child maltreatment

child maltreatment

• physical abuse

• sexual abuse

• neglect

  • physical

  • medical

  • environmental

  • emotional

  • nutritional

  • supervisory

  • educational

etiology of child maltreatment

exact cause unknown

three factors influencing potential for abuse

• characteristics of parents

• characteristics of child

• environmental characteristics

family and environmental characteristics for child maltreatment

• single parent (or primary caregiving role with little help)

• inter partner violence (IPV)

• unemployment/financial stressors

• isolation

• poverty/limited resources

• change in primary caregiving role

• number of people living in household

• major life changes

caregiver characteristics that increase risk of child maltreatment

• unrealistic expectations for the child’s behaviors

• immature (young) parents

• substance abuse

• caregiver abused as child

• prior CPS involvement

• depression low self esteem

child characteristics that increase risk of child maltreatment

• 0-3 years old

• colic (abnormal amount of crying for no reason

• physical/developmental disabilities

• emotional/behavioral disabilities 

• prolonged or chronic illness

• hyperactivity

• resemblance to abusive person from past relationship

• unwanted child

neglect

failure of parent or caregiver to meet child’s basic needs

types of neglect

• physical

• medical

• educational

• emotional

physical neglect

• food

• shelter

• lack of supervision

medical neglect

failure to provide necessary medical or mental health treatment

educational neglect

failure to educate child or attend special education needs

emotional neglect

inattention to a child’s emotional needs

contributing factors in neglect

• ignorance of 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

signs of neglect in child

• is frequently absent from school

• begs or steals food and 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 ro provide care

• has not received help for physical or medical problems brought to parents attention

signs of neglect in parent

• appears to be indifferent to child

• denies existence of, or blames 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

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

injuries of physical abuse

• bruising (#1 sign)

• fractures

• burns

• abdominal injuries

• abrasions (typically nonspecific)

• lacerations

triggering situations

• crying baby (colic)

• feeding issues

• toilet training

• childs misbehavior

• argument/family conflict

• parental stressors outside of home

recognition of abuse

• abuse is not always black and white

• there are no injuries which are always caused by abuse

• there are no injuries which are never caused by abuse

• there are common patterns of abuse and behaviors seen at various ages

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 (review developmental milestones)

• 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 appropriate

behavior characteristics of abused children

• wary of adults

• vacant stare or is always watchful, as if preparing for something bad to happen

• is overly compliant, passive, 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 to no concern for the child

• denies the existence of or blames the child for the childs problems in school or 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 child for care, attention, and satisfaction of emotional needs

bruising

• #1 sign

• earliest form of physical child abuse

• most common form of physical child abuse

• most easily recognized sign of physical abuse

• most easily recognized sign of physical abuse

• most common direct sign of physical abuse to be missed

TEN4FACESp

tool used by nurses when bruising is concerning for abuse in children less than 4 years

TEN4FACESp stands for

TEN

• torso (chest, neck, buttocks)

• ears (highly protected area

• neck

4

• infants 4 months and under

FACES

• frenulum (thin band of tissue connects lips to gums or tongue to floor of mouth) from forcing something in mouth

• angle of jaw

• cheeks (fleshy part)

• eyelids

• subconjunctival hemorrhage (tiny blood vessels break in whites of eyes)

p

• patterned injuries (cord, belt, handprint)

babies that don’t cruise rarely bruise

• 4 months or younger

• ask where child is at developmentally

developmentally appropriate bruising

it can be normal for mobile children to bruise overlying bony areas of body

• shins

• knees

• elbows

• forehead

congenital dermal melanocytosis (mongolian spots) vs. bruise

• mongolian spots are documented since birth and are even in color

abdominal injuries

• 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

burns

• contact burns

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

• chemical burns

• pattern burns; iron, heater grates, cigarettes

• rope burns

• cigarette burns

  • 9-10 mm in diameter

  • circular

  • sharp edges

  • typically see several

  • 3rd degree, 2nd degree and elevated peripherally

fractures

• is child mobile? (walking, running, etc)

• majority of fractures in child <1 year are from abuse

• high percentage of fractures <3-1yr = abuse

• common areas include femurs, 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 rub fractures caused by violent squeezing of chest

• back is unsupported so ribs bend back over sides of backbone

• posterior fractures are not a result of direct impact (fall)

• highly specific for physical abuse

metaphyseal (growth plate) 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

patterns of abuse in infancy

more likely than any other age group to suffer the following forms of abuse or neglect

• fatal abuse

• abusive head trauma

• abusive fractures

• muchausens syndrome by proxy

• global neglect with ftt

features predisposing infants to serious abuse

• dependency

• isolation

• lack of language

• size

• trigger for most infant abuse is crying, especially when prolonged

pediatric abusive head trauma (PAHT)

PAHT (shaken baby syndrome) is defined as injuries to the head and spine of a child that occur as a result of abuse

• mechanisms of injury include shaking, impact, crush or any combo of these mechanisms

• number one cause of mortality and morbidity related to child abuse

incidence/prevalence of PAHT

• PAHT is most common cause of morbidity (disability) and mortality in physical child abuse

• 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 1-2 mo

what is PAHT exactly

• global brain injury caused by rotational/angular forces

• involves shaking, impact, or both

• subdural hematomas or other intracranial bleeds, +/- retinal hemorrhage, scalp bruising, skull fracture… but its injury to the brain tissues itself that causes death and disability

• symptoms occur immediately following abusive act, can be highly variable ranging from somnolence/stopping crying to loss of consciousness, apnea, or cardiac arrest

• uncommon for child to present the first time they are abused

infant characteristics of PAHT

typically infants are more affected by PAHT due to factors related to anatomy and development

• 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

impact with PAHT

• if impact is involved, may see skull fracture, scalp bruise, or scalp swelling, but not necessarily

• impact on soft surface can leave no evidence of impact

• never be falsely reassured by absence of bruising

• it is astounding the severity of injury in children that can remain clinically normal

PAHT injury types

• closed head injury

• open head injury; skull fractures

• subdural hematoma

• death

• irreversible brain damage

• vision impairment

• spinal cord or CNS injury

• loss of speech and hearing

• problems with memory and attention

• learning disabilities

• cerebral palsy

s/s of PAHT

• altered mental status

• persistently irritable, difficult to console

• breathing abnormalities

• increased head size compared to previous measurements (esp dramatic increases)

• bulging or tense fontanelle

• bruises

• poor feeding

• poor head control

• seizures or posturing

• unequal pupils

• high pitched cry

• retinal hemorrhages

• pale, mottled, cold, clammy skin

• vomiting

• behavior changes

• can have relatively normal exam

common associated symptoms of PAHT

• retinal hemorrhages

• skeletal fractures: skull, metaphyseal, rib, long bones, etc

• bruising of skin (black eyes)

• internal abdominal injury (won’t necessarily see bruising)

• or nothing

perpetrator characteristics for PAHT

• male

• less than 30

• education less than high school

• illiteracy

• depression

• social isolation

• substance abuse

• low self esteem

• poor impulse control

risk factors for PAHT in child

• male gender

• colic

• prematurity

• low birth weight

• drug/nicotine/alcohol exposure or withdrawal syndrome

• special needs or medically fragile

• infants with neonatal abstinence syndrome or being a child who cries frequently

• being one of a multiple birth

nursing responsibilities

goal is always to protect child

• prevention

• recognition

• reporting

prevention

educate families and give strategies on how to cope with triggers for abuse (#1 is crying)

• period of purple crying

• dr harvey karps five S’s

• walk away and call for help

• make sure basic needs are met (change diapers, 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 pacifier

• call doctor

PURPLE

Peak of crying 

Unexpected

Resists soothing

Pain-like face

Long lasting

Evening

five S’s

• swaddling

• side/stomach position

• shushing

• swinging

• sucking

identifying/recognizing

• look for skin findings on physical exam (nurses are one of first to recognize)

• know TEN4 FACESp

• know developmentally appropriate skin findings

• when talking with family and patient be understanding and open minded

• stay objective

• look at development of child and make sure injury matches developmental level of child

• examine bruises carefully

• ask yourself:

  • does injury and age of child match

  • is history feasible

  • was injury witnessed

  • what is social situation

  • can described mechanism of injury account of the actual injury

red flags

• no or vague explanation of injury

• detail changes

• explanation that is not consistent of injury

• explanation inconsistent with child’s physical or development abilities

• different witnesses provide different explanations of injury

common mistakes

• non-specific signs and symptoms attributed to benign causes

• diagnose injury as accidental

• subtle physical exam clues missed

• contaminate history

• nice people gig

• give benefit of the doubt to adult instead of baby

what are we most likely to overlook

• intact families

• middle class, well-educated parents

• families perceived to be similar to ours

• very young infants (may have normal neuro exam)

• infants with nonspecific symptoms only

action

• stay calm and conversational if you notice bruising on a child

  • ask nonleading questions (what happened, where were you when it happened, did an adult see it)

  • refrain from asking specific questions or jumping to conclusions

• document what you see, hear, and ask

  • color, shape, location, and size of bruising

  • what child or parent says happened

  • a list of all questions you asked

• make a report

nurses role

• meet physical needs

• provide a role model for parenting

• provide support

• document fully and objectively

• report

how to interact with patient and family

• remain objective

• be nonjudgmental

• do not place blame or make assumptions, stick with open ended questions

• offer support

documentation

• location, size, shape, and color of lesions

• distinguishing characteristics

• any pain; any bone tenderness; any swelling

• health and hygiene

• developmental level of child

reporting

• kentucky law requires when any person knows or has reasonable cause to believe that a child is dependent, neglected, or abused

  • report to statewide abuse reporting hotline, web referral, local cabinet for health and family services, kentucky state police

  • local attorney

  • duty to report applies to all people

sexual abuse

using children for sexual gratification

• caregivers

• juveniles or adults

examples of sexual abuse

• genital exposure

• fondling

• sexual penetration

characteristics of sexual abuse

• male

• well known to child

• all social levels

• often in positions where they work closely with children

• abuse is repetitive

• use coaxing and threats

characteristics of sexual abuse victims

• little physical evidence

  • bruises, bleeding, irritation of external genitalia

  • torn, stained, bloody underclothing

  • oain on urination, swelling, itching, recurring UTIs

  • STDs

  • difficulty walking or setting

• seldom ever make up abuse

• possess sexual knowledge beyond what is developmentally normal

• antisocial behaviors

• behavioral changes

  • signs of stress or anxiety

  • new or existing sexual curiosity

  • constant masturbation

  • seductive behavior

  • fear of strangers

  • new unwillingness to visit other homes

nursing interventions with sexual abuse

• always believe victim

• provide safe space

• do not ask leading questions

munchausen syndrom by proxy (MSP)

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

perpetrator characteristics of MSP

• being parent, usually mother

• sometimes being healthcare professional or having medical knowledge

• being very friendly and cooperative with HCP

• appearing to be quite concerned, maybe overly concerned, about child or designated patient

• suggests certain tests or procedures

• possibly also suffering from factitious disorder imposed on self

  • caregiver repeatedly acts as it he or she has physical or mental illness when he or she has caused symptoms

child characteristics of MSP

• < 6 yo

• uncooperative

• anxious

• fearful

• negative

• isolation

common presentations of MSP

• 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 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 parents presence

• knowledgable parent who refuses to leave childs room

• parent very interested in interacting with medical staff

• family members with similar symptoms

spanking

• spanking without bruise → not abuse

• spanking with bruise → abuse