with a minor, unrelated complain, and significant trauma is found

histories are contradictory among caregivers

mechanism of injury provided is not possible given age or developmental level of the pt

spiral fractures: from violent twisting, can’t get by accident

incest

any physical sexual activity between family members; blood relationship is not required

molestation

touching, fondling, kissing, single or mutual masturbation, or oral genital contact

exhibitionism

indecent exposure, usually exposure of the genitalia by an adult man to children or women

physical signs of sexual abuse

bruises, bleeding, lacerations, or irritation of external genitalia, anus, mouth, or throat

torn, stained, or blood underclothing

pain upon urination or defecation; odor, swelling, itching of genital area

STI, UTIs, pregnancy

signs of sexual abuse: behaviors

inappropriate sexual play

withdrawn or isolates self

regressive behavior

aggressive, self destructive

sudden onset of phobias

running away from home

substance abuse

personality changes

poor school performance

suicidal ideation

frequent runs away

characteristics of abusers and victims

typical abuser is a male the victim knows but may be anyone

all socioeconomic backgrounds

risk factors putting children at risk: parental unavailability, lack of emotional closeness and flexibility, social isolation, emotional deprivation, communication difficulties

initiation and perpetuation of sexual abuse

often starts with insidious cycle

pressured into as an accessory

not reveal the truth; afraid

incestual relationships

pattern of silence

adverse outcomes

nursing care of the maltreated child

identify abusive situations as early as possible

history pertaining to the incident

physical evidence of maltreatment: protect child from further abuse, support the family, plan for discharge, prevention

management of the maltreated child

separation of all children to prevent further injury

support child based on developmental age

support family using communication

talking with children who reveal abuse

provide a private time and place to talk

do not promise not to tell

do not express shock or criticize their family

use their vocab to discuss body parts

avoid using any leading statements

reassure they did the right thing by telling

tell them that the abuse is not their fault

determine their immediate need for safety

let the child know what will happen when you report

nursing implications

documentation:
- date, time, and place of occurrence
- sequence of events with recorded times
- use verbal quotes from pt when appropriate
- physical exam findings
- labs, X-rays, test results

report

referrals as necessary

prevention