Child Abuse

Child Abuse Means

• Intentional infliction of physical or mental injury upon a child

• Intentional act that could reasonably be expected to result in physical or mental injury to a child

• Active encouragement of any person to commit an act that results or could result in physical or mental injury to a child

• Anyone who engages in violent behavior that demonstrates a wanton disregard for the presence of the child

  • Could reasonably result in serious injury to the child

  • Cases of domestic violence in the home

What are the Numbers?

• 4.1 million reports annually

• ~ 1 in 7 children

• ~ 5 deaths/ day

• 1 in 4 girls & 1 in 13 boys will be sexually abused before 18 years of age

• 80% fatal head injuries are non-accidental under 2 years of age

Who Are The Abusers?

• Female

  • 59% of perpetrators

• Male

  • 41% of perpetrators

• Parent

  • 81% of perpetrators

Abuse Risk Factors

• Socioeconomic status

  • Economic stress can impact abuse

  • But it can happen across all categories of income

• Gender/ age

  • Higher risk w/ younger parents

• Caregiver w/ mental health problems

• Caregiver w/ drug/ alcohol usage

Abuse Risk Factors Continued

• Domestic violence in the home

• Child is premature/ medically complex/ chronic illness

• Parental Hx of abuse

  • Parents abused them, may abuse their kid

• Caregiver Hx of animal cruelty

Recognizing Child Abuse

• Detailed Hx

  • If coming in for an “accidental” injury, get a detailed Hx

  • Was there a delay in seeking help?

  • Parent’s story correlates?

• Physical exam

  • May NOT be obvious signs

  • If delay in seeking help: Area may have healed

• Dx studies

  • Lab tests & Dx tests to rule out other things that may have led to these “accidental” injuries

Red Flags

• Hx given does NOT explain the injury

  • No Hx offered or Hx changes over time

  • Mechanism of injury does NOT fit the injury

  • Ask the parent multiple times to see if the story stays the same

• Child reports injury done by parent

• Child afraid to go home

• Multiple injuries

  • Various stages of healing

Red Flags Continued

• Delay in seeking medical attention

• Child developmentally NOT capable or would NOT reasonably be expected to have acted as described

• Child gives unbelievable explanation

  • Kid may have been coached or told to say that

• Serious injury blamed on another child

Bruises

• Most common type of physical abuse

• Most likely to be missed as an abusive injury

• How do they happen & where do they occur?

• Face, neck, & ears are unusual

• Look out for bruise areas hidden by clothing

Common Sites for Bruises

• Forehead

• Eyebrow

• Knees

• Shins

• Elbows

Questionable Sites For Bruises

• Between eyes & nose

• Ears

  • 7x more likely

• Cheeks

• Neck

• Tips of shoulders

• Arms

• Abdomen

• Pubic area

• Thighs

• Back of head

• Neck

• Spine

• Arms

• Buttocks

  • 10x more likely

• Back of thighs

• Calves

TEN 4 FACESP

• TEN 4 FACESP

• T- Trunk

• E - Ears

• N - Neck

• 4 - 4 years or younger

• F - Frenulum

• A - Auricular area (Lobes of the ear)

• C - Cheek

• E - Eyes

• S - Sclera

• P - Patterned bruising

• Any bruising on a child less than 4 months

  • “Kids that don’t cruise rarely bruise”

Strangulation S/S

• Any injury around the neck

• Difficulty breathing

• Changes in voice

• Petechiae in the eyeball

• Neck:

  • Redness

  • Scratch marks

  • Finger nail impressions

  • Bruising

  • Swelling

  • Ligature or clothing marks

Bite Marks

• Semi-circular or oval

• < 2.5 cm:

  • By another little kid

• > 2.5-3.5 cm:

  • Bite coming from an adult

Fractures

• < 3 years old

  • 24% of fractures in children are inflicted

• 80% of abusive fractures occur in children < 18 months

• Most common inflicted fractures:

  • Skull

  • Humerus

  • Femur

  • Tibia

  • Ribs

• Bucket handle fracture:

  • From pulling or throwing them

• Spiral fracture:

  • Twisting of the bone

• Kid’s bones are more malleable

  • Needs more pressure to break

Burns

• Up to ¼ of all physical abuse is caused by some type of burn

• Most children are burned by some type of heated liquid

• Accidental/ splash burn:

  • Would be asymmetrical

• Abuse burn:

  • Would be SYMMETRICAL

• Immersion burn:

  • Symmetrical

  • Abuse

Types of Burns

• Scald burns

• Contact burns

• Other types of burns

  • Electrical

  • Chemical

  • Solar

Scald Burns

• Thick liquids maintain heat much longer

  • More extensive burn

• Typical ACCIDENT is a splash or spill

• Typical INFLICTED scald burn has well demarcated margins

  • Well defined margins/ borders of the burn

  • Symmetrical

Contact Burns

• Made w/ heated objects

• Look for pattern

• Location is revealing!

Other Types of Burns

• Electrical burns

• Chemical burns

• Solar burns

• Usually happens in the context of inadequate supervision &/or neglect

Abusive Head Trauma (AHT)

• An inflicted injury to the head and its contents

  • Including those caused by both shaking & blunt impact

• The term “Shaken Baby Syndrome” (SBS) is commonly used to describe one form of AHT

• Occurs most often in children < 2 years

  • Average age is 3-8 months

• 70% of perpetrators are males

• 25% of babies dies

• 90% have lifelong disabilities

• Crying is #1 trigger

  • Crying triggers the parent to shake them

  • Colic baby

Abusive Head Trauma (AHT) Patho.

• Head in infant = 25% of body weight

  • Weak neck musculature

  • High water content in brain

• Veins in brain are stretched

  • Exceed elasticity

• Tear

  • Causing bleeding

• Brain strikes skull

• Immediate swelling

  • Swelling of the brain

  • Obstructs ventricles in the brain = death of brain tissue (Irreparable)

• Internal injury

What is the biggest sign of AHT?

• Retinal Hemorrhages

  • We look at the eyes

  • Biggest sign of internal head trauma

Sexual Abuse

• Involvement of adults, older children, or adolescents in sexual activities w/ children who CANNOT give the appropriate consent & who do NOT understand the significance of what is happening to them

Consider Sexual Abuse If…

• They tell you they’ve been sexually abused

• Injury to the genital area

• Sexually transmitted disease

• Pregnancy

• Child reports/ engaged in inappropriate sexual behavior

  • If a kid is drawing or performing an inappropriate sexual behavior

  • Being curious about the genital area is NORMAL

  • Doing more nuanced & specific actions to the genital area is a RED FLAG (Oral sex)

Neglect

• Act of omission

  • Failure to provide adequate clothing, nutrition, shelter, medical care, dental care, supervision, education

• Abandonment

• May be chronic or acute

Neglect Statistics

• MOST common form of abuse

• 30% child abuse deaths solely from neglect

• 64% death

  • Neglect was a contributing factor

• 70% deaths occurred in children < 3 yo

Types of Neglect

• Medical neglect

  • Includes dental neglect

• Drowning

• Motor vehicle crashes

• Children left unattended in vehicles

  • Left in hot car

• Co-sleeping

  • Unsafe sleeping

  • Back sleeping decreases SIDS rate

• Firearms

• Drug endangered children

Infant Safe Sleep ABC

• ABC

• A - Alone

• B - Back

• C - Crib

• Baby sleeps safest alone, on their back, in a crib

Emotional Abuse

• A repeated pattern of damaging interactions between parent(s) & child

• Involves words, actions, & indifference

• Constantly reject, ignore, belittle, dominate, & criticize child

• Child repeatedly feels unloved, unwanted, worthless

• Harder to prove

Consider Emotional Abuse If…

• Lack of attachment

• Lack of responsiveness to their environment

• Failure to thrive

• Child discloses repeated pattern of emotional abuse

We are ALL Mandatory Reporters!

• ANY person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for their child’s welfare..

  • SHALL report such knowledge to the department

Methods of Reporting

• 1-800-96-ABUSE

• https://reportabuse.dcf.state.fl.us/

How to Report

• Provide your name, work address, & phone number

• Provide child’s name, age, race, sex, DOB

• State your concern for child’s safety & what TYPE of abuse is taking place

• If possible give names of siblings

• Provide parent/ caretaker information

• Request name & ID of hotline counselor

Conclusion

• Child maltreatment is more common than you think it is

• Child abuse occurs in EVERY socioeconomic group

  • “Nice”, “Appropriate” parents can abuse their children

• You don’t have to be 100% certain to report abuse

  • Reasonable concern is all that is needed

  • Better safe than sorry

• You are advocating for the safety of your patient