JC114 (Paediatrics) - Child abuse Flashcards
Definition of child abuse
Any act of commission/ omission that endangers/ impairs the physical, psychological health, and development of
an individual under the age of 18
Types of child abuse
Physical abuse Sexual abuse Neglect Psychological abuse Mixed/ multiple abuses (most often)
Risk factors for child abuse
- Family factors
Domestic violence, e.g. spouse battering (violence to resolve issues)
Crisis/ tension in family, e.g. pregnancy, divorce/ separation, in-law conflict
Social isolation
Cultural/ superstitious beliefs
Risk factors for child abuse
- Parent factors
History of childhood abuse, experience of domestic/ other violence
History of psychiatric disorder
Alcoholism /drug abuse/ gambling
Rigid/ unreasonable expectation on the child (middle class family)
Strong belief in corporal punishment
Immature parents (don’t know how to take care of child)
Poor impulse/ anger control
Poor parenting skill
Risk factors of child abuse
- Child factors
Family issue:
Unwanted child (unwanted pregnancy)
Illegitimate child
Child associated with family misfortune (superstitious belief)
Child disability:
Baby with feeding/ sleeping problem (difficulty to be looked after)
Child with physical/ mental disability
Child upbringing:
Early separation from parents (adopted by grandparents)
Child exposed to conflicting child care rearing practices, e.g. child reared away from home
Describe the change in neuroplasticity with age
Plasticity: greatest in the first years of life
Genes and early experiences interact to shape the developing brain
Serve and return interaction (interaction between care and baby) shapes brain circuitry
Pruning occurs with age and decreases number of neural connections for more efficient brain circuits
Long term neurological effect of child abuse
Toxic stress:
- Prolonged activation of stress response systems by Adverse Childhood Experiences
- without protective relationships to buffer stress
Weakens brain architecture:
- underdeveloped neural connections in prefrontal cortex and hippocampus**
- lifelong problems in learning, behaviour, physical, mental health
- Developmental delay causes child to adopt health-risk behavior
- Increase incidence of disease, disability, social problems, early death
Long-term health problems caused by childhood maltreatment
Later-life health problems (mental + physical):
Alcoholism, substance abuse, smoking
Depression, suicide attempts
Ischaemic heart disease
COPD
Liver disease
Multiple sexual partners, STDs, unintentional pregnancies
How to prevent long-term effects of Adverse Childhood Events
Best ways to prevent adverse effect of Adverse Childhood Events:
Remove sources of stress
Strengthen core life skills
Support responsive relationships
Strategies to prevent child abuse
- Primary, secondary and teritary level
Primary/universal: Educate the entire community to create social change that is intolerant of child maltreatment Mass media Family and child health services Family life education
Secondary:
Focus on those who are at risk for abuse/ neglect of their children
Intervention program focused on transition to parenthood
Tertiary: Treatment for families who already have encountered child abuse/ neglect, prevent recurrence Family support program Family group conferencing Parenting skill classes
Indicators of families at risk of child abuse
Role of doctor in child abuse cases
Health risks (assessed antenatally): Substance abuse Mental illness Teen pregnancy Domestic violence
Role of medical practitioner: Be familiar with the common manifestations of child abuse, identify early Be motivated to report findings Keep a good medical record Be prepared to testify Prevention
Types of physical child abuse
Non-accidental use of force Deliberate poisoning Suffocation Burning Medical child abuse (Munchausen’s Syndrome by Proxy) – fabricated illness
Various presentations of physical child abuse
Severe life-threatening injuries (e.g. head injuries go to ICU)
Delay in seeking medical help in less severe injuries (consider why didn’t they seek help earlier)
Bruises/ minor injuries noticed by teachers/ nursery staff
Discovered on routine medical check-up (incidental finding of bruises)
How to differentiate accidental vs non-accidental physical injuries in a child
Careful history of how the injuries has occurred
Features suggestive of abuse:
Injuries not consistent with history/ developmental age of child (e.g. <3mo shouldn’t be able to walk)
Unexplained/ poorly explained injuries (e.g. “don’t know”, siblings hit the child)
Inconsistent history between care-givers
Changing history (when asking for in-depth details)
Delay in seeking help
Denial and defensiveness
Which type of physical injuries are most common in child physical abuse?
Superficial injuries/ cutaneous bruises (most common)
- Suspicious sites: Buttocks, abdomen, cheeks, genitalia, medial side of legs and arms
- Includes burns and scalding
- Do not try to age the bruise: Absorption of bruises depends on vascularity of affected tissue and extent of injury
Bone fracture (2nd most common)
Intracranial injuries
Medical conditions that mimic physical child abuse
Bleeding tendency:
Idiopathic thrombocytopenic purpura
Hemophilia
Henoch Scholein purpura (IgA vasculitis; raised purpuric lesions over lower limbs)
Folk remedies (Traditional Chinese Medicine: cupping 拔罐, scraping 刮痧)
Birth marks (e.g. Mongolian spots)
Child abuse
Differentiating features of deliberate burns
Cigarette burns: 7-8mm in diameter
Scalds/ immersion injury:
- Burn of uniform thickness
- Clear demarcation line (glove or stocking)
- Absence of splash marks
- Doughnut pattern in buttock
- Sparing of palms, soles, areas between toes, abdominal skin creases (grip protects palmar aspect)
Fracture types highly suggestive of child abuse
Classic metaphyseal lesion (CML/ bucket handle fracture) in proximal tibia caused by forceful avulsion
Posterior rib fracture (e.g. swellings along ribs)
Scapular fracture
Spinous process fracture
Sternal fracture
Spiral fractures of lower extremities in non- ambulatory children
How to date the age of fracture
Fractures without early callus formation: <7- 10 days old
Soft callus visible: after 1st week to 3-4 weeks
Intracranial injuries in child abuse
- Types of forces that cause these injuries
- How to differentiate accidental vs abusive skull fractures
Injury inflicted by blunt force trauma/ shaking/ combination of forces, e.g. thrown onto bed/ sofa/ ground:
If hard surface - swelling, scalp fracture
If soft surface - may not have scalp fracture
Accidental skull fractures from short falls <4 ft:
Single linear fractures
Parietal bone most commonly involved
Abusive fracture features:
Multiple/ complex fractures
Depressed fractures (e.g. hit by hammer)
Diastatic fractures (fracture line transverses >1 sutures)
Involving >1 cranial bone
Growing fracture (separated by cerebral edema)
Non-parietal fracture
Associated intracranial injury
Most common cause of child abuse deaths
Which paediatric age group is most commonly affected? Why?
Abusive head injuries (AHI)/ “shaken-baby syndrome”
Infants <6 months old especially vulnerable:
Head large in proportion to body size
Weak neck muscles (head swung to and fro)
Fragile, undeveloped brains (not fully myelinated)
Abusive head injuries (AHI)/ “shaken-baby syndrome”
- Most common trigger of abuse
- Clinical features
- Ix for confirmation
Trigger: crying causes parent to become agitated
Clinical features:
- lethargy, irritability, impaired consciousness
- vomiting without gastroenteritis symptoms
- poor feeding
- breathing difficulties and apnea
- Seizures (40-70%) without extracranial trauma
- bruises: grip marks over upper arms/ chest
Ix:
- Ophthalmoscopic examination: retinal hemorrhages (65-95%): intraretinal, preretinal, multiple
- Non-contrast CT scan: subdural hemorrhages (frontal, temporal, interhemispheric), subarachnoid hemorrhages, Cerebral edema
- X-ray: posterior rib fractures, metaphyseal fractures
Long term sequelae of Abusive head injuries (AHI)/ “shaken-baby syndrome”
Mortality: 25%
80% of survivors suffer from lifelong disabilities:
- Small head and brain atrophy (61- 100%)
- Visual impairment (18-48%)
- Intractable epilepsy (11-32%)
- If comatose on presentation: mental retardation, cerebral palsy
Types of mouth injuries seen in child abuse
Broken teeth in older children (direct blow by fist from front)
Torn frenulum in infants (forced feeding)
Pharyngeal injuries (spoon pushed too far)
Types of abdominal injuries seen in child abuse
Abdominal injuries = 2nd most common cause of death from child abuse
Direct blows:
a) Crushing of organs: liver laceration, pancreatic injuries
b) Hollow viscus perforation (small intestine, jejunum*)
Indirect shearing forces (tearing of mesentery) - Multiple visceral injuries common
First-line investigations for suspected child abuse
Blood tests
Full blood count (internal bleeding)
Coagulation screen (multiple bruises)
Liver and renal function tests, amylase (pancreatitis)
Urine microscopy for RBC (kidney injury)
Radiology
Full skeletal survey (SXR (skull), CXR, XR 4 limbs, XR spine) in <2 years old: repeat imaging at 10-14 days
CT scan (convulsion)
MRI scan
Medical child abuse/ Munchausen syndrome by proxy
- Defining characteristics
Fabricated/ induced illness (mom makes up S/S to seek psychological support from doctor)
Characteristics:
1) A parent/ other caregiver fabricates an illness;
2) The child is presented persistently for medical assessment, often resulting in multiple procedures;
3) The perpetrator denies the cause of the child’s illness; and
4) Acute symptoms and signs of the illness stop when the child and perpetrator are separated
Warning signs of Medical child abuse/ Munchausen syndrome by proxy
Warning signs:
Illness unexplained, prolonged
Discrepancy between symptoms/signs and history
Inappropriate/incongruous symptoms/signs/ appears only when mother is attending (e.g. suddenly become blue only when mom is there)
Children alleged to be allergic to a number of drugs/ food
Approach to diagnose Medical child abuse/ Munchausen syndrome by proxy
High index of clinical suspicion
Objective verification of medical history
Review of all medical records
Monitor social media (mom post to catch attention/ sympathy/ financial gain)
Video surveillance (cyanotic spells due to mom suffocating the child)
Child sexual abuse:
Definition
Involvement of a child in sexual activity (e.g. rape, oral sex) which is unlawful, or to which a child is unable to give informed consent
Differentiates from casual sexual relationship that does not include any sexual exploitation (e.g. between a boy and a girl)
Involves forcing/ enticing a child/ young person to take part in sexual activities,
not necessarily involving a high level of violence, whether or not the child is aware of what is happening
Sexual acts that qualify as child sexual abuse
physical contact, including assault by:
Penetration (e.g. rape, oral sex)
Non-penetrative acts (e.g. masturbation, kissing, rubbing and touching outside of clothing)
non-contact activities, e.g.:
Involving children in looking at/ in the production of sexual images, watching sexual activities (pornography)
Encouraging children to behave in sexually inappropriate ways (undress)
Grooming a child in preparation for abuse (including via the internet)
Typical perpetrators of child sexual abuse
Typical presentation of child sexual abuse
Perpetrator:
Usually known to child (e.g. carers, tutors, coaches)
Intend to maintain secrecy (ask child to keep it secret)
Can be by adult males, women, other children
Presentation:
Disclosure of inappropriate sexual contact
Behavioral concerns (play sexual game, have sexualized behavior, fearful of particular individual)
Physical injury to genitals
Genitourinary symptoms (secondary nocturnal enuresis)
Sexually transmitted infections (STIs)
Indicators of child sexual abuse on examination
Genital lesions:
Genital injuries not consistent with accident
Unexplained vaginal soreness/ bleeding (perineal redness)
Urinary tract infections
Psychiatric dysfunction:
Severe psychiatric disturbance, e.g. mutism, eating disorder, suicide, self-mutilation
Repeated and frequent sexualized behaviour
Marked frozen behaviour (when seeing somebody)
Sleep disturbances
Anorexia
Reporting:
Worrying information from adults
Role of doctor in managing child sexual abuse
Child safety: refer to child protection agencies, Inform social worker, police
Safe to go home?
Will child be punished by disclosing abuse?
child’s mental health: treat by psychiatrist or therapist
Depression
Post-traumatic stress disorder
physical examination
To rule out injury, special examination of genital region by specialist
forensic evidence collection: refer to forensic pathologist within 72 hours
For sexual contact with exchange of body fluids
Conclusive evidence of sex abuse
Semen/ blood/ hair foreign to the child within the vagina/ anus
Sexually transmitted diseases, e.g. gonorrhoea, syphilis, HIV, Chlamydia trachomatis
Not all STDs are diagnostic of sexual abuse
Child neglect
- Definition
- Assessment
severe/ repeated pattern of lacking of attention to a child’s basic needs that endangers/ impairs the child’s health/ development
Assessed by severity, chronicity, frequency, intentionality (sometimes not intentional)
Cultural context, e.g. young children as carers for sibs (not acceptable in HK)
Types of child neglect
Physical, e.g.:
Failure to provide necessary food/ clothing/ shelter
Failure to prevent physical injury/ suffering
Lack of appropriate supervision/ left unattended
Medical (not bring to doctor)
Educational
Emotional
Long-term sequelae of chronic child neglect
alter the development of biological stress response systems:
- Less able to cope with adversity
- More likely to have cognitive problems, academic delays
- deficits in executive function skills, and difficulties with attention regulation
Psychological child abuse
- Definition
- Types
Definition:
acts that damage immediately/ ultimately child’s behavioural/ cognitive/ affective/ physical functioning
Types:
- Spurning (hostile rejecting/ degrading)
- Terrorizing
- Isolating
- Exploiting/ corrupting (encourage the child to develop inappropriate behaviour)
- Denying emotional responsiveness/ ignoring
multidisciplinary approach to management of child abuse
- Processing and referral to which professionals
Healthcare: Doctor, nurse, HCP of different specialties
School: Teachers, social workers
Social workers:
- SWD (social welfare department): Family Child Protective Services Unit (FCPSU)
- Integrated Family Services Centre (IFSC)
- Medical social workers (in hospitals)
Police:
- Child abuse investigation unit (CAIU)
- CID (criminal investigation department)
Governing principles in the multidisciplinary approach to child abuse
- Should not require the child to repeat the abuse incident(s) except when necessary
- Share relevant information on a need-to-know basis
- priority to ensure immediate safety of the child, reach consensus for safety and welfare of the child
- Protecting a child from abuse = joint responsibility of different professionals
Line of investigations for child abuse
- Social enquiry/ investigations
- Medical assessment and treatment and Strategic planning meeting in hospital:
- Report to police
- Safety issues: other siblings
- Home/ temporary placement
3, Joint investigation with school or police
- multi-disciplinary case conference (MDCC)
- Share information
- Refer carer or protection order against abusive parent/ guardian
- Welfare plan: placement in residences
- Discuss with family
