Non-accidental trauma and Neurodevelopmental disorders

Non-accidental trauma overview

1.)Clinical flags such as trauma have become well established over last 20 years

2.) Acute victimization includes physical abuse and affects a small but significant percentage of children → requires immediate action

Physical Abuse:

intentional use of physical force against a child that results in, or has the potential to result in, physical harm

includes: hitting, shaking, burning, biting, etc

Emotional Abuse

behaviors that harm a child’s self-worth, emotional well-being or development

may include constant criticism, threats, rejection, isolation, or emotional neglect

Can result in long term psychological damage

Sexual abuse

involves engaging a child in sexual activities that they cannot understand, consent to, or are developmentally inappropriate.

Includes both physical contact and noncontact activities (exposure to sexual acts, exploitation, producing porn)

Neglect

failure to provide for child’s basic physical, emotional, educational and medical needs.

Inadequate supervision, failure to provide adequate food, shelter or clothing or not seeking medical care when necessary

Neglect is often chronic and can have severe developmental consequences

Types of maltreatment

1.) self-inflicted intentional injury, such as self-harm or suicide attempts, is also a form of abuse particularly among adolescents

2.) self-mutilation is a coping mechanism used by teenagers to deal with feelings of anger or anxiety, not necessarily an attempt at suicide

Epidemiology of child maltreatment

1.) majority of fatal child abuse and neglect cases occur among children younger than 5 years, with 41% occurring among infants

2.) rates of substantiated sexual abuse increase with age up to 14-15 years, while rates of substantiated neglect are highest for those age 1 and younger

Factors influencing maltreatment

1.) results from various interacting factors affecting parental capabilities, including stress

2.) determining the degree of physical injury necessary for abuse determination is challenging, leading some jurisdictions to mandate reporting of suspected abuse

3.) sociological indicators such as paternal involvement, family structure, and socioeconomic status may offer insights into prevalence of abuse

Risk factors for maltreatment

1.) young maternal age, unwanted pregnancy

2.) family disturbances, foster care

3.) poverty

understanding stressors within the family environment can aid clinicians in suspecting maltreatment

Shaken Baby Syndrome

1.) symptoms: vomiting, irritability, lethargy, poor feeding response, ocular findings such as retinal hemorrhage and subconjunctival hemorrhages are key diagnostic features

2.) additional findings of extremity and rib fractures further support a diagnosis of non-accidental injury

Indicators of NAT

1.) sudden changes in behavior or temperament, sleep disorders, constant complaints of headache or abdominal pain

2.) difficulties at school, relating to peers or adults, self-destructive behaviors, and excessive concerns about physical privacy

Physical indicators

1.) bruises in uncommon areas in various stages of healing

2.) disproportionate explanation

3.) pattern-shaped burns

Behavior indicators (physical)

inconsistent explanations, fear of parents or guardians with observable dynamics during examination, extreme behavioral changes

indicators of NAT: Emotional (behavior)

1.) low self-esteem, behavioral changes like passivity, fearfulness, aggression, or apathy

2.) depression, extreme anxiety, and poor social skills

3.) developmental delays, habit disorders and self-destructive behaviors

Indicators of NAT: Sexual (physical)

1.) genital irritation or infection, inadequately explained

2.) trauma to anogenital area, persistent vaginal discharge, pregnancy in young adolescents, recurrent UTI

Indicators of NAT: sexual (behavioral)

1.) preoccupation with symptoms related to the anogenital region

2.) inappropriate sexual activity, knowledge or behavior

3.) fear of diaper changes or bathing, avoidance of familiar adults or places

Indicators of NAT: neglect (physical)

constant hunger, failure to thrive or malnutrition, poor hygiene, lack of supervision

Indicators of NAT: neglect (behavioral)

knowledge of the child, family circumstances, and clinical experience aid in identifying neglect through a comprehensive assessment of physical and behavioral signs

-stealing food, extending school days, constant fatigue, etc

Techniques for taking history

1.) recognize inconsistencies between physical sign's/symptoms and explanations given by parents/guardians

2.) approach the child gently and reassuringly, as they may be disclosing abuse for the first time

3.) maintain calmness and detachment, avoid blaming or pressuring the child for information

“index of suspicion during history”

1.) direct disclosure of abuse by child, reports of abuse by someone other than child

2.) statement implying abuse, behavioral changes or injuries inconsistent with known family background

3.) sudden appearance of symptoms like secondary enuresis, encopresis, constipation, or recurrent abdominal pain

4.) signs of neglect (failure to thrive) hygienic neglect or unattended for long periods of time

5.) unexplained marks on child’s body

Reporting: immediate

1.) oral report → within 24 hours of suspecting abuse mandatory reporter must make an oral report to iowa department of health and human services

2.) law enforcement notification: if child is in immediate danger

Reporting: written report

1.) submission: within 48 hours of initial oral report

2.) include child’s name, address, nature of suspected abuse, name and address of suspected abuser, and any other information that might help the investigation

Reporting: confidentiality

protection of identity

Follow up with DHHS

Sensory Processing Disorder

1.) brain struggles to properly process sensory information from the environment, leading to abnormal responses to sensory input

2.) affects approx. 1 in 20 to 1 in 6.25 children in US

3.) diagnosed via clinical observation and questionnaires

Sensory over-responsivity

1.) easily overstimulated

2.) bigger than expected reactions to sounds and lights

3.) emotional outbursts when over stimulated

Sensory under-responsivity

1.) seeming unaware to stimulus occurring like a ringing doorbell

2.) clumsy or uncoordinated

3.) does not react appropriate to pain

Sensory seeking

constantly touching people or objects, frequently talks to themselves for auditory

ADHD

1.) 11% of school aged children in US → symptoms must be present for at least 6 months in more than 1 setting

2.) 3 classifications: inattentive, hyperactive impulsive and combined

3.) frontal lobes 10% smaller, affecting decision making and impulse control

4.) clinical signs: inattention, hyperactivity, impulsivity, dysregulation of behavior and emotions, academic and cognitive challenges

ADHD management

1.) maladaptive neuroplasticity

2.) subluxation considerations: ADHD affects NS and sympathetic system → chiro care aims to balance parasympathetic system (targeting C0-C5 and sacrum), addressing retained primitive reflexes (Moro and galant)

3.) prognosis: no cure but symptoms may improve with age. early diagnosis and combined therapy helps improve outcomes

Autism Spectrum Disorder

1.) Social cmmunication/interaction difficulties

2.) restricted/repetitive behaviors

3.) Diagnosed based on DSM -V system of 3 support levels

4.) 1 in 54 children

5.) co-occurring conditions: ADHD, anxiety, sleep disorders, seizures, GI issues

ASD: levels

1.) level 1: requires support

2.) Level 2: requires substantial support

3.) level 3: requires very substantial support

ASD signs

1.) decline in eye contact by 2-6 months , difficulty responding to name by 12 months, abnormal motor development (delayed or atypical crawling or rolling over)

2.) sensory processing in ASD: hypo-reactivity to sensory stimuli

ASD theories and research

1.) polyvagal theory: ASD linked to a dysregulated vagal system, shifting child into chronic state of distress

2.) new research includes the use of eye-tracking technology for early diagnosis, esp in high risk infants

ASD: comprehensive treatment plan

1.) speech and language therapy, early intensive intervention, special education, parent training

2.) behavior therapy, pharmacotherapy, occupational therapy

3.) changing needs: treatment and support evolve as the child grows