Child Maltreatment Flashcards
Children’s Characteristics of Maltreatment
- feel they deserve the treatment
- another persona of the parent
- hide food
- longing to play
Prevalence of Maltreatment is mainly unknown due to the
underreporting and not recognized
esp. sexual abuse and emotional abuse is hard to prove
___ in _____ children are victims of child abuse and neglect
1 in 5
The prevalence of the different child maltreatment in order
1 - Physical Neglect
#2 - Physical Abuse
#3 - Sexual Abuse
#4 - Emotional Abuse/NEGLECT (psychological maltreatment)
S/S of child abuse/neglect
Changes in behavior
Changes in school performance and attendance
Unexplained injuries
Changes in eating
Insomnia
Lack of personal care or hygiene
Comes to school early, stays late, and does not want to go home
Risk-taking behaviors
Fear of certain places or people
Returning to earlier behaviors (regression with stress)
Inappropriately dressed for the weather
Inappropriate sexual behaviors
Physical Neglect is
Deprivation Of Necessities
Food
Clothing
Shelter
Supervision
Medical Care
Education
Most common form of maltreatment
Physical neglect
Physical neglect could be due to
lack of knowledge of the child’s needs, lack of resources, and caregiver substance abuse
Emotional Neglect:
FAILURE to meet the needs of affection, attention, and emotional nurturance
Emotional Abuse:
DELIBERATE attempt to destroy or significantly impair a child’s self-esteem or competence
Verbal abusive words is a type of
emotional abuse
Forms of Emotional Abuse
Rejecting
Isolation (basement)
Terrorizing – bleach on garbage for him to pass out
Ignoring
Verbally assaulting
Overly pressuring the child
Physical Abuse
deliberate infliction of physical injury on a child,
- usually by the child’s caregiver
Anticipatory Guidance:
The rule of thumb for parents who believe in spanking as a form of discipline is that they should
only use an open hand (no objects such as a wooden spoon, paddle, etc.) and only on the seat of the pants (or buttocks area) with clothes on.
- no bruising
Injuries from abuse can occur from
Punching
Beating
Shaking
Kicking
Biting
Throwing
Burning
Injuries from abuse result in
Bruises
Bites
Burns
Lacerations
Pinch Marks
Swelling
Tenderness
Sexual Abuse
Persuading Any Child To Engage In, Or Assisting Another Person To Engage In, Sexual Conduct Or Simulation Of Such Conduct
Sexual abuse has significant
increased in the past decade due to increased awareness and increased reporting
Incest
between family members
Molestation
Touching, fondling, kissing, masturbation, oral sex
Exhibitionism
“Indecent exposure” by an adult man to kids/women
Child pornography
Photographing sexual acts involving children
Child prostitution
Involving children in sex acts for profit
Pedophilia
Preference of an adult for pre-pubertal children as a means of achieving sexual excitement
Sexual abuse is typically is the abuser of someone
male who the victim knows but could be women and siblings
usually family members (father, step father, relatives)
Methods used to pressure children into sex
Children are offered gifts or privileges
The child is told that it is “okay to do”
They may meet the child’s need for love & affection
Pressures them into secrecy by describing it as “a secret between us”
The offender plays on the child’s fear (of punishment, repercussions, abandonment)
Physical S/S of Sexual Abuse
Injury to external genitalia, anus, mouth or throat
Painful urination
Recurrent UTI’s
Constipation or stool incontinence
Sexually transmitted infections
Difficulty walking or sitting
Pregnancy
Emotional and Psychological s/s of Sexual Abuse
Sexual comments, behaviors, or play
- hypersexual for developmental age
Regressive behavior i.e., bed-wetting
Personality change (withdrawn)
May resist in removing clothes for exam
Phobias (dark, strangers, leaving the house)
Reports nightmares
Sudden change in appetite
Factors for Child Maltreatment
exact cause unknown
- child, parent, environmental
- not predictive of abuse
The interaction of these contributing factors does
increase the risk of abuse occurring in particular families
Child’s unintentional Characteristics of Factors with Maltreatment
- Temperament (difficult)
- Ordinal position/birth order (1st born expect more, youngest is the accident child so not excited)
Age – Birth to 1 year - Prematurity, behavioral disorder, unwanted pregnancy, cognitive impairment, hyperactivity or a physical disability or chronic illness
- parents have more responsibilities with needs to be met
What age has the highest risk for maltreatment?
Birth to 1 year - egocentristic
birth to 2 years (25%)
Usually how many children are the victim of abuse in a household
1
Difficult developmental stages concerning maltreatment
colic
Purple crying
potty training
teens
Removal of the child from the family will generally put
other siblings at risk
Parental Characteristics of Child Maltreatment
Hx of abuse /neglect – “Parenting Imprint”
Uncontrolling aggression
Substance abuse (alcohol and drugs)
Inadequate support systems (few supportive relationships)
Usually one parent that is the abuser, the other permits it
Younger parents (anticipatory programs )
Socially isolated
Marital problems
Single-parent families may include an unrelated partner
Low-income
Little education
Low self-esteem
”Parenting Imprint”
concept that the way you were raised and disciplined as a child can leave a lasting imprint on you and affect how you parent. We know that parents who were abused as a child are at an increased risk of abusing their children
- I will never do that to my child but it might slip up
- angry they want to remove themselves before dealing with it (with abuse they don’t walk away)
The biggest cause of child maltreatment
Inadequate knowledge of appropriate parenting skills /inappropriate or unrealistic expectations for child’s developmental level
Examples of unrealistic expectations related to development
A parent almost severed their 8-month-old’s penis due to incontinence when the parent was trying to potty train them.
You can not potty train an 8-month
An infant with a severed frenulum who refused to take their bottle.
A toddler’s legs and wrists were tied and mouths gagged because they would not stop walking and talking.
They are curious and want to be busy
Jodi Frankie case
Anticipatory guidance
parents about normal growth and development are so important and should be part of a child’s well-checks at the pediatrician’s office or clinic.
to help with lack of knowledge
Environmental Characteristics of Child Maltreatment
Chronic stress
Poverty
Unemployment
Poor housing/crowded living conditions
Frequent relocation
Divorce
Daycare providers and babysitters (especially if they have not been fully evaluated)
Assessment findings of maltreatment
Inconsistent with injury
For example, a concussion, broken arm, and bruises all over thebody from fallingoff ofthe couch onto a carpeted floor
Incompatible with development
A 6-month-old turning on the hot water of thebathtubandclimbing in and getting burned
Delay in medical treatment (afraid of consequences)
Hx changes with repetition
Asking over and over and look for changes
Contradictory histories
Parent says one thing the another says something else
Non-accidental injuries, i.e.,loop mark bruises
Index of suspicion
type and location of the injury do not add up
Types of Injuries
Skin or Soft Tissue Injuries
Musculoskeletal Injuries / Fractures
Abdominal Injuries
Head Injuries
Skin/Soft Tissue Injuries
Bruises:
Bites
Burns
Lacerations
What is the most common manifestations of suspicious injuries with abuse?
bruises
Bruises in various stages of _______ are suspicious
healing
Accidental bruises
Location –
Bony prominences i.e., knees and elbows
Shins
Lower arms
Under the chin
Forehead
Appearance – minor/small
how many
where
color
Colors of bruises over time
Red → Blue/black → Yellow/green → Yellow
- the contusion appears dull red to blue, but over time the red cells are broken down, releasing bilirubin and heme to give the yellow-brown hue seen after a week.
Non-accidental bruises location
Upper arms
Trunk
Upper anterior /posterior legs
Sides of the face
Ears and neck
Genitalia and buttocks
extensive bruising raises the
index of suspicion unless child involved in traumatic crash
Non-accidental bruises age/development
less than 4 months
Those who don’t cruise rarely bruise
Patterned bruises
look like object that caused the bruise
Grab marks orfingertipbruises (face, extremities, and thorax)
Slap marks /handprints
Pinch marks which are often in occult areas – behindears, ongenitalia
Loop marks
Instruments
Occult areas
meaning difficult to see
- behind the ear
more than how many bruises is suspicious unless crash from ATV
4-5
Symmetrical Bruises
Bruises that are on both sides of the body, e.g., both upper arms.
Binding Bruises
The result from being tied with an object such as an electrical cord, rope, belt, etc.
Bite Marks forensic implications
Adult Canine-to-Canine Distance is > 3 cm (between the two Dracula teeth)
The distance between the canines would be what in cm for adults
> 3cm
Recommended to lower the water heater to
120 F
Accidental Burns Patterns
splash - anterior surfaces and tapering
- usually front
object - palms, soles, forearms
Nonaccidental Patterns
forced immersion
pattern object burns
Forced Immersion Burns
extremity = glove or sock-like
trunk = donut - buttock pattern
-circumferential and symmetrical
delay in seeking tx
Pattern intentional burns
Irons
Curling Irons
Cigarette Burns
Suspicious lacterations
Frenulum of upper lip
- forced feeding can tear
Pull up upper lip and find webbing (falling while walking starts to sever the webbing
Rectal area
Vaginal area
Suspicious skeletal fx
single or multiple
new/old/combo
Femur (less than 1 year)
Rib (especially bilateral) and anterior (squeezing)
Scapular
Sternal
Skull
Humerus (less than 3 years)
Spinal Fx
twisting and pulling
Metaphyseal Fx
twisting/pulling/yanking
Corner/Bucket Handle Fx (Metphyseal corner fx)
Mechanism: twisting injury with consequent separation of the corner piece of the metaphysis from the remainder of the bone
Caused by a shaking type injury (an adult may grab, twist, or shake a child’s limb in frustration)
What is the Second Most Common Cause of Death in Child Abuse Cases?
abdominal injuries
- secondary to direct blow
Abd injuries include
Ruptured liver, spleen, bladder, intestinal perforation, pancreatic injuries, etc.
Suspicious abd injuries
Injury inconsistent with history(subtle)
Delay in seeking care
- perforation of the gut; hemorrhage, laceration, contusion, or hematoma of liver, spleen, kidney.
What is the Most Common Cause of Death in Child Abuse Cases?
Head injuries
- external
- fx
- intracranial
External head injuries
ear boxing, periorbital injuries, traumatic alopecia
Traumatic alopecia
partial or complete loss of hair due to someone or something pulling it out intentionally.
Abusive head Trauma aka
Shaken Baby Syndrome
Inflicted head injury
Neuro-inflicted brain injury
Abusive Head Trauma
violent shaking of infants and young children
25-30% die
Abusive Head Trauma s/s
poor feeding
vomiting
irritability
listlessness
seizures
posturing
apnea
bradycardia
alterations in LOC
increased ICP
Characteristic Injuries OF Abusive Head Trauma
Intracranial bleeding (subdural & subarachnoid hematomas)
Bilateral retinal hemorrhages (80% of cases)
Bleeding from the eyes?
May also include fractures of the ribs and long bones
Most often, there are no signs of external injury
Abusive Head Trauma Patho and what happens inside the skull
Vulnerability of Infant
Violent shaking causes the brain to rotate within the skill, resulting in torn blood vessels and neurons
Large head-to-body ratio
Weak neck muscles
Large amount of water in the brain
Common triggers for Shaking
Crying
Maternal stress or depression (post partum depression)
What can you do to reduce abuse related to these triggers?
Anticipatory guidance about how to care for infants with inconsolable crying
v=5pAw8fJ_kUchttps://www.youtube.com/watch?
Purple Crying periods
starts at 2 weeks and gets worse before it gets better
PURPLE crying CHARACTERISTICS
- Peak around the 2 month of life (increase t
- Unpredictable not related to anything in the environment regardless of solutions presented
= come and go for no reason with long periods - Resistant to soothing
- Pain looking
- Long lasting 40-45 mins to 2-3 hours
- Evening hours are more likely
Munchausen Syndrome By Proxy aka
Medical Child Abuse Or Factitious Disorder By Proxy
Munchausen Syndrome By Proxy is
The caregiver (usually the mother with some degree of health care knowledge and training) deliberately exaggeratesorfabricates histories and symptoms or induces symptoms.
The caregiver is often very attentive to the child and may refuse to leave them - understand healthcare.
Examples of Munchausen Syndrome By Proxy
Dr. Judy Ho
https://www.youtube.com/watch?v=SHMy83Qvr7A
overview
Sixth Sense Movie
https://www.youtube.com/watch?v=JqW9iC0DAHM
- poising the child
Gypsy Rose Blanchard
https://www.youtube.com/watch?v=v-ZOB1sHLr8
Munchausen Syndrome By Proxy caregiver may
Fabricate/lie
Induce illness
Be the only one who sees the signs/symptoms
Munchausen Syndrome By Proxy common symptoms
Seizures
Nausea and vomiting
Diarrhea
Altered mental status
nurse do the work with mother not present
Munchausen Syndrome By Proxy reality for the child
The child endures painful and unnecessary medical testing and procedures
The resolution of symptoms after separation from the perpetrator, confirms the diagnosis
Examples of Munchausen Syndrome By Proxy
May give drugs or poison to the child – sixth sense
May suffocate them to cause seizures
May give large doses of laxatives to cause diarrhea
“Mothers have been known to inject feces or lighter fluid in their children’s IV lines…”
Rare type of sepsis
Mimicking Maltreatment of Abuse in cultures or health issues
Cultural practices – cupping and coining by Vietnamese
Mongolian spots
SIDS -
Osteogenesis imperfecta – brittle bone disease
Congenital anomalies of genitalia
Erythema multiform or Phytophotodermatitis – almost burn like meds like dilantin
Idiopathic Thrombocytopenic Purpura (ITP) or Hemophilia
Henoch Schonlein Purpura (HSP)
Leukemia
Accidental straddle injuries
Osteogenesis Imperfecta (OI) is a
genetic bone disorder characterized by fragile bones that break easily. It is also known as “brittle bone disease.” The term literally means “bone that is imperfectly made from the beginning of life.” A person is born with this disorder and is affected throughout his or her lifetime.
Erythema multiform is a
skin immune reaction than an infection or medication can trigger. It is characterized by a red rash on the body where each mark resembles a bullseye.
Cultural Practices that mimick child abuse are
Cupping
-Chinese practice – Used to treat illness e.g., headache or abdominal pain.
-Vietnamese, Russian, Asian and Mexican cultures primarily. However, this has also been utilized by athletes,
- A heated cup is applied to the skin which creates suction on the skin, causing bruises (use a tumbler, bottle, jar, cup that contains steam).
“Draws out poison”.
Cao gio, also called coin rubbing or coining
- ,- Vietnamese practice used to relieve a variety of illnesses such as aches, pains, fevers, colds, cough, nausea, abdominal pain, chills and symptoms related to changes in the weather.
last a few days
Mongolian Spots
Usually disappears by age 2 years
Bluer than bruises
Can be on the back and as well as the buttocks.
Common in African/American and Asian populations.
How to respond if a child reveals abuse or neglect?
Remain calm without an expressive reaction
Believe the child (kids rarely lie if they tell)
Be supportive , not sympathetic
Allow the child to talk
Show interest and concern
**Reassure and support the child’s feelings
Document all statements verbatim with quotation marks
Talk in a private place
Use their vocabulary to describe body parts
Take action – you could save the child’s life!
What not to do if a child reveals abuse?
Promise not to tell or anything you can’t control
“I can’t promise you that, but I can promise you that I am going to get you some help.”
Panic or overreact
Do not express shock or criticize their family
Pressure the child to talk(not investigating with questions)
Confront the offender
Minimize the child’s feelings
Overwhelmthe child with questions
Communication over Abuse/Neglect
as much as they are able or want to say
Ask open-ended questions – who, when, and what?
What happened to your arm?
When you ask the child a question, don’t lead them
Do not make assumptions about what they are saying – clarify and then verify by repeating their words back to them
May want to have them write a story or draw a picture
Ask them if they feel safe going home
Tx of Child Abuse/Neglect
Trauma-focused cognitive behavioral therapy (CBT)
“Helps a child who has been abused to better manage distressingfeelings and to deal with trauma-related memories.”
Child-parent psychotherapy
“Focuses on improving the parent-child relationship and on building a stronger attachment between the two,”
If you suspect abuse/neglect, then
Document history (who said what in quotes)
Document physical findings
Drawings and photo-documentation
Report to CPS (consider law enforcement report as well)
Consider hospital admission for child’s safety
Nurses role in reporting abuse
Anyone who suspects child abuse or neglect should report it within 48 hours
Nurses are mandatory reporters
A person making the report is immune from civil or criminal liability provided the report is made in good faith
The priority is to remove the child from the abusive situation to prevent further injury
If you request identity to be confidential then
may not reveal your identity to the child’s parents, to alleged perpetrators, or to others without your consent or a court order. However,DFPS may disclose your identity to the district attorney or law enforcement if the case requires further investigation.
Information to give when reporting
Name, age, & address of the child
Your name & contact information
Description of the situation
Child’s current condition
Any information that will help identify or locate the child
Local Agencies for Child Abuse
Children’s Advocacy Center (social workers, examiners, and law enforcement)
CASA of the South Plains
Parenting Cottage
Voice of Hope
- A 3-month-old infant presents to the Emergency Department with subdural and retinal hemorrhages but no external signs of trauma, and dies after arriving. What would the nurse suspect?
A. Poisoning
B. Abusive head trauma
C. Sudden infant death syndrome
D. Congenital neurologic disease
B. Abusive head trauma
- What is the most important criterion on which to base the decision to report suspected child abuse?
A. Inappropriate parental concern for the degree of injury
B. Absence of parents for questioning about the child’s injuries
C. Inappropriate response of the child
D. Incompatibility between the history and injury observed
D. Incompatibility between the history and injury observed
- Which are common characteristics of those who sexually abuse children? Select all that apply.
A. Pressure the victim into secrecy
B. Are usually unemployed and unmarried
C. Typically a man whom the victim knows
D. Have many victims that are abused once only
E. Typically have a poor criminal record
A. Pressure the victim into secrecy
C. Typically a man whom the victim knows
- The nurse is teaching a parenting class on Child Abuse prevention. What parental characteristics should she include, that can increase the risk of abuse? Select all that apply.
A. Their “parenting imprint”
B. Middle class
C. College education
D. Nuclear families
E. High self-esteem
F. Inadequate support systems
G. Has difficulty controlling anger and aggression
H. Substance abuse
I. Older aged parents
J. Socially isolated
A. Their “parenting imprint”
F. Inadequate support systems
G. Has difficulty controlling anger and aggression
H. Substance abuse
J. Socially isolated
