Child and Elder Abuse

Question 1

What is the doc’s primary role if suspecting child abuse?

Answer 1

To report, not investigate

Question 2

Child risk factors for abuse

Answer 2

Fussy, colicky child
Hyperactivity
Ill
Non-biologic relationship with caregiver
Prematurity

Question 3

Major caregiver risk factor for abuse

Answer 3

Substance abuse

Question 4

Definition: Child Abuse

Answer 4

A recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm.

Question 5

4 main types of child abuse

Answer 5

Neglect
Emotional
Physical
Sexual

Question 6

Most common cause of death in abused children is…

Answer 6

Neglect: failure to provide, food, clothing, shelter, emotional support, education, medical care, etc.

Question 7

What “other” elements should be included in a well-child visit? (5)

Answer 7

Nutrition
Safety, injury prevention
Developmental stages
Dental and eye care recommendations
Educational needs

Question 8

What is the physician’s role when suspecting neglect?

If a diagnosis is unclear, what can be done?

Answer 8

Obtain a full medical history, full psychosocial history and complete PE.

If unclear:

• arrange a home visit by a social worker or home nurse.
• arrange a “well check” by local police.

ensure safety of child and contact CPS even when in doubt (?)

Question 9

What is the definition of emotional abuse?

Is it easy to recognize?

Answer 9

Abuse that results in demonstrable harm to the child (e.g. impaired psychosocial growth and development).

Question 10

What is the doc’s role when suspecting emotional abuse?

Answer 10

If appears isolated and no immediate danger to child: May recommend family therapy, parenting classes, supportive therapy, behavior therapy for parents.

If appears recurrent or possibility of imminent harm to child: Report to child protective services

Question 11

What are suspicious signs during a PE that might suggest abuse?

Answer 11

Bruises, bites, fractures, abdominal trauma, head trauma.

• Posterior rib fxs
• Scapular fx, spinous process fx
• Sternal fx
• Cigarette burns
• Metaphyseal lesions

Question 12

Actions the doc can take if suspecting abuse: (3)

Answer 12

Meet separate with caregiver to gather info.

Document carefully.

Photograph injuries and download to a secure location (remove immediately if a personal device was used).

Question 13

Definition: Sexual Abuse

Answer 13

The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or to assist any other person to engage in, any sexual explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct.

Question 14

3 types of sexual abuse and definitions/examples

Answer 14

Non-touching - exposing child to porn; neglectfully allowing a child to see/hear sexual activity.

Touching - fondling, touching, penetration, etc.

Exploitation - engaging a child for purpose of prostitution, using child to film sex or model porn, human trafficking, etc.

Question 15

What are some stats/demographics regarding sexual abuse?

Answer 15

*Most victims are 9-12 y/o*
50% of cases are within the family
60% of victims are female (...of victims reporting abuse)
25% < 8 y/o
*70% of victims have never told anyone*

Question 16

What PE findings are common in a patient who has been sexually abused?

How should the visit be documented?

When must a PE be done ASAP?

What should be avoided in a pre-pubertal child?

Answer 16

Usually there are no positive PE findings.

History is most important and use quotations.

Do PE ASAP if there is dysuria, anal or vaginal bleeding, vaginal discharge, or pain upon defecation.

Avoid touching the hymen and use of a speculum.

Question 17

Which kind of abuse is described by “no single behavior, sign or symptom is diagnostic”?

Answer 17

Sexual abuse

Question 18

When is there increased concern for sexual abuse

Answer 18

• Puts mouth on other child/adult’s sex parts • Puts objects in vagina or rectum
• Touches another child’s sex parts
• Asks others to engage in sexual acts
• Tries to have sexual intercourse with another child or adult
• Pretends dolls or stuffed animals are having sex
• Tries to undress other children against their will (open pants, shirt, etc.)
• When kissing, tries to put their tongue in other person’s mouth
• Draws sex parts when drawing pictures of people

Question 19

What is the “best practice” for dealing with a patient that is suspected to have been abused sexually?

Answer 19

Refer for forensic interview: CPS, trained interviewers.

If an immediate interview is needed, do a Minimal Facts Interview (who, what, where, how…?)

Question 20

What question should be avoided in a Minimal Facts Interview? Why?

Answer 20

Avoid asking “when?” because children have poor spatial timing and can be confused. Instead, ask “did this happen more than once?”

Question 21

Which populations are considered “very high risk” for sexual abuse?

Answer 21

Intellectually disabled (4x more likely)

**Deaf children (50% are victims in childhood or adulthood)

**Among developmentally disabled adults, 83% of females are victims (32% of males)

LGBTQ are 3x more likely

**Transgender - 50% are victims in childhood or adulthood

Question 22

What is the penalty if a doctor does not report child abuse in the state of MO?

What is it in the state of KS?

How does this apply to medical students?

Answer 22

MO - Class A misdemeanor for failure to report (1 year in jail + $2K fine).

KS - Class B misdemeanor for failure to report, even when another mandated reporter has made a report (6 mo. in jail + $1K fine). All mandated reporters must report!

Med students are not required to report yet, but they must alert the attending doc.

Question 23

Major risk factors for elder abuse include: (3)

What is a major characteristic of elder abuse perpetrators?

How many cases go unreported?

Answer 23

Dementia, psychiatric diagnosis
Physical dependence
Incontinence

Substance abuse

Approx. 80%

Question 24

What are the 5 types of elder abuse?

Answer 24

1. Physical: e.g., hitting, slapping, shaking, strike with object, physical or chemical restraint.
2. Sexual: e.g., rape, unwanted touching, innuendo, sexual advances.
3. Psychological: e.g., threaten to institutionalize or to withdraw RX, nutrition, or hydration.
4. Financial: e.g. theft, blackmail; coercion to change will or other legal document that counters victim’s best interest.
5. Neglect (50% of cases): failure to provide goods/services necessary for maintaining health and avoiding harm/illness.
   - Active/Intentional: refusal to provide basic needs of hygiene, food, RX, physical assistance as needed for safety.
   - Passive/Unintentional: due to ignorance or inability of caretaker.

Question 25

What are signs of elder abuse on PE?

Answer 25

Bruising, burns
Unexplained injuries
Findings of sexual abuse
Poor physical care
Falls
Cognitive decline

Question 26

What is a physician’s role when suspecting elder abuse?

Answer 26

1. Report to Senior Protective Services (SPS).

2. Careful documentation: photos, XRs, diagrams of injuries, written documentation.

Question 27

What is the consequence for not reporting elder abuse in MO?

What about in KS?

Answer 27

MO - Class A misdemeanor for failure to report (1 year in jail + $2K fine).

KS - Class B misdemeanor for failure to report, even when another mandated reporter has made a report (6 mo. in jail + $1K fine).