Psychiatry/Social Medicine Flashcards
HCPs must protect children from harm. Other than physical and sexual abuse, what other forms may present?
NB: witnessing intimate partner violence is also one
- neglect
- emotional abuse
- sexual exploitation
- fabricated illness (Munchausen)
- female genital mutilation
What are the 4 rights of the child from the UN convention of rights of the child 1989
- survival rights (food, shelter, healthcare)
- developmental rights (to achieve full potential)
- protection rights (vs all forms of abuse/discrimination)
- participation rights (active role in communities)
Who should be involved in suspected child abuse cases?
- Important to involve MDT in all cases e.g paediatric radiologist/ortho surgeon
- involve seniors
What is emotional abuse?
-persistent emotional maltreatment of child –> severe and persistent adverse effects on the child’s emotional development
Suggest some ways emotional abuse may be directed: e.g. telling child they are ____
- worthless
- unloved
- valued only as far as they meet x’s needs
- inappropriate expectations put on child
Serious bullying that causes child to feel in danger,
exploitation/corruption of child are examples of what type of child abuse?
Emotional abuse
(it’s involved in all forms of maltreatment but may occur alone_
Sexual exploitation is abuse in which children are sexually exploited for ____, ___ or _____
money, power or status
neglect is the persistent failure to meet a child’s basic ____ and/or _____ needs, likely to result in the serious _____ of the child’s health or _______.
physical and/or psychological
serious impairment, health or development
Neglect may involve carer failing to provide: - - - - - or to meet child's basic emotional needs
- adequate food/clothing
- shelter, e.g. excluding from home/abandoning
- protection vs physical/emotional harm
- adequate supervision
- access to appropriate medical care
Fabricated/induced illness is a group of behaviours which involves the carer causing harm to the child.
- Describe verbal fabrication
- who is used as the instrument to harm? how?
- parents invent signs/symptoms in child, telling false story to HCPs leading them to believe child needs Ix/Rx
- then medical/nursing staff are used as the instrument to harm through unnecessary Ix/meds, intrusive tests/surgery
Fabricated/induced illness is a group of behaviours which involves the carer causing harm to the child.
-what may induction of illness involve?
- suffocation of child
- administering noxious substances/poison
- excessive administration of ordinary substance e.g salt
- the use of medically provided portals of entry e.g. central lines
Fabricated/induced illness is v hard to diagnose, what features may point towards this diagnosis? What pattern of presentation/symptoms?
- frequent unexplained illnesses
- multiple hospital admissions
- symptoms that only occur in carers presence
- symptoms not substantiated by clinical findings
- child safeguarding is _______ responsibility
- there should be a ____-centred approach based on a clear understanding of needs and views of children
- everyone’s responsibility
- child-centred approach
Give 2 risk factors for child abuse based on factors in the child:
- failure to meet parental expectations/aspirations
- wrong gender/disabled/’difficult’ child
- born under forced/coercive/commercial sex
Give 2 risk factors for child abuse based on factors in the parent/carer:
- mental health problems
- parental indifference/intolerance/over-anxiousness
- alcohol/drug-abuse
Give 2 risk factors for child abuse based on factors in the family:
- step-parents
- domestic violence
- multiple/closely spaced births
- social isolation/lack of social support
- young parental age
Name 1 risk factor for child abuse based on factors in the environment:
- poverty
- poor housing
name some factors to consider in the presentation of a physical injury in a case of suspected child abuse:
e.g. inappropriate reaction of carer (vague/evasive/unconcerned/excessively distressed)
- child’s age/development
- history given by child (if can communicate)
- plausability of injury/reasonableness of explanation
- background e.g. past child protection concerns, multiple A&E/GP visits
- delay in reporting injury
- inconsistent history from caregivers
Suggest fracture features that may suggest child abuse inflicted injury:
- fracture in non-mobile child
- rib fractures
- multiple fractures (unless signif accidental trauma)
- multiple fractures of different ages
Suggest bruises features that may suggest child abuse inflicted injury:
- bruising in shape of a hand
- bruises on neck that look like attempted strangulation
- bruises on wrists/ankles like ligature marks
- bruise to buttocks in a child <2yrs or any age w/o good explanation
Suggest burn features that may suggest child abuse inflicted injury:
- any burn in a child that is not mobile
- in shape of an implement e.g. cigarette, iron
- ‘glove or stocking’ burn consistent with forced immersion
Consider neglect if the child:
(in a medical setting)
e.g. says there’s no one at home to provide care
- consistently misses medical appts
- lacks needed medical/dental care/immunisations
- seems ravenously hungry
- dirty
- inadequate clothing in cold weather
- abusing alcohol/other drugs
Consider neglect if the parent/caregiver:
in a medical setting
- appears indifferent to child
- seems apathetic/depressed
- behaves irrationally/in a bizarre manner
- is abusing alcohol/other drugs
Give a couple of features of behaviour of the child or the carer that may suggest emotional abuse, in children of baby age:
- apathetic
- delayed development
- non-demanding
- described by mother as ‘spoiled/attention seeking/in control’
Give a couple of features of behaviour of the child that may suggest emotional abuse, in children of toddler/nursery age:
- violent
- apathetic
- fearful
Give a couple of features of behaviour of the child that may suggest emotional abuse, in children of school age:
- wetting/soiling bed
- relationship difficulties
- non-attendance
- anti-social behaviour
Give a couple of features of behaviour of the child that may suggest emotional abuse, in minors of adolescent age:
- self-harm
- depression
- oppositional
- aggressive
- delinquent behaviour
What is an important form of emotional abuse in school-aged children that should be recognised/picked up/acted on?
-bullying by other children
Suggest what sort of presentation may a young person come with that would make you suspicious of sexual abuse in a child?
- child identified in pornographic material
- child pregnant if under age of 13=abuse
- STI with no clear explanation
Suggest a sign/symptom a young person come with that would make you suspicious of sexual abuse in a child?
- vaginal bleeding
- discharge, itching
- rectal bleeding
Suggest what sort of behavioural symptoms a young person may come with that would make you suspicious of sexual abuse in a child? (same applies for emotional abuse) plus:
- unexpected awareness/acting out sexualised behaviour beyond what is expected for age
- soiling, secondary enuresis (wet bed)
- self harm, aggressive or sexualised behaviours
- regression
- poor school performance
What are the challenges in examining a child with suspected sexual abuse?
- few diagnostic signs
- hard to find positive findings even days post-assault
- genital heal v quickly
- sexual abuse often is without much physical force (less signs)
- forensic material decays rapidly
Due to the challenges in examining a child with suspected sexual abuse, an expert doctor with _____ should examine, important tests to run include:
- expert with specific training and facilities for photographic documentation
- STI screening and management
- if needed: forensic testing for DNA may reveal perpetrator body fluid
What type of imaging should be done in all children with suspected physical abuse <30months old?
-full radiographic skeletal survey
-with oblique views of ribs
(NB: some lesions may not be seen initially but become evident on a repeat x-ray 1-2weeks after if indicated).
What medical conditions may explain suspected physical child abuse in the form of bruising, fractures, and scalds/cig. burns?
- bruising-coagulation disorders, Mongolian spots
- fractures-osteogenesis imperfecta type I
- scalds-bullous impetigo, scalded skin syndrome
Osteogensis imperfecta type I is an ___ condition that often presents with unexplained ____, child may have ___ ___ and there will be generalised _____ and Wormian bones in the skull (____ ____ within skull sutures)
- AD condition
- unexplained fractures
- blue sclera
- generalised osteoporosis
- Wormian bones (extra bones within sutures)
If brain in jury is suspected, all children require:
e.g. what form of imaging? who needs to examine x for what? Screen of what?
- immediate CT head followed later by an MRI
- a skeletal survey to exclude fractures
- an expert ophthalmologist to rule out retinal haemorrhage
- a coagulation screen
Any child abuse injuries should be carefully noted, what detail needs to be taken?
NB: notes must be meticulous, signed, dated and timed on each page
- injuries should be measured, recorded and drawn on a body map and photographed (with consent)
- height, weight and head circumference, record and plot on a centile chart
- note interaction between parents and child
When dealing with any child suspected of been abused, what else should be considered? Who should be involved?
- the safety of other siblings/children living at home
- police and/or social services
Signs of depression in child/adolescents?
e.g. -guilt/despair, lack of motivation
- social withdrawal
- apathy, boredom, inability to enjoy oneself
- separation anxiety reappearing
- decline in school performance
- hypochondriacal ideas/pain chest/abdo/head complaints
- irritable mood/frankly antisocial behaviour
What is it important to ask about depression in child/adolescents? Why should you talk to child alone?
- ask about feelings directly and about suicidal ideas/plans
- teenagers out of loyalty may pretend to parents that all things are all right
Treatment of depression in child/adolescents depends on severity, children with mild symptoms can be managed in 1 care, and often recover spontaneously ~4weeks observe, if 2-3months later no response, who to refer to?
-specialist mental health services
mod-severe depression should be referred immediately
children with mod-severe depression should be referred immediately to specialist Mental Health services, what rx may be available for them?
- psychological intervention e.g. CBT
- family therapy
- interpersonal therapy
- identifying contributing factors e.g. bullying
children with mod-severe depression under specialist Mental Health services for CBT/therapy that do not respond after _weeks, what should be considered?
- after 6 weeks
- consider SSRI e.g. fluoxetine
Depressed young people who are suicidal may need ___
-admission to an adolescent inpatient unit
Name a few reasons why some children may deliberately be self-harming?
- coping technique for negative feelings e.g. low self-esteem
- expressed wish to punish themselves
- positive feeling of control they experience when harming
- physical pain as a distraction from emotional pain
15% adolescences self-harm during development, many don’t actively present to HCPs so in assessing an adolescent with emotional/behavioural difficulties, what must you ask about?
-ask about self-harm, consultation is not complete until you do so
Name common methods of self harm other than cutting:
- burning
- scratching
- tying ligatures round neck
- punching walls (suspect in boxers fractures)
How may you notice signs of deliberate self harm in an adolescent?
- full physical examination good time to look
- cutting into thighs can often be missed
- pt wearing long sleeves/reluctant to show skin should raise concern
How to ask about deliberate self harm in an adolescent?
e. g. -validate the young persons distress, -assure…
- normalisation of the problem is key
- take history w patient alone
- create safe environment
- allow enough time to conduct consultation sensitively, wo interruptions
- set rules of confidentiality out clearly
- give assurance they will be supported
- ask questions directly but sensitively
Suggest a good phrase to ask about self-harm/suicide in a low mood adolescent:
-sometimes if people are feeling particularly stressed worried or low, they can have thoughts about harming themselves, or ending their lives. Has this ever happened to you?”
The screening tool PATHOS can be used to assess suicide risk after adolescent overdose, what do the letters stand for?
NB: P, A, T, HO, S
P-Problems A-Alone T-Three hours HO-Hopeless S-Sad
explain this tool for suicide RA post overdose: P-Problems A-Alone T-Three hours HO-Hopeless S-Sad
- Have you had PROBLEMS > 1month?
- Were you ALONE in house at the time?
- Did you plan the OD for longer than THREE hours?
- Are you feeling HOPELESS about the future?
- Were you feeling SAD for most of the time before the OD?
In this tool for suicide RA post overdose, each q is worth 1 point, child is at high risk if score is >\_\_, but final judgement...?: P-Problems A-Alone T-Three hours HO-Hopeless S-Sad
- if >2points = high suicide risk
- final judgement is a clinical and qualitative decision not one based on a cut-off score
When will a man have parental responsibility:
- father on birth certificate (even if not biological father)
- father at time of birth if was married to the mum
What are the 3 risk factors used to predict the risk of recurrence of a febrile seizure?
- young age at onset <18months
- family history of febrile seizures
- seizures at temperature <40 degrees
What is the risk of developing epilepsy after febrile seizures in healthy children?
3%
What medication can help with febrile seizures?
-Paracetamol/NSAIDs (anti-pyretics)
