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Child Abuse

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... suspected abuse. Maintain a safe environment for the child ... Understand legal requirements for reporting suspected child abuse. General considerations (cont) ... – PowerPoint PPT presentation

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Title: Child Abuse


1
Child Abuse
  • James L. Lukefahr, MD

2
General considerations
  • Suspect abuse with any unusual physical or
    psychological complaint
  • Is the injury consistent with the history?
  • Identify signs and symptoms of suspected abuse
  • Maintain a safe environment for the child
  • Maintain objectivity
  • Understand legal requirements for reporting
    suspected child abuse

3
General considerations (cont)
  • Case management should be a team approach
  • Physicians and nurses
  • Social services
  • Law enforcement agencies
  • Document, document, document
  • Document some more

4
INCIDENCE OF ABUSE
  • 15/1000 Children Confirmed
  • Each Year as Abuse Victims
  • 1996 Validated CPS Cases
  • True Incidence 22-30/1000
  • 1993 Natl Incidence Study

5
Injuries associated with non accidental trauma
can involve many different organ systems
  • Soft tissue/skin
  • Head and neck injury
  • Chest injury
  • Abdominal injury
  • Skeletal trauma
  • Genitalia

6
Bruises
  • Common to all children
  • Accidental injuries typically occur on the
    forehead and extremities
  • Bruising can occur secondary to medical
    conditions
  • Leukemias
  • Idiopathic thrombocytopenia purpura (ITP)
  • Coagulopathies (bleeding disorders)
  • Suspicious injuries
  • Occur in different planes of the body
  • Different stages of healing
  • Central distribution
  • Injuries to the back
  • Pattern injuries

7
  • Bruising and other soft tissue injury is
    extremely uncommon in children younger than 6
    months of age and increases in frequency as
    children becomes older and more mobile
  • Any bruising on an infant be considered suspicious for abuse

If youre not old enough to cruise, youre not
old enough to bruise
8
Facial bruises
  • Contusions are the most common injury seen in
    abused children and are the most common injury
    sustained to the head and face

9
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10
Handmarks
  • Bruising occurs in the tissues between the
    fingers, where tissue is squeezed or compressed
  • Slap marks
  • Grab marks
  • Knuckle marks

11
Bruises from grabbing the upper arm
12
Slap marks across the face
13
Pattern marks
  • Injuries that occur from foreign objects will
    often leave specific patterns or markings
  • Ropes
  • Cords
  • Belts and belt buckles
  • Shoes
  • Kitchen tools

14
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15
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16
Discipline? Or Abuse?
17
Discipline? Or Abuse?
  • AAP Guidelines for Effective Discipline (2002)
  • Discipline is a multifaceted approach to assuring
    a childs safety and successful development,
    involving positive as well as negative
    reinforcement.
  • Corporal punishment is child abuse if
  • Its performed when the adult is angry or out of
  • control
  • The intention is to inflict pain
  • Involves anywhere other than the clothed
    buttocks or
  • backs of the thighs
  • Leaves a mark for more than a few minutes
  • An object is used (belt, cord, paddle)

18
Burns
  • Thermal injuries can be caused by accident,
    abuse, or neglect
  • Pattern of injury is important
  • Burns secondary to falling or splashing of hot
    liquid should have a non specific pattern
  • Inflicted injuries typically involve many
    different planes
  • Thermal injuries with a stocking glove
    distribution represent immersion injuries
  • Is the injury consistent with the history?

19
Intentional burn injuries
  • Inflicted injury
  • Extent of the burn depends on
  • Water temperature
  • 117 F is the threshold for scald injuries
  • Duration of exposure
  • 3rd degree burns occur on adult skin after
  • 1 minute in 127 F water
  • 30 seconds in 130 F water
  • 2 seconds in 150 F water
  • Presence or absence of clothing and material
  • Area of body exposed
  • Soles and palms tend to have thicker skin than
    other parts of the body

20
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22
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23
Skin Protected by skin folds
Skin protected by bottom of tub
24
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25
Contact burns
  • Typically leave a patterned mark
  • Cigarette lighters
  • Irons
  • Heaters

26
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28
Iron floor
29
Iron butt
30
Curling iron
31
Head and neck injuries
  • Bruises and contusions
  • Injuries to the oral cavity
  • Shaking injuries
  • Injuries to the neck
  • Most serious injuries are related to direct
    trauma
  • Shaking injuries
  • Blunt force trauma

32
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34
Shaken Baby Syndrome / Abusive Head Trauma
35
SBS is a form of AHT
  • SBS is a form of Abusive Head Trauma that occurs
    when a frustrated caregiver violently shakes
    and / or slams a child head against a
    stationary object, usually to stop them from
    crying or to get a child to respond to the
    expectations of the caregiver.
  • There are usually no outward signs of trauma, but
    there is significant injury to the brain and
    often the eyes

36
AAP Policy Statement on SBS
  • the act of shaking leading to Shaken Baby
    Syndrome is so violent that individuals observing
    it would recognize it as dangerous and likely to
    kill the child.

American Academy of Pediatrics Policy Statement,
Vol. 108, Number 1 July 2001
37
Common Triggers for Shaking
CRYING
Feeding Problems
Toilet Training
Interrupting
Dr. Jacy Showers, 1998
38
  • Example Of Shaking
  • The child is grasped by trunk or arms
  • They are violently shaken back and forth
  • Chin impacts chest
  • Back of head impacts upper back

39
Symptoms of SBS / AHT
  • Mild cases
  • Irritability
  • Poor Feeding
  • Vomiting
  • Lethargy
  • Severe cases
  • Respiratory distress
  • Cardiac arrest
  • Seizures
  • Coma
  • Death

40
Timing and Onset of Symptoms in SBS / AHT
  • Mild Cases
  • Immediate onset of symptoms will occur with any
    injury but the symptoms may be vague
  • These symptoms can be missed by medical
    professionals
  • (C. Jenny, JAMA, 1999, 281621-626)
  • Severe or fatal cases
  • Immediate onset of symptoms
  • No lucid interval (normal behavior) following
    traumatic insult to the brain

41
Medical Diagnosis
  • Subdural hemorrhage
  • Retinal hemorrhage
  • Cerebral edema (Brain swelling)

Subdural Bleeding
The Big 3
Retinal Bleeding
Brain Swelling
42
History Given by Caregivers
  • The history provided by caregivers is frequently
    absent or attributed to a common, low energy
    accidents such as a fall down the stairs or off a
    couch, or rough-housing with another young child

43
Skeletal Trauma (Fractures)
44
Skeletal trauma
  • Consider the mobility and developmental level of
    the child
  • Fractures in small infants and non-mobile
    children are highly suspicious for non-accidental
    trauma
  • History should be consistent with physical
    findings
  • Multiple fractures, especially if they are of
    differing ages are highly suspicious of abuse
  • Skeletal trauma often accompanies abusive head
    and abdominal trauma

45
Imaging recommendations
  • An initial skeletal survey should be performed in
    all infants under 2 years of age that are
    suspected of having been abused or severely
    neglected.
  • All films should be reviewed by a pediatric
    radiologist
  • In seriously-abused children, follow-up skeletal
    films should be performed two weeks later for
    evaluate for occult or hidden fractures

46
Types of fractures
  • Metaphyseal and Epiphyseal fractures
  • Referred to as Corner or Bucket Handle
    fractures
  • Occur from a pulling or jerking type motion of
    the limb as well as rotational forces that can be
    applied during shaking of a child
  • Considered to be pathognomonic (diagnostic) of
    abuse

47
Metaphyseal Fracture
48
Long bone fractures
  • Commonly seen in accidental and non accidental
    trauma
  • Most common site for abusive trauma in the arm is
    the humerus
  • Most common sites for abusive trauma in the leg
    is the femur and tibia

49
Spiral Fracture of Femur
50
Skull fractures
  • Skull fractures in abused children can be
    produced by a direct blow to the head or by the
    child being thrown onto a hard object
  • Skull fractures can be simple or complex
  • Depressed skull fractures in young children are
    indicative of trauma
  • Simple linear skull fractures can be caused by
    accidents or abuse, but it is rare to have
    associated brain injury or retinal hemorrhages
  • Is the history consistent with the injury

51
Skull fractures
52
Child Abuse Reporting Requirements
  • Any person having cause to believe that a
    childs physical or mental health or welfare has
    been or may be adversely affected
  • must report their concern to Child Protective
    Services or to a law enforcement agency.

53
Why should I report?
  • Health care professionals are especially expected
    to report, given our expertise and influence.
  • A child with unrecognized abusive injury has a
    50 chance of sustaining a 2nd serious injury.
  • Failure to report child abuse is a class B
    misdemeanor (up to 1000 fine, 180 days in jail).

54
How do I report?
  • Texas Child Abuse
  • Reporting Hotline
  • 1-800-252-5400
  • Or
  • https//reportabuse.ws

55
What happens when I report?
  • CPS intake worker evaluates risk, assigns
    priority
  • Priority 1 local CPS makes contact within 24
    hours.
  • Priority 2 contact within 10 days.
  • CPS can take emergency custody if reason to
    believe child is in danger.
  • Custody hearing before a judge within 14 days,
    then every 60-90 days.
  • Final order 1 year after initial hearing.

56
What do I tell the family?
  • Honesty is the best policy. People know when we
    act sneaky.
  • Parents know were required to report.
  • We dont accusewe take care of kids.
  • Im really concerned about your childs injury.
    You may know Im required by law to report
    injuries like this to Child Protective Services.
  • CPS appreciates us informing the parents easier
    to have rapport if parents are expecting them.
  • Exception if youre worried about your safety,
    or safety of child or family.

57
What do I tell the family?

58
What about parental permission and release of
medical records?
  • Texas Family Code says parental permission is not
    required to examine a child if abuse is
    suspected. This includes taking pictures.
  • A health care provider who makes a report of
    child abuse may release medical records to CPS or
    law enforcement without parental consent if they
    are relevant to the investigation of the reported
    abuse. (Supersedes HIPAA)

59
Preventing Child Abuse
  • Individual patients, families
  • Parenting education
  • Treat mental illness
  • Recognize high-risk families
  • Community efforts
  • Education
  • Healthy Families Initiative

60
Healthy Families Initiative
  • Community collaboration
  • Identify high-risk families
  • Support, empower parents to change risky
    lifestyles

61
Conclusions
  • Child abuse occurs frequently in our society
  • Always consider the developmental age of the
    child
  • Is the history consistent with the injury
  • If you dont think about the possibility of
    abuse, you will miss it every time
  • Reporting suspected abuse is imperative
  • Prevention is difficultimpossible for one of us,
    possible for all of us
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