Child Abuse Flashcards
What are 5 categories of child maltreatment?
Child maltreatment may be divided into five categories- physical abuse, sexual abuse,
psychological abuse, neglect, and Munchhausen-by-Proxy.
What are some family/parent risk factors for physical abuse? Child risk factors?
A. Risk factors
Family / parental Risk factors include financial stress, social isolation, substance abuse, mental illness, young parental age, and history of being abused as children. It is important to recognize however that some people who abuse their children have none of these risk factors.
Child Children who are premature, have mental or physical disabilities, and/or are temperamentally “difficult” or colicy are at greater risk of abuse. Infants and toddlers
are more likely to be abused than older children.
What are some presenting signs and symptoms of children that have been physically abused? What are key questions that physicians must answer in their minds to help determine whether an injury was intentional or accidental?
Children can present for medical care with a wide range of signs and symptoms including bruising; burn marks; fractures; signs and symptoms of head trauma such as lethargy, irritability, seizures, coma; or signs and symptoms of abdominal trauma such as pain, pallor, vomiting, or shock
When a child has an injury, physicians need to obtain detailed histories of how the injury occurred. Key questions that physicians must answer in their own minds to help determine whether an injury was intentionally caused or accidental include
- whether the child was developmentally capable of suffering the injury in the way the parents described and
- whether the severity and nature of the injury is consistent with the mechanism described.
What are 4 types of physical findings that are found on children that might signify physical abuse? What specific findings would point towards abuse?
Bruising- Accidental bruises tend to occur more peripherally on the shins, forearms, and foreheads of toddlers. Concerning locations of bruises would be a more central location such as the back, abdomen or buttocks. Looking for evidence of hand prints or belt marks is important.
Burns- Accidental hot liquid burns tend to have splash marks, while non-accidental immersion burns are often bilateral, have well-demarcated lines, and lack splash
marks.
Fractures- Certain fractures are more commonly seen with child abuse. One example is the spiral fracture of a long bone which generally occurs with twisting of an
extremity. Posterior rib fractures are commonly seen in infants who have been shaken.
Head trauma- Bulging of the anterior fontanelle in infants may be seen with intracranial bleeding. Focal neurologic deficits can also be seen so a careful neurologic examination is indicated if head trauma is suspected. Also, if shaken baby syndrome is suspected, examination of the retinas looking for retinal hemorrhages is also important.
What other things should be considered on a differential diagnosis when physical abuse is possible?
D. Differential diagnosis
In addition to trying to determine whether an injury is accidental or caused by abuse,
one needs at times to consider medical conditions that can present with signs and
symptoms suggestive of abuse. In a child with extensive bruising, bleeding
abnormalities such as those caused by a low platelet count are important to consider.
In patients presenting with fractures, bone disorders such as osteogenesis imperfecta
need to be in the differential diagnosis.
What lab studies should be taken when physical abuse is questionable? What symptoms would indicate the?
With extensive bruising, a complete blood count and tests to check for coagulation problems such as a PT, PTT, and bleeding time are warranted.
With fractures, particularly in infants and toddlers, a skeletal survey looking for other fractures is also warranted.
With head trauma, some type of neuro-imaging is essential.
What reporting requirement laws exist? What is missouri’s definition of abuse?
All states have child abuse reporting requirement laws. In general, they mandate that health care providers report all cases in which there is reasonable cause to suspect
that a child has been subjected to physical abuse. This reporting requirement applies not only for physical abuse but for sexual abuse and neglect as well.
Missouri’s definition of abuse is as follows, “any physical injury, sexual abuse, or emotional abuse inflicted on a child other than by accidental means by those responsible for the child’s care, custody, and control, except that discipline including spanking, administered in a reasonable manner, shall not be construed to be abuse”.
What are some possible outcomes of physical abuse?
In addition to the morbidity and mortality caused by child abuse, a wide range of long
term effects can also be seen. Victims of child abuse are more likely to have
psychiatric disorders such as depression, anxiety, post traumatic stress disorder, and
eating disorders; engage in criminal activity; be imprisoned; develop drug addiction;
and abuse their own children.
What is the epidemiology/risk factors for sexual abuse?
A. Epidemiology/ Risk factors
Sexual abuse of children is extraordinarily common. Girls are more than twice as
likely to be sexually abused as boys. Sexual abuse occurs across a wide age range in
childhood with high incidence from eight to seventeen years of age. Most children
are sexually abused by a person that they know well and the abuse is often recurrent
and chronic.
How might a child that is sexually abused present? How should interviews concerning possible sexual abuse be undertaken?
Children who are sexually abused may present with a wide range of signs and
symptoms including somatic complaints such as recurrent abdominal pain, headache,
or chest pain; new-onset of bedwetting; vaginal discharge or bleeding; dysuria;
depression; anxiety; insomnia; and/or poor school performance. They also may
present because of disclosure of the abuse to a parent.
Given the high prevalence of sexual abuse, physicians must keep a high index of
suspicion when a child presents with any of these signs or symptoms.
When interviewing a child about possible sexual abuse, one needs to use
developmentally appropriate language, ask non-leading questions, and provide as
comfortable and non-threatening an environment as possible. Caregivers should be
interviewed separate from the child and separate from each other.
What physical findings might be found with sexual abuse? What lab studies should be performed for sexual abuse? Outcomes?
Careful exam is warranted when sexual abuse is suspected but it is important to remember that most children who are sexually abused, including girls, have no
physical findings present on examination.
In girls, careful external examination of the vulvar area, hymen, and anus is critical looking for erythema, lacerations, tears, and/or scarring. Whether a speculum exam is required depends on a number of factors.
Depending on the contact that is suspected and signs and symptoms present, testing for a range of sexually transmitted diseases may be warranted. Collection of forensic evidence, if the child presents within 72 hours of contact, may also be indicated.
Long term psychological outcomes include higher risk of depression, PTSD, anxiety, sexual dysfunction, and propensity for re-victimization in adulthood.
What is psychological abuse?
Psychological abuse is a difficult area to address in part because coming up with a
definition is somewhat difficult. Some 22 states now have definitions for
psychological abuse. Typical language in some statutes is as follows, “injury to the
psychological capacity or emotional stability of the child as evidenced by an
observable or substantial change in behavior, emotional response, or cognition,” or as
evidenced by “anxiety, depression, withdrawal, or aggressive behavior.”
Psychological abuse often accompanies physical abuse, sexual abuse, and neglect. It
tends to be reported much less commonly than other forms of abuse or neglect.
What is missouri’s definition of neglect?
Missouri law, 210.110.(12) defines neglect as: “failure to provide, by those
responsible for the care, custody, and control of the child, the proper or necessary
support, education as required by law, nutrition or medical, surgical, or any other care
necessary for the child’s well-being.”
What are some family/parental risk factors for neglect? Child risk factors?
Family/ parental Risk factors for neglect include poverty, single parent, multiple young children, substance abuse, and social isolation. Post-partum depression can also lead to neglect.
Children with special needs such as premature babies and children with chronic illness or physical or mental disabilities are at higher risk for being neglected.
What are some presentations of children who are neglected? What is then indicated?
C. History/ Patterns of Presentation
Examples of ways that children who are neglected may present include
developmental delay, poor hygiene, delay in or absence of seeking health care, and
non-intentional injuries from an unsafe home environment. Poor weight gain in
infancy is one of the most common ways that infants who are neglected present.
If neglect is suspected, a detailed social history is indicated. If a baby presents with
poor weight gain, a detailed history of feeding, vomiting, and stool pattern is
essential. To make the diagnosis of neglect when poor weight gain is found, several
days of hospitalization is often required.
