Child Maltreatment Notes (NUR 121)

Overview of Child Maltreatment

  • Significant long-term consequences for children and families.

  • Prevalence/impact statistic: 30%30\% of maltreated children become maltreating parents.

  • Nurses play a key role in detecting possible signs and initiating appropriate action.

Types of Child Maltreatment

  • Physical Maltreatment

  • Psychological Maltreatment

  • Sexual Maltreatment

Specific Types and Subtypes

  • Abusive head trauma (Shaken Baby Syndrome)

    • Subdural hematoma / hemorrhage

    • Retinal hemorrhages

    • Difficult to prove from history alone; CT scan / MRI helpful in detection

    • Classified as physical maltreatment

  • Physical neglect

    • May be more subtle than other physical maltreatment but can be equally damaging

    • Indicators: failure to provide food, basic hygiene, medical treatment, education

    • May appear as unwashed, malnourished, lack of warm clothing

    • Can co-occur with or be mistaken for physical maltreatment

  • Munchausen Syndrome by Proxy (Factitious Disorder by Proxy)

    • Symptoms not easily detected by physical exam

    • Symptoms often disappear when the child is under another caregiver’s supervision

    • Considered physical / psychological maltreatment

  • Psychological maltreatment

    • Child is made to feel unintelligent or inadequate

    • Verbal maltreatment and emotional neglect

    • More difficult to identify

  • Failure to thrive

    • Falls below 5th5^{\text{th}} percentile on growth chart

    • Can have organic or nonorganic causes

  • Sexual maltreatment

    • Any sexual interaction between an adult and a child

    • Affects both girls and boys

    • Physically and emotionally destructive

    • Includes molestation, pornography, prostitution, incest, rape

Risk Factors

  • Special parent

  • Special child

  • Special circumstances

Socio-cultural and Economic Factors

  • Education level

  • Mental illness

  • Drug use

  • Stress

  • History of being maltreated as a child

Case-Study Activities (Overview of Scenarios)

  • Scenario prompts: 3-month-old with pertussis; 2-year-old with fractured skull from a motor vehicle accident (MVA); 8-year-old with appendicitis.

  • Activity format: Think, pair and share; choose one scenario to discuss with a partner/group of 3.

Case-Study Scenarios in Detail

  • Case 1: A 3-month-old infant hospitalized for pertussis

    • You are caring for a 3-month-old infant with pertussis.

  • Case 2: A 2-year-old with a confirmed skull fracture following an MVA

    • The child repeatedly says, “I’m not allowed to tell you what happened …” when parents are away.

  • Case 3: An 8-year-old recovering from an appendectomy, post-op day 1

    • The father appears agitated and smells of alcohol; he says, “I can’t believe I have to be here to deal with this.”

Case-Study Assessment Prompts (What Actions to Consider)

  • Case 1 question: bruising on the infant’s torso during morning head-to-toe assessment; parents present. What actions will you take?

  • Case 2 question: child with skull fracture; child’s statement indicates possible concealment. What actions will you take?

  • Case 3 question: agitated father with alcohol smell; potential safety and abuse concerns. What actions will you take?

Assessment Criteria for Suspected Maltreatment

  • Ask caregivers to account for any injuries to the child’s body

  • Do the injury description and severity match the story?

  • Does the child’s description match the parents’ description of events?

  • Employ health history techniques to assess consistency and plausibility

Physical Assessment Techniques for Suspected Maltreatment

  • Expose the child completely for thorough examination

  • Use accurate measurements and appropriate terminology

  • Identify hallmark signs of abuse or neglect

Physical Assessment Findings in Maltreatment

  • Multiple injuries at different healing stages

  • Circular and linear lesions; circular scars or blistered areas

  • Abrasions or scars on wrists/ankles

  • Human bites

  • Missing chunks of hair

  • Fractures and head injuries in preschool-aged and younger children

  • Bruises on non-ambulatory child; the phrase “Bruises on Babies are nearly always Bad” used colloquially in practice

Common Injury Indicators and Burn Patterns

  • Bruises, belts and other injury patterns consistent with abuse (e.g., belt buckle, looped cords, paddles, hand/knuckles)

  • Burn patterns suggest non-accidental injury: immersion burns, scalds, or patterned burns

  • Note: Upper body vs lower body burn patterns; palmar vs dorsal surfaces; splash marks vs demarcation patterns

  • Immersion burns often show characteristic patterns and can indicate forced immersion; typical donut-hole appearances and uniform depth

  • Toddlers’ curiosity predisposes them to accidental injuries, which should be distinguished from intentional harm

  • Immersion burn features:

    • Uniform degree of injury with interspersed areas spared by flexion

    • Donut-hole appearance on buttocks or perineal area

    • Demarcation line indicating depth and immersion time

    • Flexion and surface contact protect skin

  • Negative cues for accidental injury include inconsistent or incongruent injury patterns and delayed medical care

Additional Indicators of Maltreatment

  • Negative caregiver-child interaction

  • Developmental delays

  • Enuresis without medical cause

  • Severe psychosomatic complaints

  • Severe depression or anxiety

  • Child acts as caretaker to parent or is overly compliant

  • Aggression or self-harming behaviors

  • Exposure to sexual vocabulary beyond age-appropriate levels

Visual and Other Indicators of Abuse (CHILD ABUSE Summary)

  • Withdrawal from physical contact with adults

  • Head injuries, skull and facial fractures

  • Bruises and welts in shapes of objects

  • Child may protect abuser due to fear of punishment

  • Burns (including immersion burns), human bites, rope burns from being tied

  • Limited eye contact; poor response to pain; fractures in different healing stages

  • Internal injuries; burns on buttocks, genitals, or soles of feet from immersion

Nursing Diagnoses Related to Maltreatment

  • Pain r/t inflicted injury

  • Impaired skin integrity r/t inflicted injury

  • Altered nutrition, less than body requirements r/t inadequate caloric intake

  • Impaired parenting / Caregiver role strain

  • Social isolation

  • Knowledge deficit about protective measures and reporting

  • Dysfunctional family processes (e.g., alcoholism)

  • Risk for violence

  • (Note: Use clinical judgment to tailor diagnoses to the patient and setting)

Role of the Nurse in Suspected Maltreatment

  • Identify signs and symptoms that could result from maltreatment

  • Report suspected child maltreatment to the appropriate authorities

  • Document specific and factual observations and assessments

  • Consult with members of the care team

  • Inform parents of suspected maltreatment and the reporting process

Immediate Nursing Responsibilities Upon Suspected Maltreatment

  • Healthcare facility may hold the child for 72 hours72\text{ hours} after a report is made

  • Question involved parties separately when feasible and obtain explanations for injuries

  • Observe the entire body and document growth and development norms

Health Promotion and Prevention

  • Identify parents at risk and families with high stress or poor coping mechanisms

  • Help connect families to supportive services and resources

  • Promote access to parenting courses and problem-solving techniques

  • Support efforts to enhance parental self-esteem and resilience

  • Begin discussions about responsible family planning as appropriate

National Health Goals and Educational Resources

  • Educate parents about normal growth and development

  • Identify and address risk factors in families

  • Report suspected child abuse to appropriate authorities

  • Educate parents on more effective parenting strategies

  • Healthy People 2030 goals include child health and safety objectives

  • Resources: health.gov and related federal/state resources

Community Resources and Hotlines

  • Reporting information by state (e.g., Maine hotlines)

  • Maine State Child and Family Services

  • Maine state mandated reporter resources

  • Healthy People 2030 | health.gov

  • CDC resources: Child Abuse and Neglect Prevention; Facts-at-a-Glance; Child Welfare Information Gateway; Children’s Bureau; Office of the Administration for Children and Families