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Physical Abuse of Children

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Physical Abuse of Children by Jim Carpenter MD,MPH,FAAP October 21, 2009 Reporting All states have reporting laws of suspected child abuse by mandated reporters ... – PowerPoint PPT presentation

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Title: Physical Abuse of Children


1
Physical Abuse of Children
  • by
  • Jim Carpenter MD,MPH,FAAP
  • October 21, 2009

2
Objectives
  • 1.Develop a schema to identify the signs and
    symptoms of Child Physical Abuse(CPA)
  • 2. Report reasonable suspicion of physical abuse
    to the appropriate agencies

3
Missed Diagnoses
  • Family Violence including child abuse, elder
    abuse and domestic violence
  • Mental health conditions including depression and
    anxiety disorders
  • Substance use and abuse

4
Definitions of Child Abuse
  • Physical injury inflicted intentionally upon a
    child
  • Neglect general or severe
  • Sexual abuse including molest, assault and
    exploitation
  • Emotional abuse including willful cruelty,
    unjustified punishment and mental suffering

5
Prevalence
  • Second to neglect in reported cases of child
    maltreatment accounting for 18-20.
  • 26.4 of an adult cohort reported CPA.
  • 1.3-15 of ED visits for child injury.
  • Underreported and misdiagnosed
  • 31 of children with AHT were initially
    misdiagnosed
  • Due to lack of training, reluctance to report,
    failure to consult, and low index of suspicion

6
Fiscal Year 2006
  • 3.3 million referrals to child protective
    services.
  • 62 were screened in for investigation.
  • 30 of reports found at least 1 child who was a
    victim.
  • 60 of reports were not substantiated.

7
Who Reported?
  • 56 of all reports were made by professionals.
  • Teachers 16.5.
  • Police, lawyers 15.8.
  • Social services 10.
  • Medical, mental health professionals 12.
  • Other professionals 2
  • 2/3 of substantiated reports were made by
    professionals.

8
Who Were the Victims?
  • 905,000 total
  • Birth to age 1 years 24.4/1,000
  • Younger than 7 years 55
  • Race
  • White 49
  • African American 23
  • Hispanic 18
  • Other, unclassified 10

9
Types of Maltreatment
  • 64 Neglect
  • 16 Physical abuse
  • 9 Sexual abuse
  • 7 Emotional maltreatment

10
Child Abuse Fatalities
  • 1,530 died.
  • Rate of death 2.04 children per 100,000.
  • 42 of deaths caused by neglect.
  • 27 caused by combinations of maltreatment.
  • 24 caused by physical abuse.
  • 2.5 caused by medical neglect.
  • 76 of deaths occurred in children younger than 4
    years.

11
Perpetrators
  • 79 were parents.
  • 7 were other relatives.
  • Unrelated caregivers 10.
  • Women 58.

12
Sequelae of Physical Abuse
  • Mortality and Morbidity from the injury.
  • Behavioral and Functional problems including
    conduct disorder, aggression, school problems and
    failure, anxiety and depression, low self esteem,
    PTSD, criminality.
  • Subsequent generations of family violence.
  • ACE(Adverse Childhood Experiences) sequelae

13
ACE and Chronic Disease
  • ACE including all forms of child maltreatment
    increase the risk for
  • Diabetes and Obesity
  • Hypertension
  • Depression
  • Substance Abuse
  • Ischemic Heart Disease
  • Risk taking behaviors ie. STIs
  • Chronic Lung Disease

14
Risk Factors for Abuse
  • Age less than 2-3 years
  • Poverty
  • Single, isolated parent
  • Unrelated adult in home
  • Low birth weight
  • Substance use/abuse
  • Developmental delays in child
  • Family history of DV or child maltreatment

15
Medical History Concerning for Intentional Trauma
  • No or vague explanation for injury.
  • Details of injury change.
  • Explanation that is inconsistent with the injury.
  • Explanation is inconsistent with childs physical
    or developmental abilities.
  • Different explanations by witnesses.
  • Delay in seeking care

16
Past Medical History
  • Pregnancy(prenatal care, planned, substance use,
    depression, support)
  • Family Hx(bleeding, metabolic or genetic
    disorders, violence, depression, substance use)
  • Medical(trauma, chronic illness, FTT,shot delay,
    developmental delays)
  • Social(poverty, stressors, support)

17
Physical Examination
  • ABCs and VS including Ht, Wt and HC
  • Early Neurologic assessment
  • Skin(bruises, abrasions, patterned marks, burns,
    SQ fat, hygiene)
  • HEENT(swelling, contusions, alopecia, full
    fontanelle, hemotympanum, black eyes, slap or
    choke marks)

18
Cutaneous Injuries
  • Key characteristics
  • Location
  • Pattern
  • Multiple ages of lesions
  • Failure of appearance of new lesions in new
    environment

19
Incidence and Prevalence
  • 50 to 60 of all physical abuse cases have skin
    injuries, in isolation or in combination with
    other abusive injuries.
  • Cutaneous injuries are the single most common
    presentation of physical abuse.
  • Johnson CF. Pediatr Clin North Am.
    199037791814.

20
Usual Locations of Bruises
ACCIDENTAL ABUSIVE
Shins Upper arms
Lower arms Anterior thigh
Under chin Trunk
Forehead Genitalia
Hips Buttocks
Elbows Face
Ankles Ears
Bony prominences Neck
21
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Slap Mark in 4-Month-Old Infant
23
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Strangulation Marks on Neck
25
The canine impressions are labeled with red
arrows and have a distance of 4 cm between them.
The 4 outlines of teeth between the arrows are
from the incisors.
?
?
26
Aging of Bruises
  • Visual aging of bruises is inexact.
  • Bruise with yellow is more than 18 hours old.
  • Red, blue, purplepresent 1 hour to resolution.
  • Red color can be present anytime.
  • Bruises of same age on same person can vary in
    color.

27
Differential Diagnosis of Bruises
28
Typical Distribution of Slate-gray Nevi
29
Phytophotodermatitis
30
Cao Gio (Coin Rubbing)
31
Henoch-Schönlein Purpura
32
Forehead Bump With Migration
33
Abusive Burns
34
Bic Cigarette Lighter Burn
35
Iron BurnNote Location
36
Immersion Burn
37
Differential Diagnosis of Burns
  • Second degree
  • Bullous impetigo
  • Staphylococcal scalded skin syndrome (SSSS)
  • Toxic epidermal necrolysis
  • Epidermolysis bullosa

38
Staphylococcal Infection
39
Contact DermatitisEx-Lax
40
Moxibustion
41
Abusive Head Trauma
  • Leading cause of CPA death and significant
    morbidity(blindness, CP, ADHD, retardation,
    seizures).
  • Survey showed 2.6 of mothers shake their
    children lt2 yo for discipline.
  • Correlates with normal crying behavior.
  • Often is asymptomatic and easily missed by HP.
  • Prevention works! Anticipatory guidance or Mark
    Dias MD Program or Period of Purple Crying Program

42
Period of PURPLE Crying
  • Peak of crying(second month)
  • Unexpected
  • Resists soothing
  • Pain-like face
  • Long-lasting(30-40 minutes and longer)
  • Evening crying

43
Suspicious Stories in Fatal Child Abuse Cases
(Kirschner)
  • Child fell from low height.
  • Child fell onto furniture, floor, or object.
  • Child unexpectedly found dead (age and
    circumstances not suggesting SIDS).
  • Child choked shaken to dislodge object.
  • Child turned blue shaken to revive.
  • Child experienced sudden seizure activity.

44
Common Suspicious Stories
  1. Resuscitation efforts caused injuries.
  2. Caused by traumatic event a day or more prior.
  3. Adult tripped or slipped while carrying child.
  4. Childs sibling did it.
  5. Child left alone for short time.
  6. Child fell down stairs.

45
Clinical Presentation
  • Poor feeding, vomiting
  • Lethargy, irritability
  • Seizures
  • Apnea or respiratory distress
  • Color change
  • Unresponsiveness
  • Hypothermia

46
Parietal Skull Fracture
47
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Retinal Hemorrhages
  • Dilated retinal exam by Ophthalmologist
  • Found in 80-90 of infants with severe shaking
    with or without impact.
  • Can occur from birth but are small and resolve by
    2-4 weeks.
  • R/O vitamin K deficiency or glutaric aciduria
    type 1.

49
Chest Examination
  • Rib fractures(pain, crepitance,
    splinting,palpable callus, tachypnea, shallow
    breathing)
  • Rib fractures often occur in adults from CPR but
    rarely in children and almost never in infants.
  • Heart trauma is rare but if present is
    severe(hemopericardium and contusions)

50
Rib Fractures
  • Posterior fractures are most common.
  • Next most common is mid-axillary.
  • Overlying bruises may be seen, but are often
    absent.
  • Symptoms are usually absent.
  • Grating feeling may be present.

51
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53
Abdominal Injuries
  • Abusive
  • Younger child (2.6 y)
  • Vague histories
  • Delayed medical care
  • Hollow viscera
  • Mortality rate 53
  • Accidental
  • Older child (7.8 y)
  • 90 credible accident history (eg, MVC, fall)
  • Prompt medical care
  • Solid organ
  • Mortality rate 21

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Signs and Symptoms
  • Abdominal tenderness
  • Abdominal distention
  • Absent bowel sounds
  • Obtundation
  • Low hematocrit
  • Blood in nasogastric drainage, hematuria
  • Bruising of abdominal skin

56
Extremity Examination
  • Observe for deformity, swelling, lack of use,
    discoloration, tenderness, ROM.
  • Skeletal survey is indicated in lt2 yo with
    suspected CPA/neglect.
  • Repeat in 2 weeks in selected cases.
  • R/O rickets, scurvy, syphylis, and osteogenesis
    imperfecta(blue sclera, osteopenia,bad teeth, lax
    ligaments)

57
When to Suspect Abuse
  • Metaphyseal fractures in children younger than 2
    years
  • Posterior rib fractures
  • Scapular fractures
  • Spine fractures
  • Sternal fractures
  • Multiple, especially bilateral fractures

58
When to Suspect Abuse
  • Fractures to hands or feet
  • Fractures in infants or young children
  • Fractures in children of poverty
  • Fractures in prematurely born children
  • Fractures in developmentally handicapped
  • Fractures with unexplained associated injuries

59
Diagnostic Testing for CPA
  • Bleeding screen(CBCD, platelets, INR, PT/PTT,
    VWF, Vit K, or other factors).
  • Abdominal screen(LFTs, amylase, lipase,
    urinalysis, CT scangt KUB).
  • Fracture screen(skeletal survey, bone scan, 2
    week f/u survey).
  • Cranial screen(MRI, CT, skull XR, urine organic
    acids, retinal exam).

60
Other Diagnostic Testing
  • Cardiac screen(troponin, CK-MB)
  • Osteogenesis imperfecta(FHx, skin bx for
    fibroblast culture, blood for DNA).
  • Other bone disordersie. rickets(Ca, Alk P,
    Phosphorus, Vit. D, PTH, Vit. C, RPR).
  • Tests to diagnose mimics of CPA.
  • Consider toxicology and forensics.

61
Diagnostic Studies
62
Documentation of CPA
  • Photography is recommended for all significant
    injuries.
  • Completion of the CalEMA 2-900 and SS8572
    reporting forms.
  • Completion and review of all other medical
    records.
  • Inconsistencies in the record will haunt you if a
    case goes to prosecution.

63
Reporting of CPA
  • Mandated reporters are required to report
    suspected CPA to CFS/LE by phone as soon as
    possible and in writing within 36 hours.
  • Many cases are ambiguous so consult with
    pediatrician/supervisor to discuss management and
    need to report.

64
CalEMA 2-900 Reporting Form
  • 7 pages
  • 5 years in the making
  • Prompts for Hx, PE, forensics and diagnostics

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Reporting
  • All states have reporting laws of suspected child
    abuse by mandated reporters
  • Reports go to CPS and/or LE
  • Immediately by phone and in writing within 36
    hours
  • To commence investigation, protect the child, and
    help the family

75
Mandated Reporters
  • Nurses
  • Doctors
  • EMTs
  • Teachers
  • PT
  • OT
  • Firemen
  • Police
  • Childcare providers
  • Photo processors
  • CPS workers
  • Animal control
  • Clergy
  • Child visitation monitors

76
Reasonable Suspicion
  • It is objectively reasonable for a person to
    entertain a suspicion, based on the facts that
    could cause a reasonable person in a like
    position, drawing when appropriate, on his or her
    training and experience, to suspect child abuse
    and neglect (PC 11166a1)

77
Obstacles to Reporting
  • Denial
  • Fear of making a mistake
  • Deferring to another reporters lower index of
    suspicion
  • Fear the report will make things worse or make no
    difference
  • Fear of angry parents
  • Fear of court testimony

78
Penalties for Failure to Report
  • Misdemeanor punishable by up to 6 months in jail
    and/or 1000 fine
  • If GBI or death results- up to one year and/or
    5000 fine
  • Civil liability
  • Potential loss of credential or license

79
Safeguards for Reporters
  • Immunity from criminal liability if report made
    in good faith
  • Supervisors may not impede or sanction reporters
  • Reports and reporter are confidential
  • Examination, photography and indicated tests do
    not require consent from potentially abusive
    parent.

80
Prevention of Child Abuse
  • Recognition and reporting
  • Home visitation
  • Parenting education
  • Substance abuse identification and treatment
  • Mental health diagnosis and treatment

81
Resources for CPA
  • Child and Family Services-(925-646-1680 or
    877-881-1116) or CPS Alameda County(510-259-1800)
  • Jim CrawfordMD/Center for Child
    Protection(510-428-3742)
  • Jim CarpenterMD/CCRMC (x210 or drjimcarpenter_at_yaho
    o.com)
  • Child Abuse Prevention Council - (925-798-0546)
    or www.capc-coco.org.
  • www.dontshake.org

82
Bibliography
  • Nursing Approach to the Evaluation of Child
    Maltreatment Giardino Giardino, 2003
  • Child AbuseMedical Diagnosis Management, 3rd
    edition Reece Christian AAP 2009
  • Visual Diagnosis of Child Abuse,3rd editionLowen
    Reece AAP
  • The Relationship of Adverse Childhood
    Experiences to Adult Health, Well-being, Social
    Function, and Healthcare Felitti and Anda
    AAP/San Francisco 2007

83
Bibliography- continued
  • Diagnostic Imaging of Child Abuse AAP Section
    on Radiology Peds1235, pp1430-35 5/2009
  • Abusive Head Trauma in Infants and Children
    Christian and Block Peds1235, pp1409-11 5/2009
  • Evaluation of Suspected Child Physical Abuse
    Kellogg Peds1196 pp1232-41

84
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