Mod 3

Child Abuse Study Notes

Theories – Triad Model

• Child abuse theories involve a triad of three connected elements:

  • A “special” parent.

  • A “special” child.

  • A “special” circumstance.

• Special Parent (or non-parent abuser) Factors:

  • Abused as a child.

  • Poor self-control.

  • Unrealistic expectations of the child; lack of knowledge of developmental norms.

  • Socially isolated.

  • Alcohol or substance abuse.

• Special Child Factors:

  • Unplanned.

  • Personality does not “fit” with the parent.

  • Handicapped.

• Special Circumstance Factors:

  • Stress.

Who Typically Abuses Children?

• Abuse can be committed by anyone, including siblings and mothers.

• Sexual abuse: Most commonly committed by a male the child knows.

• Roles/Abusers include: Parent, Guardian, Boyfriend of child’s mother, Other relative, Neighbor, Teacher, Coach.

Child Reporting and Mandatory Reporters

• Nurses are mandatory reporters in most states.

• Follow agency protocol for reporting abuse.

• Resources (examples from Florida): Links to abuse hotlines and mandated reporter publications (e.g., myflfamilies.com).

Options for Newborns

• Florida Safe Haven laws: Provide legal options for parents to anonymously surrender newborns (safehavenlaws.uslegal.com/florida-safe-haven-law/).

• Safe Haven organization: Offers assistance and resources for newborns (asafehavenfornewborns.com/getting-help/).

Physical Abuse

• Definition: An action of an individual that causes injury to a child.

• Common injuries include: Burns, head injuries, or hand injuries.

• Visual cues and assessment: Require careful inspection and thorough documentation.

Spiral Fracture

• A spiral fracture is a notable pattern of injury that can be specifically associated with physical abuse.

Identifying and Interviewing

• Ask parents how the injury occurred.

• Use open-ended questions.

• Look for injuries that are out of proportion to the history provided.

• Be alert for conflicting or changing stories.

• Consider if the story is incongruent with the child’s developmental stage or physical abilities.

• Note that the child often corroborates a (false) story, especially in abusive situations.

Assessment and Documentation

• Examine every inch of the skin; remove diaper, socks, and hat to inspect thoroughly.

• Look for: Handprints, the imprint of an object used, or “sock/mitten” burns.

• Document objectively what is seen and heard.

• Do not use leading questions.

• Report suspected abuse immediately and follow agency protocol.

Bruises Caused by Abuse

• Bruises may include a characteristic bruise from forceful slapping.

• Looped cord injury: Bruises may resemble the shape of the instrument used.

• Bruises caused by abuse may mimic the specific shape of an instrument used to inflict injury.

Shaken Baby Syndrome

• Acknowledged as a specific, severe form of physical abuse requiring immediate awareness and prompt response.

Physical Neglect

• Definition: Failing to provide for a child’s basic needs.

• Signs: The child may appear unwashed, thin, malnourished, or dressed inappropriately for the weather.

• Medical neglect: Failing to seek appropriate or necessary medical care for the child.

• Supervision neglect: Lack of appropriate supervision at home or after school hours.

• Education neglect: Failing to ensure the child goes to school or receives appropriate schooling.

Ritual Abuse

• Ritual or cult-based abuse can involve physical, sexual, and psychological abuse combined with bizarre or ceremonial activities.

Psychological Abuse

• Characteristics: Constant belittling, threatening, rejecting, isolating, or exploiting a child.

• Marked by the absence of positive parenting.

• This is the most difficult form of abuse to detect.

• Negatively affects the child’s self-esteem and their ability to become emotionally secure and mature.

• Practice: Objectively document parent-child interaction behaviors.

Munchausen Syndrome by Proxy (MSBP)

• Definition: A caregiver may actively induce symptoms or fabricate illness in the child.

  • Examples: Giving a child laxatives to cause diarrhea, or putting blood into the child’s urine sample.

  • The parent fabricates the child’s illness; symptoms are not easily detected by physical exam and are primarily identified via history.

  • Symptoms are present only when the abuser is providing care and often disappear when someone else takes over care.

• Two Classic Findings:

  • 1)$ The “ideal parent” of a hospitalized child: very involved and helpful in the child’s care; very friendly and appreciative of staff; often possesses some medical or healthcare knowledge.

  • 2)$ Characteristics of the abuser: covert behavior; often requires covert video surveillance for diagnosis due to the hidden nature of their actions.

Failure to Thrive (Nonorganic)

• Definition: An infant falls below the $5^{th}$ percentile for weight and height, or shows a significant drop across percentiles on a growth chart, due to a disturbance in the parent-child relationship.

• Considered a form of child neglect; it includes emotional and developmental deprivation.

Manifestations of Failure to Thrive

• Lethargy, poor muscle tone, loss of subcutaneous fat.

• Lack of resistance to the examiner’s manipulation.

• Neurodevelopmental signs: Excessive rocking on all fours (often seen with emotional deprivation).

• Possible reluctance to reach for toys or initiate human contact.

Additional Manifestations of Failure to Thrive

• Staring hungrily at people approaching, as if starved for human contact.

• Little cuddling or willingness to be held.

• Developmental delays (e.g., delays in sitting, standing, crawling, walking) requiring extra time for play or time out of a crib/contained area.

• Delayed or absent speech.

• Diminished or nonexistent crying.

Sexual Abuse – Possible Signs

• Reports of having sex with an adult.

• Child demonstrates an awareness of sexual acts beyond age expectations.

• Demonstrates sexual expression with dolls.

• A girl younger than $15$ years is pregnant.

• Vaginal tears or anal fissures.

• A child younger than $15$ years has a Sexually Transmitted Infection (STI).

• Sleep disturbances, nervous tics, nail biting, stuttering.

Additional Signs of Sexual Abuse

• Change in school performance; truancy or school phobia.

• Develops fear of being left alone with a particular adult.

• Reports vague abdominal pain.

• Starts acting out behaviors.

Reporting and Education for Sexual Abuse

• Do not use leading questions; document objectively; report accordingly and follow agency protocol.

• Preschool children should be taught, and this should be reinforced with older children, that “private parts are private!”

Box 55.3: Measures to Prevent Child Abuse

• $1$. Advocate for high school courses on parenting and growth and development of children.

• $2$. Help children learn problem-solving techniques so they are not overwhelmed by mounting problems as adults.

• $3$. Foster high self-esteem in children so they are not dependent on others but are assertive (they will not become passive observers to abuse).

• $4$. Help parents with responsible reproductive planning, so children are desired.

• $5$. Help parents locate support people in their community, such as Parents of Retarded Citizens or church or social contacts.

• $6$. Teach children to verbalize their problems and to seek help for problems so problems do not mount to overwhelming proportions.

• $7$. Role model caring behaviors with children for parents.

• $8$. Identify children who may be viewed as special in some way by parents (e.g., separated at birth, premature, or physically challenged).

• $9$. Identify parents who were abused as children, and offer specific help to them to break the chain of child abuse.

• $10$. Suggest that potential abusers join Parents Anonymous, an effective support group.

Physical Assessment of Children

Health History: Database

• Clinic vs. inpatient: Interview settings (acute vs. well care).

• Types of Questions:

  • Closed-ended: Used to get specific information.

  • Open-ended: Used to see the big picture.

  • Compound: Should be avoided; often require a follow-up clarifying question.

  • Expansive: An “open-ended question gone wrong,” too vague.

• Examples:

  • Compound example: “Do you have nausea and vomiting?”

  • Expansive example: “What can you tell me about Candy?”

  • Leading questions: Can bias responses (e.g., “Candy has had all of her immunizations, right?” – avoid these).

• Health Interview Components (overall framework):

  • Introduction and explanation of the process.

  • Demographic data.

  • Chief concern.

  • History of chief concern: onset, duration, intensity, frequency, description, associated symptoms, actions taken.

• Health Interview Tools Include:

  • Health and Family profile: Can be covered under demographics and health history.

  • Day history: Involves asking about a typical day, starting from waking in the morning.

    • Areas: Day, Play, Sleep, Hygiene, Nutrition.

• Emphasize follow-up questions and clarifying questions to ensure complete information.

Health History: Interview Structure and Content

• Health Interview Elements:

  • Introduction, explanation.

  • Demographic data.

  • Chief concern.

  • History of chief concern (onset, duration, etc.).

• Health and Family Profile: Integrated into demographics/health history.

• Day History Components: Day, Play, Sleep, Hygiene, Nutrition.

Past Health History and Family Health History

• Past health history includes:

  • Routine health care.

  • Immunizations.

  • Allergies.

  • Chronic illnesses.

  • Medications.

  • Hospitalizations.

  • Surgeries.

• Pregnancy history: Important for children under $5$ years.

• Family health history.

• Review of systems.

Physical Assessment: Overview

• Purpose and techniques: Inspection, auscultation, percussion, palpation.

• Equipment, setting, approach.

• Age-Related Variations in Examination Approach:

  • Newborn/Infant: Rectal temperatures discouraged; axillary from birth; temporal thermometry usable at ~$3$ months; tympanic usable at ~$6$ months; oral around $4-5$ years.

  • Toddler: Approach with caution and patience.

  • Preschooler: Begin discussing private parts; Blood Pressure (BP) assessment typically starts at age ~$3$ years.

  • School age/Adolescent: Explain that what you are doing is normal; involve them in the process and respect their privacy.

• Emphasis on developmentally appropriate communication and privacy during the examination.

Vital Signs and General Assessment

• Components of physical examination:

  • Vital signs (temperature, pulse, respiratory rate, blood pressure).

  • Pain as the $5^{th}$ vital sign.

  • Hypothermia can be an important indicator of infection in infants.

  • General appearance.

  • Odor.

  • Mental status: observed as alert, drowsy, talkative, active, hiding behind mom, crying.

Body Measurements and Growth Monitoring

• Weight:

  • Weigh infants nude or with a zero-scale and a dry diaper.

  • Keep one hand above the infant/toddler when on the scale for safety.

  • Important conversion: $2.2 ext{ lbs/kg}$. (Note: More precisely, $1 ext{ kg} hickapprox 2.20462 ext{ lbs}$).

• Height: Measured as length when the child is lying down (especially true for infants and toddlers).

• Growth Plotting:

  • Plot on growth charts; or Electronic Health Record (EHR) systems can do it automatically.

  • Compare percentiles to the child's last visit to track trends.

• CDC Growth Charts: References provided for clinical use (e.g., cdc.gov/growthcharts/data/set1clinical/cj41c017.pdf).

Head Circumference and Body Circumference

• Head circumference: Measured until the fontanelles close or as per agency policy.

• Fontanelle closure:

  • Anterior fontanelle closes: $12 – 24 ext{ months}$.

  • Posterior fontanelle closes: around $2 ext{ months}$.

• Chest and abdominal circumference: Measure at the nipple line or umbilicus as the specific condition warrants.

Skin, Hair, and General Surface Examination

• Skin: Assess temperature, color, dryness, texture, and turgor.

• Ensure a full skin examination by removing socks/diapers as needed.

• Head: Assess shape and scalp; note fontanelles in newborns/infants.

• Age-related notes:

  • Newborn/infant: Fontanelles are present and examined.

  • Toddler to adolescent: Varied findings depending on age and individual characteristics.

Eyes: Vision and Findings

• Eye findings to assess:

  • Conjunctivitis.

  • Hordeolum (stye).

  • Ptosis (drooping eyelid).

  • Strabismus: Assessed using the cover/uncover test and Hirschberg’s test (corneal light reflex); types include Esotropia and Exotropia.

• General eye exam components include evaluation for redness, drainage, eyelid edema, presence of red reflex, and strabismus screening.

• Vision screening should align with the child’s age and the availability of appropriate vision charts.

• Vision Assessment References (example concept): Visual angle concept and distance-based charts, preschool/kindergarten charts; distances shown on test materials (e.g., $20 ext{ ft} / 6.1 ext{ m}$ equivalents) and corresponding acuity scales.

• Vision Referral Criteria (per slide 17):

  • Preschool ($3-5$ yrs): $20/50$ or worse in one or both eyes.

  • $6+$ years: $20/40$ or worse in one or both eyes.

  • $2$-line inter-eye difference (e.g., $20/20$ vs. $20/40$).

  • Strabismus persisting older than $6$ months.

  • Any visual symptoms or disturbance of vision reported.

• Common Note: Ensure regular screening and timely referrals when these criteria are met.

Nose and Ears; Hearing Assessment

• Nose:

  • Newborn/infant: Are obligate nose breathers.

  • Older children: Are less obligate nasal breathers; assess for obstruction or discharge.

• Ears: Assess alignment and the condition of the ear canal/anatomy.

  • Newborn/infant: Pull the ear down and back (under age $3$) to straighten the ear canal for otoscopic examination.

  • Older children: Pull the ear up and back (age $3+$) to straighten the ear canal.

• Hearing Assessment:

  • Auditory screening question: “Are you at all concerned about your child’s ability to hear?”

  • Newborns: Routine BAER (brainstem auditory-evoked response) screening is performed in most hospitals.

  • Principles of audiometric assessment: Involve evaluating frequency (Hz) and loudness (decibels).

• Practical Implications: Early detection of hearing impairment is crucial for timely intervention and improved developmental outcomes.

Mouth, Tonsils, Geographic Tongue, Neck

• Geographic tongue:

  • Can occur normally or with illness; may resolve spontaneously.

• Normal tonsils in children: Relationship to hard palate, soft palate, uvula, tonsils, and tongue is assessed.

• Tonsillitis: Characteristic examination findings for inflammation of the tonsils.

• Mouth exam includes: Inspection of teeth, gums, tongue, pharynx, and tonsils.

• Neck exam includes: Assessment of a midline trachea, palpation of lymph nodes, evaluation of the thyroid, assessment of movement, and evaluation for head lag in infants.

Chest and Lungs

• Chest exam:

  • Breast development: Newborns may have breast buds; during adolescence, boys may develop breast tissue (gynecomastia).

  • Lungs: Findings typically improve with age; describe normal or transient findings in newborns/infants (e.g., crackles immediately after birth).

• Thoracic cross-section visualizations: Include normal chest, barrel chest, pectus excavatum, thoracic scoliosis (diagrams used in teaching to illustrate these conditions).

Cardiac Examination

• Point of Maximal Impulse (PMI):

  • In infants: Located at the $4^{th}$ intercostal space (ICS), left of the nipple line.

  • By age $7$: PMI is typically at the $5^{th}$ ICS, near the midclavicular line.

• Heart sounds:

  • S1, S2 are normal heart sounds.

  • S3 can be a normal finding in young children/adolescents.

  • A split S2 with inspiration is a normal physiological finding.

  • S4 is considered abnormal.

• Rhythm:

  • Sinus arrhythmia: Heart rate increases with inspiration and decreases with expiration; may vary with breath-holding and is a normal finding in children.

• Murmurs: Assess if present and characterize their qualities (e.g., timing, intensity, location, radiation).

• Valve Positions (diagrammatic references):

  • Pulmonary valve at left $2^{nd}$ intercostal space.

  • Aortic valve at right/left $2^{nd}$ intercostal space.

  • Tricuspid valve around the left lower sternal border (approx. $4^{th}$ ICS).

  • Mitral valve at left $4^{th}/5^{th}$ ICS, near the midclavicular line.

Abdomen Examination

• Abdomen:

  • Bowel sounds: Normal rate is typically around $1$ sound every $5-10$ seconds.

  • Examine all four quadrants; listen for $3-5$ minutes before determining absent bowel sounds.

• Ticklishness can affect the examination and may require a gentle, patient approach.

• A bruit or thrill along the midline may indicate an aortic aneurysm (rare in children but noted as a teaching point).

• Liver and spleen:

  • May be felt up to $2 ext{ cm}$ below the costal margins in normal exams.

  • Considered abnormal if enlarged beyond that measurement.

Genitorectal Examination

• Female:

  • Inspect labia, swelling, redness, discharge.

  • Tanner staging: Used for assessing pubertal development.

• Male:

  • Inspect penis for swelling, redness, discharge.

  • Tanner staging: Used for assessing pubertal development; assess foreskin if uncircumcised.

• Inguinal region:

  • Inguinal hernia: Look for bulging in the groin area.

  • Palpate inguinal lymph nodes.

Extremities, Neurological Function, and Spinal Health

• Extremities: Assess full range of motion (ROM).

• Neurologic function: Includes motor and sensory assessment.

• Back:

  • Scoliosis screening: Begins around age $12$ years.

• A pilonidal dimple or tuft of hair may be noted in the sacral region, which can sometimes indicate underlying spinal anomalies.

Idiopathic Scoliosis: Screening and Detection

• Standing exam findings:

  • Unequal waist angles (the angle between the waist and the hanging arm).

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