15.2.2 Child Abuse (Non-accidental Injuries) Flashcards
Define abuse
Children’s Act [No. 38 of 2005] (www.gov.za)
“abuse”, in relation to a child, means any form of harm or ill-treatment deliberately inflicted on a child, and includes-
- assaulting a child or inflicting any other form of deliberate injury to a child
- sexually abusing a child or allowing a child to be sexually abused (not just rape, but showing child pornography);
- bullying by another child
- a labour practice that exploits a child
- exposing or subjecting a child to behaviour that may harm the child psychologically or emotionally
Neglect def
- Caretaker omissions that result in harm or potential harm to a child Failure to provide
- Food
- Clothing shelter
- Appropriate medical and dental care (when child dies of something that could have been prevented by taking them to dr)
- Education
- Supervision
- Emotional support
- family violence
Emotional abuse
Neglecting
- Mental health
- Medical care
- Educational needs
- Humiliating a child in public
- Witnessing domestic violence
Sexual abuse
Incidence
- One out of three children in South Africa; boys marginally higher)
Non-contact sexual abuse
- Flashing
- Child pornography (allowing, possessing, distribution), inappropriate speech, sexual grooming)
Contact non-penetrative
- Inappropriate touching (over clothing, female breasts, sexual grooming involving touch)
Penetrative abuse
- Any penetration whatsoever into or beyond the anus, genitalia, mouth with genitals
Polivictimisation
Children experience
- Repeated victimisation
- Multiple types of victimisations (physical + neglect + abuse)
- Likely to suffer from traumatic symptomatology
Risk factors for abuse
Child factors
Parental factors
Family factors
Environmental factors
Child factors
- Younger than 4 years
- Premature birth (higher needs)
- Special needs
- Physical disability
- Chronic illness
- Cognitive disabilities
- Mental health issues
Parental factors
- History of being abused (parent see it as normal)
- Inappropriate expectations
- Lack of empathy to child’s needs
- Parental belief in corporal punishment
- Children born to young mothers (18 years)
- Mental health problems
- Non-related caregiver in home
- Frustration intolerance
Family-level
- Domestic violence
- Presence of several children
- Presence of transient non-related caregivers
- Poverty
- Social isolation
Environmental
- High violence community
- High poverty
- Residential instability
- High unemployment
- Easy availability of drugs and alcohol in neighbourhoods
Non-Accidental injury of children 5 steps
- Think the unthinkable
- Listen
- Look and think
- Investigate
- Report (very important)
Step 1: Think the unthinkable
- Add NAIC to the differential diagnosis
Didn’t do it in so much detail, just main points
Red Flags
Presentation - Delayed presentation
o Repeated injuries, fractures or ingestions
• Characteristics of parents-Inflicted
o Hostile; abusive to staff; angry
o Refuse admission of child/premature discharge
o Mothers may be depressed, withdrawn, seeking help o May be victims of abuse/sexual abuse
o Lack of concern for the child
o Disturbed parent-child interaction
▪ Anger and hostility (It’s his fault!)
▪ Inability to cope with the child’s behaviour
• Sentinel injuries
• Young and developmentally immature infants
o Bruises
o Oralinjuries
o Subconjunctivalhemorrhages
o Sentinel: superficial and not require medical intervention
• Previous sentinel injuries common in infants with severe physical abuse and rare in children found not to be abused
• Detection of sentinel injuries could prevent many cases of abuse.
• Characteristics of children-Inflicted
Step 3: Look and think
- Cutaneous manifestations (Bruising; Burns and Scalds; Adult bites)
- Head trauma
- Skeletal manifestations
- Visceral manifestations
- Maxillofacial manifestations
- Ocular manifestations
- Poisoning
- Growth faltering
- Factitious disorder imposed on another (Munchausen syndrome by proxy)
(3) Bruising, haematoma and petechiae
Red flags
The rule of TEN
Patterned bruising
Differential diagnosis
Red flags
- Bruises in babies who are not yet ‘cruising”
- Bruises on the ears, neck, feet, buttocks or torso (torso includes chest, back, abdomen, genitalia)
- Bruises not on the front of the body and/or overlying bone
- Bruises that are unusually large or numerous
- Bruises that are clustered or patterned (patterns may include handprints, loop or belt marks, bite marks)
- Bruises that do not fit with the causal mechanism described
- Petechiae on face and neck due to strangulation/suffocation
The rule of TEN: Decision rule for predicting NAIC
- Bruising on the Torso, Ear or Neck, if child >4 years old
- Bruising anywhere if child <4 months old?
➡️If either present, is there history of confirmed accident in public setting that accounts for bruises?
➡️Sensitivity: 97%; Specificity: 84%
Patterned bruising
- Tramline
- Linear objects- rigid or flexible
- Often ascribed to discipline methods
➡️“Negative imprinting”
➡️Object sinks into the skin,
➡️Edges drag skin down and tear marginal blood vessels
➡️Centre compresses the skin but with no bone underlying little
or no damage to vessels caused – spared area of non-bruised skin
- Pinch, grip marks
➡️ 2 small areas (1- 2cms), relatively round • Initially separated by
normalskin, latermaycoalesce
- Fingertip (six-penny) bruises
➡️Often face, limbs, trunk (shaking/squeezing) injury Oval or round ➡️One surface up to 4 bruises, other surface thumb imprint
➡️Reasonable to assume significant force
➡️Can be accidental – “saving” child from running across road
- Slap marks
➡️Parallel linear bruises
➡️Might be petechial
➡️Separated by areas of central sparing
➡️Often on the cheek
- Implements
➡️ Outline of object on the skin
- Base of skull fracture
➡️Raccoon eyes
➡️Battle sign
Differential diagnosis
- Accidental (ant tibial bruise)
- Normal variants
- Accidents
- Cultural practices
- Infectious processes
- Dermatological conditions
- Haematological disorders
- Phytophotodermatitis
- Insect bites
- Drug reactions
- Self-inflicted bruising
- Factitious bruising
(3) Adult bites
Responsibilities
Animal vs human
Age of human biter
Responsibilities
- Hepatitis B
- Swabbing for DNA
- Inside and outside indentation line
- Not on broken skin
- Photography
➡️Without and with measure standard
➡️Get LCRC (SAPS)
- Animal vs human
- Age of human biter
➡️Unreliable
▪ Variation in jaw size
▪ Distortion of tissue - May be self-inflicted
- Forensic Odontologist/Dentist
(3) Burns
- Cutaneous manifestations: Burns
- Thermal
- Electrical
- Chemical
- Radiation
(3) Scalds
Abusive scald burns
- Trunk, buttocks, perineum,
- Arms, legs hands and feet (stocking, glove distribution)
- Clear demarcation between burned and normal skin
- Uniform depth (all will be same classification of burns)
- Absence of splash marks
- Sparing of buttocks, skin folds, soles of feet if pushed against cooler surface
➡️Hole-in-the doughnut
Accidental scald burns
- Child pulls hot liquid onto self
➡️Front of body
➡️Face
➡️Shoulder
➡️Sparing under chin
➡️Deeper where clothing keeps hot liquid in contact with skin
➡️Not uniform depth
➡️Cools as run down
➡️Arrow shape
(3) Cigarette burns
- Circular 0,75-1 cm
- Central crater of deeper burn
- Often grouped
- Often hands and feet
- Accidental: Ovoid, superficial
Burns: differential diagnosis
- Accidental burns
- Traditional medicine
- Dermatological conditions
- Impetigo
- Infections
- Phytophotodermatitis
- Allergic reactions
- Sunburn
- Scars from enuresis blankets
