Child Maltreatment Flashcards
which of the following is the greatest risk factor for child maltreatment in Canada
- caregiver diagnosed with a mental health condition
- family lives in public housing
- caregiver is a victim of intimate partner violence
- child has history of developmental delay
- caregiver history of alcohol abuse
caregiver is a victim of intimate partner violence
what are some risk factors for child abuse?
alcohol abuse * drug/solvent abuse * cognitive impairment mental health issues* physical health issues few social supports * victim of domestic violence ** history of foster care/group home
what are bruising red flags
mobile children:
- patterned bruising
- bilateral/symmetrical bruising
- bruises that are unusually large or numerous
- bruises that do not fit the mechanism described
- location
what locations are suspicious for bruising in mobile children?
ears
genitals
buttocks
feet
what are the recommended first line lab tests for bruising?
CBC = diff INR, PTT fibrinogen vXF studies (+blood group for interpretation) Factors VIII, IX liver function tests renal function tests
what are red flags for fractures
- fractures in a non-mobile child
- location- higher specificity fractures include: ribs (especially posterior) metaphases of long bones (corner/bucket fractures) scapula sternum vertebral spinous processes humerus in <18 mo femur in non-mobile
- multiple fractures
- fractures in different stages of healing
who should get a skeletal survey? (3)
child <24 months in whom physical abuse or severe neglect are suspected
often done in younger siblings when severe injuries in older child
consider in older children with gross motor delay (they can’t tell you they have pain)
what is the DDx for subdural hemorrhages
trauma (birth, accidental, inflicted)
coagulopathy (vWF disease, factor deficiencies VIII, IX, XIII, plt problems, fibrinogen disorders, vit k deficiency)
structural causes (AVM, aneurysms)
neoplastic (brain tumor, leukemia)
infectious- meningitis
genetic/metabolic- menkes disease, glutaric aciduria type I
benign enlargement of subarachnoid space
what is the most common sentinel injury in cases of child abuse?
bruising
what is a sentinel injury
a minor injury that is externally visible to caregivers or health care providers
most commonly bruises (80%) or intra-oral injuries (10%)
what does hymen transection indicate?
This finding is considered to be a definitive sign of past injury to the hymen (suggesting sexual abuse), which was torn through to the base of the hymen.
what is the most common form of child maltreatment?
neglect
What is the most significant risk factor for abuse?
The most significant risk factor for abuse is
the age of the child, with infants and toddlers being at
greatest risk for serious and fatal child physical abuse.
should infants have bruising?
Because infants are essentially nonmobile and nonweight-bearing, they should never have bruising
what causes classic metaphyseal lesions?
shearing of new bone at ends of long bone
- only seen in pre mobile infants
-highly associated with inflicted injury
typically from a yanking force in a non-mobile infant
what are red flags for fractures on history?
no history of trauma/unwitnessed changes with repetition of story delayed presentation age of child <1 presence of other injuries age or developmental stage, or mechanism does not fit with the injury
Ddx fracture
Trauma- MOST LIKELY
- accidental, birth, inflicted
Nutritional/metabolic
- vit d deficiency rickets
- osteopenia of prematurity
- copper deficiency (longterm TPN)
- chronic renal insufficiency
- scurvy
Genetic
- osteogenesis imperfecta
- menkes
Infection
- osteomyelitis
- congenital syphilis
Neoplastic
- leukemia
- bone tutor
- Langerhans cell histiocytosis
Toxicity
Hypervitaminosis A**
MTX
what is the bone health workup for concerns regarding fracture
CBC calcium, phosphate ALP, renal and liver function tests 25-OH vit D, PTH copper, ceruloplasmin OI testing (consider if enough concerning features)
what physical exam features make infants most at risk for abusive head trauma (3)
relatively large head
weak neck muscles
heavy brain
name 3 characteristic injuries for abusive head trauma?
intracranial hemorrhages
parenchymal brain injury
retinal hemorrhage
also skull/rib/metaphyseal fractures
what are the potential outcomes of AHT?
no apparent effect
developmental delay
seizures
death
what is the most common head injury resulting from abusive head trauma? what is the mechanism?
subdural hemorrhage
acceleration/decceleration or focal impact
can you date AHT on imaging?
NO
can monitor changes in head circumference percentiles or onset of symptoms
Ddx for subdural hemorrhage (4)
trauma!! **by far the most common cause
- accidental, birth, inflicted
bleeding disorder
metabolic disorder
- glutamic aciduria
structural
- large extra-axial spaces/rebleeds/AVMs
what features of retinal hemorrhages make you more worried for inflicted injury?
numerous
multi-layered
extend to the edge of the retina
when retinoschisis present (abnormal splitting of retinal layers)
occur in 75% of cases of AHT (not all cases but highly associated)
you have been asked to assess a 5 month old girl who’s twin is admitted to PICU for traumatic brain injury, suspected to be inflicted. What 3 investigations would you do?
head imaging- CT +/- MRI
skeletal survery
abdominal trauma labs (AST, ALT, Amylase)
what investigations are included for suspected AHT
head imaging: CT +/- MRI: <1 with an unexplained injury
skeletal survey: <2 with an unexplained injury
bloodwork:
bleeding disorder workup PLUS FACTOR XIII
METABOLIC SCREEN FOR GLUTARIC ACIDURIA
screen for abdominal trauma: AST/ALT/ Amylase
Interdisciplinary:
Ophthalmology: dilated fundoycopic exam
medical photography
CAS/police invetsigation
List 5 sexualized behaviours that are concerning for possible sexual abuse? (6)
- any sexual behaviours that involve children who are 4 or more years apart
- a variety of sexual behaviours displayed on a daily basis
- sexual behaviour that results in emotional distress or physical pain
- sexual behaviours associated with other physically aggressive behaviour
- sexual behaviours that involve coercion
- behaviours are persistent and child becomes angry if distracted
What are 5 normal sexual behaviors (6)
- touching/masturbating genitals in public/private*
- viewing/touching peer or new sibling genital *
- showing genitals to peers*
- staying/sitting too close
- trying to view peer/adult nudity
- behaviours are transient, few, and distractable
what is a key question to ask on history for sexual abuse?
do they have any symptoms?
- bleeding
- discharge
- vaginal/anal pain
Should you restrain or force a child to conduct the forensic examination?
NO
if the child is in distress the exam should be deferred to a later time
what is the most common finding on genital examination following a disclosure of sexual abuse?
normal genital exam
what are 5 conditions associated with genital redness?
vulvovagintiis lichen sclerosis contact dermatitis candida diaper rash perianal streptococcal dermatitis
What finding of the hymen would make you concerned for abuse?
any missing tissue to base at 4-8 o’clock
how would lichen sclerosis present?
pruritic white patches with skin atrophy
“figure 8” involving vulval and peri-anal area
what infections can be transmitted by sexual contact? (5)
HIV gonorrhea chlamydia syphilis trichomonas vaginalisis
list 2 residual (healing) findings concerning for sexual contact/trauma
perianal scar
scar of posterior fourchette or fossa
injuries indicative of acute or healed trauma to the genital/anal tissues? (4)
bruising, petechia or abrasions on the hymen
vaginal laceration*
perianal laceration with epxposure of tissues below the dermis*
defect in the hymen between 4 o’clock and 8 o’clock that extends to the base of the hymen, with no hymenal tissue discernible at that location*
14 year old was sexually assaulted several hours ago and is complaining of vaginal pain and bleeding. List 5 things you would consider in your management
gyne exam sexual assault evidence kit emergency contraceptive pill pregnancy test testing for STI and prophylaxis call CAS Hep B and HIV prophylaxis psychosocial supports
within what time frame should you do a sexual assault evidence kit? prepubertal?post pubertal?
pre pubertal- within 72 hours
post pubertal- within 7 days
list some manifestations of neglect
non-adherence/non-compliance of medical management delay seeking medical care hunger/poor growth injuries/ingestion from poor supervision emotional/ behaviour difficulties developmental/ cognitive delay
5 features of caregiver fabricated illness
diagnosis does not match objective findings
signs/symptoms are bizarre
caregiver not relieved if child improves or tests negative
caregiver insists on invasive or painful procedures and hospitalization
signs/symptoms begin only in presence of caregiver
failure of the child’s illness to respond to normal treatments
caregiver publicly solicits sympathy or donations
what does physical punishment put children at risk for? (5)
injury mental health issues impaired parent-child relationships antisocial behaviour tolerance of violence in adulthood
when do you have to report suspected sexual abuse to CAS
Suspected sexual abuse of any child under 16 by a person in position of authority
Suspected sexual assault by a stranger and parents are unbelieving
Can HCP speak with police?
HCP requires consent, warrant or subpoena to speak with Police
age of consent
Legal age of consent for sexual activity in Canada: 16 years
Exceptions to age of consent:
1. Exploitative sexual activity:
•Exploitation: child pornography, trading sex in exchange for money, drugs, food, etc
•Age of consent for exploitative activity 18 years
- “Close in age” exception:
•12 -13yr olds can consent if partner ≤2yrs older
•14 -15yr olds can consent if partner ≤5yrs older
•NB. Does notapply to relationship of trust/authority (e.g. coach)
what are some risk factors for child maltreatment? parental risk factors?
prematurity Chronic Illness Developmental disability Behavioural issues / “difficullt” temperment Multiples (twins, etc)
Parental risk factors: History of criminality or violence Substance abuse Mental health condition Personal history of childhood abuse Young parental age
what are some environmental risk factors for child maltreatment
Low educational attainment •Unemployment •Non-related adult male in home •Social isolation/lack of supports •Intimate partner violence / conflict in home
can bruises be dated?
NO
why do we care about bruising?
Sentinel injury for other occult (hidden) abusive injuries
what are 3 red flags for bruising? KNOW THIS
–Age/Developmental level
–Location of bruising
–Patterned appearance
List 3 things under each category
Medical causes of bruising
Screening for other injuries
Medical causes of bruising: •ITP •HSP •Hemophilia •Connective tissue disorders •Vitamin K deficiency -CF/malabsorption -hemorrhagic disease of the newborn •Von Willebranddisease/platelet disorders •Leukemia •Meningitis/DIC/meningococcemia •Ingestion of anticoagulants
screening for other injuries: •Head imaging (CT, MRI) •Skeletal Survey •Abdominal trauma screening •CT abdomen •Ophthalmology exam
what are the first line laboratory tests for bruising?
- Complete blood count (CBC), including platelets
- Peripheral blood smear
- Activated partial thrombopolastintime (aPTT)
- Prothrombin time (PT)/ International normalized Ratio (INR)
- Fibrinogen
- Von willebrand studies (antigen level and activity)
- Blood group (for interpretation of von willebrandlevel)
- Factor VIII
- Factor IX
- Liver function tests (for secondary platelet dysfunction
- Renal function tests (for secondary platelet dysfunction)
2 month old comes to hospital by ambulance with partial thickness burns. Parents don’t know what happened.
What are five features that make this burn suspicious for inflicted injury?
- Patterned burn (Stocking distribution and symmetrical)
- Linear demarcation
- Age/Development of child
- Lack of history provided
- Uniform depth of burn
which of the following is a risk factor for child maltreatment only child prematurity older parents attends day care
prematurity
in a 2 year old girl, which of the following fractures is MOST concerning for child abuse clavicle femur scapula linear skull fracture
scapula
3 month old baby presents to ED with bilateral femur fractures. No history of trauma is provided. What are 3 features of this presentation that raise concern for inflicted injury?
- bilateral
- non ambulatory child
- no history of trauma
what is menkes
x-linked disorder resulting in copper deficiency
which of the following findings is concerning for sexual contact and/or trauma?
perianal skin tag
anus dilated to 2cm with stool in the ampulla
diastasic ani
perianal scar
hymen opening >3mm
perianal scar
a mother of a 13yo girl with a severe visual and hearing impairment wants information regarding her child’s safety. Which of the following would decrease the risk of sexual abuse?
provide sex education
attending a daytime institution
having a seeing eye dog to allow independent outings
keeping her child separate from groups of people her age
sexual education
kids with disability are more at risk of physical, sexual and emotional abuse (less sex education, social isolation, expect low levels of privacy, communication/cognitive/mobility impairments
most common outcome for parents after physical punishment
parental guilt/regret
Which of the following would be the LEAST appropriate first line investigation for bleeding disorder in the one-month-old with unexplained knee bruising? A. INR/PTT B. vWF screen C. CBC D. Platelet function assay E. Factor VIII
Platelet function assay
how do babies with benign enlargement of subarachnoid space present?
rapid increase in head growth
otherwise healthy, developing normally
May be at increased risk for subdural hemorrhage with
minor or even no trauma
Subdural hemorrhages are generally small and anterior
A 4 year old girl is referred to you for parental concern about her behaviours. Recently she has begun asking to see her playmates’ genitals and attempting to show her genitals to her playmates. For the last 1-2 years her parents have been concerned that she rubs her own genitals for pleasure. How would you characterize these
behaviours?
A) Concerning for sexual abuse
B) Unusual behaviours for her age that should be explored further
C) Common, age-appropriate behaviours
D) Rare behaviours for her age
E) Sexualized behaviours that should prompt referral to CPS
age appropriate behaviours
A 6 week old presents with a tibia fracture. Which of the following would be LEAST appropriate to consider on your differential diagnosis? A. Accidental trauma B. Hypervitaminosis A C. Inflicted trauma D. Aicardi-Goutiere’s Syndrome E. Birth trauma
Aicardi-Goutiere’s Syndrome
