4. Child Abuse and Neglect Flashcards
1
Q
Define: Child Abuse and Neglect (1)
A
- an act of commission (physical, sexual, or psychological abuse) or omission (neglect) by a caregiver that harms a child
2
Q
Describe legal duty to report: Child Abuse and Neglect (2)
A
- upon reasonable grounds to suspect abuse and/or neglect, physicians are required by legislation to contact the Children’s Aid Society (CAS) to personally disclose all information relevant to the child’s safety concern
- duty to report overrides patient confidentiality; physician is protected against liability
3
Q
Describe Ongoing duty to report: Child Abuse and Neglect (2)
A
- if there are additional reasonable grounds to suspect abuse and/or neglect, a further report to the Children’s Aid Society (CAS) must be made
4
Q
Name risk factors: Child Abuse and Neglect (3)
A
- environmental factors: social isolation, poverty, domestic violence
- caregiver factors: personal history of abuse, psychiatric illness, postpartum depression, substance abuse, single parent family, poor social and vocational skills, below average intelligence
- child factors: difficult temperament, disability, special needs (e.g. developmental delay), premature
5
Q
Describe: Management of Physical Abuse, Child Abuse, and Neglect (4)
A
- do not take an abuse history from a young child; this must be done by trained personnel (e.g. during a forensic interview)
- report all suspicions to CAS; request emergency visit if imminent risk to child or any siblings in the home
- acute medical care: hospitalize for medical evaluation or treatment of injuries if indicated
- arrange consultation from social work and appropriate follow-up
6
Q
Describe history: Physical Abuse (6)
A
- history that is not compatible with physical findings or with child’s developmental capabilities
- history not reproducible or changes dramatically over time
- delay in seeking medical attention that is unexplained by other factors
- assess previous trauma or hospitalizations
- ask FHx: bleeding disorder, bone disorder, metabolic conditions
- ask developmental history
7
Q
Describe Physical Exam: Physical Abuse (11)
A
- physical findings not explained by underlying medical condition
- growth parameters including past recorded parameters (weight, height, head circumference)
- multiple injuries not explained by accidental injury or child’s development level
- patterned skin injuries: linear, shapes, etc. that do not match provided history
- injury location:
- bruises: on areas with abundant soft-tissue cushioning, such as abdomen, buttocks, genitalia, fleshy part of cheek or on ears, neck or feet, bruises that do not fit described cause
- fractures: posterior rib/metaphyseal/scapular/vertebral/sternal fractures (more suspicious for non- accidental injuries)
- immersion burns (e.g. hot water)
- altered mental status: head injury, poisoning
- eyes – retinal hemorrhages
- scalp – patchy hair loss from traumatic alopecia or severe malnutrition
- oral exam – check the frenula for tears
- head trauma is the leading cause of death in child maltreatment (e.g. acceleration-deceleration forces [shaking], direct force application [blow or impact])
- consider “red herrings” (e.g. slate grey macule/congenital dermal melanocytosis vs. bruises)
8
Q
Describe investigations: Physical Abuse (4)
A
- document all injuries on a body diagram: type, location, size, shape, colour, pattern
- photography of skin injuries is ideal (police or hospital photography preferred; do not use physician’s personal camera)
- rule out medical causes of bruising/fracture with appropriate investigations (e.g. blood disorders or rickets):
- if fractures evident: Ca2+, Mg2+, PO43-, ALP, PTH, Vitamin D, albumin
- if bruising present: CBC, INR, PTT, von Willebrand factor, factors VIII/IX
- screen for abdominal trauma
- transaminases and amylase if elevated: abdo CT recommended
- renal function – electrolytes, urinalysis
- toxicology screen – overdose or poisoning
- skeletal survey in children <2 yr; select imaging based on history in children >5 yr
- neuroimaging: CT and/or MRI - dilated eye examination by pediatric ophthalmologist to rule out retinal hemorrhage if subdural hemorrhage detected on head imaging
9
Q
Describe epidemiology: Sexual abuse (3)
A
- peak ages at 2-6 yr and 12-16 yr, most do not report until adulthood
- as adults: more likely to develop obesity, sexual problems, IBS, fibromyalgia, STI, substance use disorder
- more likely to experience intimate partner violence and sexual assault
- in decreasing order: family member, non-relative known to victim, stranger
10
Q
Describe history: Sexual abuse (10)
A
psychosocial:
- specific or generalized fears
- depression
- nightmares
- social withdrawal
- lack of trust
- low self-esteem
- school failure
- sexually aggressive behaviour
- advanced sexual knowledge
- sexual preoccupation or play
11
Q
Describe physical exam: Sexual abuse (3)
A
- recurrent UTIs, pregnancy, STIs, vaginitis, vaginal bleeding, pain, genital injury, enuresis
- anogenital exam performed along with head-to-toe physical for physical trauma
- instrumentation not required for anogenital exam, speculum contraindicated in prepubertal girls
- most victims have normal anogenital exam – cannot rule out sexual abuse if exam is negative
12
Q
Describe investigations: Sexual abuse (4)
A
- depend on presentation, age, sex, and pubertal development of child
- sexual assault examination kit within 24 h if prepubertal, within 72 h if pubertal
- rule out STI, UTI, pregnancy (consider STI prophylaxis or emergency contraception)
- rule out other injuries (vaginal/anal/oral penetration, fractures, head trauma)
- investigations to rule out drug and alcohol screen e.g. Rohypnol, ‘Liquid G,’ etc.
13
Q
Define: Neglect (1)
A
- omissions in care by parents or caregiver that leads to actual or potential harm
14
Q
Define history: Neglect (1)
A
from child and each caregiver separately (if possible)
15
Q
Describe physical exam: Neglect (3)
A
- head to toe (do not force), growth parameters, nutrition status
- dental care
- emotional state
