CHILD ABUSE

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CHILD ABUSE

• DR LEILA WILLIAMS
• LCDR, USN, MC
• FAMILY MEDICINE PHYSICIAN
• NAVAL HEALTHCARE NEW ENGLAND-GROTON

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OBJECTIVES

• Discuss different types of Child Abuse
• Reporting
• Family Advocacy

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(No Transcript)
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CHILD ABUSE/MALTREATMENT

• Three million cases of child abuse reported in
  the United States each year
• It includes physical abuse, sexual abuse,
  psychological abuse, and general medical and
  educational neglect
• Includes both acts and omissions on the part of
  the responsible person

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Consecquences of Child Abuse
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Child Abuse Average per year

• Total incidents over 3 million
• - Substantiated 59
• - Unsubstantiated 18
• - FINS (Family In Need of Services) 23
• - Fatalities 6/yr

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Incidence of Reported Cases of Child Abuse

• TYPE OF ABUSE
• Neglect
• Physical abuse
• Sexual abuse
• Emotional abuse
• Other

• OF TOTAL
• 54
• 25
• 11
• 3
• 7

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Child Neglect

• Physical neglect
• Emotional neglect
• Medical Neglect
• Educational Neglect

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Physical Neglect

• Lack of home, bedding, nutrition, clothing or
  safety
• Failure to thrive
• - Medical problem (genetic, structural,
  physiologic)
• - Emotional (lack of nurturance)
• - Nutritional (decreased intake/improper
  technique)

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Physical Appearance of a Physically Neglected
Child

• Large forehead
• Prominent ears
• Sunken eyes
• No fat paddings

• Glassy stare
• Hollow cheeks
• Prominent abdomen
• Defensive posturing

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Emotional Child Neglect

• Lack of love and nurturance
• Lack of discipline and boundaries
• Domestic violence
• Parental drug/alcohol abuse

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Medical neglect

• Delayed care
• ER abuse
• Chronic illness
• Religious barriers

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Educational Neglect

• Basic life skills
• Social norms
• Unstructured home schooling
• No school attendance/school withdrawal

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Neglect evaluation

• Safety
• Is it neglect or Family in Need of Services
  (FINS)
• Minor vs major issues
• Contributing factors

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Physical Abuse

• Hallmark-history that is inconsistent with the
  patients injuries
• Non accidental traumas
• Diagnosis and treatment
• Ensure childs safety and assist in collection of
  evidence for possible litigation
• Mandated to report

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Physical Indicators of Child Abuse

• Bruises on uncommonly injured body surfaces
• Blunt-Instrument marks or burns
• Human hand marks or bite marks
• Circumferential immersion burns

• Multiple injuries at different stages of healing
• Evidence of poor care or failure to thrive
• Unexplained retinal hemorrhages

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Bruising of the ear from being boxed
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Loop mark bruises inflicted by a doubled-over cord
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Bruises inflicted at different times on the
buttocks
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Immersion burn of a childs hand
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Retinal hemorrhages in a patient with shaken-baby
syndrome
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Multiple healing rib fractures from a compression
injury of the chest
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Metaphyseal or bucket handle fracture of the
tibia
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Multiple bilateral radial and ulnar fractures of
different ages
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Child Sexual Abuse

• Sexual interaction is usually intentional
• Always a felony offense potentially
  prosecutable
• - 80 or more investigated in the military
• - 50 prosecuted in the military or civilian court

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Child Sexual Abuse Presentation

• Physical findings Anogenital problems,
  enuresis, or encopresis.
• Behavioral Changes sexual acting out,
  aggression, eating disturbances and regression.
• Most examination findings are within normal
  limits or are nonspecific therefore, the child
  disclosure is often the most important piece of
  information

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Child Sexual Abuse

• Childs history as obtained by the physician may
  be admitted as evidence in court trials
  therefore complete documentation of questions and
  answers is critical (recorded verbatim)

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Physical Exam

• If the sexual assault has occurred within 72
  hours, forensic evidence collection should be
  contacted
• In non acute cases, complete physical exam using
  otoscope or colposcope
• STD work up (in some states results of nonculture
  methods are not admissible in court)

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Variants of the hymen
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Treatment

• Treatment should include coverage for gonorrhea,
  chlamydia, trichomonas and bacterial vaginosis
• Pregnancy Prophylaxis after an informed consent
  and negative pregnancy test. Must be within 72
  hours
• Post exposure Hepatitis B vaccination (without
  hepatitis B immunoglobulin) if not previously
  immunized
• Psychological services

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Reporting Requirements

• ALL DOD personnel must report all suspected child
  abuse to Family Advocacy Representative (FAR)
• FAR will notify command, Child Protective
  Services (CPS)/Department of Child and Families
  (DCF), in some cases law enforcement

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Case Review Committee (CRC) Functions

• Review cases
• Review available services
• Standard for determination is preponderance of
  information

• Make determinations
• -unsubstantiated (did not occur)
• -unsubstantiated (unresolved)
• -substantiated
• -suspected (pending)

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Treatment/counseling

• FAR (CRC) recommends options to Command
• Intervention is tailored to abuse type and
  severity
• If a member receives counseling and continues
  abusive behavior, may be processed as a FAP
  rehabilitation failure

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Transitional Compensation

• Benefits provided to family member (spouse and/or
  children) for 12 to 36 months
• Benefits include money, commissary and
  exchange, and medical
• Forfeited remarriage or cohabitation with
  offender

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Child Abuse Prevention

• Treatment of abuser has had only limited success
  and child protection agencies are overwhelmed
• Primary Prevention
• Advocacy for Children

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• At the very least, showing increased concern for
  the parents or caregivers and increasing our
  attempts to enhance their skills may help save
  our most vulnerable patients from the nightmare
  of abuse and neglect