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Child Abuse: Recognition and Reporting

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Child Abuse: Recognition and Reporting Maria D. McColgan, MD, MSEd Assistant Professor Director, Child Protection Program St. Christopher s Hospital for Children – PowerPoint PPT presentation

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Title: Child Abuse: Recognition and Reporting


1
Child Abuse Recognition and Reporting
  • Maria D. McColgan, MD, MSEd
  • Assistant Professor
  • Director, Child Protection Program
  • St. Christophers Hospital for Children

2
Agenda
  • History
  • Definitions
  • Epidemiology
  • Etiology
  • Recognition of abuse
  • Medical Evaluation
  • Reporting and Documenting

3
History
  • 1860 - Ambroise Tardieu
  • French physician
  • Medical, psychiatric, social and demographic
    features of child abuse as a syndrome
  • 1874 Mary Ellen Wilson 10 y/o
  • Removed from home
  • Provided protection by NY courts
  • Founding of NY society for Prevention of Cruelty
    to Children
  • 1899 First juvenile court in Illinois

4
History
  • 1912 FDR helped create US childrens Bureau
  • 1944 Supreme court confirms state authority to
    intervene to protect children
  • 1946 Dr. Caffey (pediatric radiologist)
  • SDH and long bone fractures inconsistent with
    accidental injury
  • 1962 Dr. C. Henry Kempe
  • The battered child syndrome in JAMA
  • 447 abuse cases reported in 1962
  • (2.9 million cases reported in 1992)
  • In response the US childrens Bureau recommends
    child abuse reporting laws
  • 1967 44 states adopted mandatory reporting laws

5
Nomenclature
  • Terms in National Library of Medicine
  • Syndrome of Ambroise Tardieu
  • 1964 Child abuse
  • 1975 SIDS
  • 1981 PTSD
  • 1987 Child abuse, Sexual
  • 1991 Battered child syndrome
  • 1992 Munchausen syndrome by Proxy
  • 1992 Head injuries, closed
  • 2003 shaken baby syndrome
  • 1993 AAP noted term

6
PA State Law Definition Of Child Abuse
  • A victim is under 18 years of age who has
    sustained
  • A serious physical, mental, or sexual injury or
    serious physical neglect as a result of the acts
    or omissions by
  • A parent, paramour of the parent, person residing
    in the same home as the child or person
    responsible for the childs welfare (at least 14
    years of age).
  • Any recent (within 2 years) act or failure to act
    by a perpetrator that creates an imminent risk of
    serious physical injury to, or sexual abuse or
    sexual exploitation of a child.

7
Pennsylvania State Law Statutory Rape
  • Consensual intercourse between children within 3
    years of age is not illegal
  • 15 y/o can consent to sexual intercourse with an
    18 y/o
  • Statutory rape victim is less than 16 years of
    age, there is 4 year difference in ages and they
    are not married to each other
  • Sexual intercourse with a child less than 13 is
    rape
  • A child less than 13 years old cannot consent to
    having intercourse
  • If one of the children is older than 12 and
    greater than 2 years difference from the age of
    the other child, then it can be considered rape
  • It is not illegal if both children are less than
    12

8
Other State Statutes
  • National Clearinghouse on Child Abuse and Neglect
    http//nccanch.acf.hhs.gov/general/legal/statutes/
    define.cfm
  • National District Attorneys Office
  • http//www.ndaa.org/apri/programs/vawa/statutes.h
    tml

9
Mandated Reporters of AbusePennsylvania
Consolidated StatuesTitle 23 6301-6319
  • Persons whocome into contact with children
    shall report when they have reasonable cause to
    suspect that any child, on the basis of their
    training and experience is an abused child.
  • While at work, physicians and other health care
    workers, teachers, pastors

10
Mandated Reporters of Abuse
  • May be prosecuted for failure to report
  • Legal immunity is granted to the reporter
  • Identity of the reporter is confidential.
  • Informing the parent
  • Not required by law
  • St. Chris advocates informing the family of the
    DHS
  • If there is a flight risk, involve police and DHS

11
Epidemiology
  • Child Maltreatment 2006 USDHHS
  • 3 million reports involving 5.5 million
    children
  • 902,000 confirmed cases
  • 12.1/1000 children
  • 18 Physical Abuse
  • 64 Neglect
  • 9 Sexual Abuse
  • Medical personnel - 8 of reports

http//www.acf.hhs.gov/programs/cb/pubs/cm04/index
.htm
12
Categories of Adverse Childhood Experiences
  • Abuse
  • Psychological 11
  • Physical (parent) 11
  • Sexual (anyone) 22
  • Household Dysfunction
  • Substance abuse 26
  • Mental Illness 19
  • Domestic Violence 13
  • Imprisoned household member 3

13
Why doctors do not report
Flaherty, Sege 2005
  • Physician recognition of child abuse
  • Lack of knowledge
  • Psychological barrier to recognition
  • Family, racial, economic factors
  • Barriers to reporting
  • Do not report all cases
  • Lack of training on how to report
  • Report will harm child
  • Poor experience with Child Protective Services
  • Poor experience with legal system
  • Misunderstanding of MD role

14
Age and Child Abuse
15
Perpetrators
  • Parents 80
  • Other relatives 6.7

16
Fatalities
  • Nearly 1530 fatalities
  • 2.04/1,000 children
  • 78 lt 4 years old
  • Infants 18/1,000

17
Risk of Abuse for Children with Special Needs
  • Type of Incidence of Incidence of
    Ratio
  • Maltreatment Children w/ Children w/o
  • Disabilities Disabilities
  • (per 1,000) (per 1,000)
  • __________________________________________________
    ___
  • Any Maltreatment 35.5
    21.3 1.67
  • Physical abuse 9.4
    4.5 2.09
  • Sexual abuse 3.5
    2.0 1.75
  • Source From A Report on the Maltreatment
    of Children w/Disabilities, U.S. Department of
    Health and Human Services, James Bell Associates,
    Inc., No. 105-89-16300, Westat, Inc., 1993.

18
Etiology
  • Multi-factorial
  • Child Characteristics
  • Parental Characteristics
  • Family/Environmental Factors
  • Triggering Situations

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DV and Child Maltreatment
  • Child maltreatment
  • occurs in 33-77 of families in which there is
    abuse of an adult (Garbarino 1992, Wright 1997,
    Zuckerman 1995)
  • Children of battered mothers
  • 6 to 15 times more likely to be abused

24
DV and Child Maltreatment
  • Physical Injuries to Children May Be
  • Accidentally caught in the crossfire
  • Intentionally injured while protecting their
    mother
  • Over-disciplined or abused by stressed, anxious,
    and depressed parent

25
AAP Committee on Child Abuse and Neglect - 1998
  • The Role of the Pediatrician in Recognizing and
    Intervening on Behalf of Abused Women
  • Intervention is crucial because children are also
    likely to be victims
  • Questions about family violence should become
    part of anticipatory guidance
  • Identifying and intervening on behalf of battered
    women may be one of the most effective means of
    preventing child abuse

26
Medical Evaluation of Victim of Suspected Abuse
  • History
  • Physical Examination
  • Laboratory and Radiologic Studies
  • Differential Diagnosis
  • Documentation

27
Taking a history from the caretaker/parent
  • Children should not be present!!
  • Interview adults who are present separately
  • Triage history often plays a critical role

28
Taking a history from the caretaker/parent
  • Who?
  • What?
  • When?
  • Where?
  • Why?
  • How?

29
Suspicious Behavioral Complaint
  • Depressed, angry, withdrawn, other changes
  • School performance
  • Aggressive behavior, temper tantrums
  • Behavior with family pets/animals
  • Detailed information about adult sexual behavior
  • Explicit demonstration of sexual play
  • Compulsive masturbation
  • Excessive sexual curiosity
  • Bedwetting
  • New risk taking behaviors

30
History from the child
  • It is OK not to take a history from the child
  • Is the information necessary to make medical
    decisions?
  • Has the child been interviewed already and
    disclosed?
  • Is the child ready to disclose?
  • Would this child be better served by a forensic
    interview?

31
Suspicious History
  • History inconsistent w/physical
  • Magical injury
  • Sibling blamed
  • History changes with time or varies between
    caregivers
  • Delay in seeking care
  • Self-inflicted injury incompatible w/development
  • Poor Parent Child Interaction

32
Physical Examination
  • Emergent care first
  • Complete head to toe evaluation
  • Must look at all skin surfaces
  • Remove ALL clothing
  • Ears, Neck, Mouth, Genitalia
  • Description of all skin findings

33
Physical Exam Red Flags
  • Most common indication of physical abuse
  • Occurs in gt50 of abused children
  • Bruises are uncommon in infants lt 6 months.
  • Those who dont cruise rarely bruise.
  • Two characteristics separate abusive from
    accidental bruises
  • LOCATION
  • PATTERN

34
Location
ACCIDENTAL ABUSIVE








35
Location
ACCIDENTAL ABUSIVE
Shins Anterior thigh
Lower arms Upper arms
Under chin Neck
Forehead Face
Hips Buttocks
Elbows Trunk
Ankles Ears
Bony prominences Genitalia
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Whats wrongwith thispicture?
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Donut diagram
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WF 7 month old
  • Mom found him at bottom of stairs with
    excersaucer on top of him

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WF 7 month old
  • Developmental history sits with support, does
    not crawl, does not pull to stand

52
WF
  • Changing histories

53
WF
  • Repeat skeletal survey with healing left distal
    radius and ulna fractures

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Diagnosis of Child Abuse
  • Labs
  • Trauma labs
  • Bruising - hematology workup
  • If fractures, Ca, Phos, Alk Phos
  • Consider Vitamin D 25 and 1,25, PTH and Copper
  • Radiology Studies
  • Skeletal survey
  • All children lt 2 years of age
  • 2-5 years selective survey
  • Bone scan
  • CTs / MRIs
  • Ophthalmology
  • Medical photography

56
The Skeletal Survey
Skull frontal and lateral views
Spine frontal, lateral thoracolumbar spine (including sternum)
Chest frontal
Extremities
Upper - frontal to include shoulders and hands
Lower - frontal to include lower lumbar spine, pelvis, feet
57
Skeletal Trauma
  • 2nd most common manifestation of abuse
  • 80 cases in children lt 18 months of age
  • 43 unsuspected at time of evaluation
  • 50 children with fracture due to abuse have more
    than one fracture

58
Dating Fractures
  • Abusive fractures often reflect multiple episodes
  • Younger children (infants) heal faster
  • 4 stages in bone injury

59
Dating Fractures
Stage Time Characteristics
Induction 3-7 days Inflammation, pain, swelling
Soft callus Infants 7-10 days Children 10-14 Periosteal new bone formation
Hard callus 14-21 days Union at fx site
Remodelling 3 months-1 year Woven to lamellar bone
60
Diagnosis of Abuse
  • Examine siblings, other children in household
  • Twins receive IDENTICAL workup

61
Differential Diagnosis
  • Must rule out medical diagnosis other than abuse

62
Differential Diagnosis of Bruises
  • Erythema multiforme palms/soles initially,
    extension upwards, can become purpuric
  • ITP, other coagulopathies
  • Henoch-Schönlein purpura normal platelets IgA
    mediated vasculitis often involves buttocks
    and lower extremities

63
Differential Diagnosis of Bruises
  • Secondary syphilis
  • Allergic shiners
  • Phytophotodermatitis
  • Cultural practices
  • Cao gio (coining)
  • quat shat (spooning)
  • cupping

64
Differential Diagnosis of Burns
  • First Degree
  • Cellulitis, erysipelas
  • Sunburn
  • Contact dermatitis
  • Diaper rash
  • Drug reaction

65
Differential Diagnosis of Burns
  • Second Degree
  • Bullous impetigo
  • Staphylococcal scalded skin syndrome (SSSS)
  • Toxic epidermal necrolysis
  • Epidermolysis bullosa
  • Phytophotodermatitis
  • Psoriasis

66
Differential Diagnosis of Fractures
  • Minor falls
  • Do not cause fractures in most instances
  • Studies show very low incidence of fractures from
    short falls
  • Obstetrical/birth trauma
  • usually produces only humeral and clavicular
    fractures
  • no rib fractures
  • Prematurity
  • Osteopenia can lead to fractures

67
DDX Skeletal Fractures
  • Neoplasm
  • Leukemia
  • Langerhans cell histiocytosis
  • Bony metastases
  • Normal variant
  • Physiologic periosteal new bone
  • Neuromuscular disease
  • Cerebral palsy
  • Congenital insensitivity to pain
  • Congenital
  • Osteogenesis imperfecta
  • Menkes syndrome
  • Nutritional / Metabolic
  • Copper deficiency
  • Rickets
  • Scurvy
  • Renal osteodystrophy
  • Infectious
  • Congenital syphilis
  • Osteomyelitis

Thompson 2005
68
18 month old with limp
69
Differential Diagnosis
  • Accidental Fractures
  • Toddlers Fracture
  • Accidental oblique fracture of tibia in children
    9 months to 3 years of age
  • Often are unwitnessed injuries of trivial nature
  • Limp, refusal to bear weight
  • Localized tenderness may be present, no swelling
  • X-rays often negative

70
Documentation
  • Carefully Documented In A Stepwise Approach
  • History Verbatim Documentation
  • Physical Pictures Are Helpful
  • Lab Radiographic Studies
  • Instructions for follow up

71
Evidence collection
  • Photographs
  • DO NOT need consent for forensic photographs
  • Photographs DO NOT take the place of
    documentation, they support visual cues to the
    documented description
  • Used to appropriately visualize described
    lesions/marks
  • Have a marker, (ruler or coin) within the
    photograph that can assist with determining size
    of lesion
  • Put the childs name, date of birth, medical
    record number, and date of ED visit on the
    photograph/ diskette

72
Conclusions
  • Child abuse is very common
  • Often missed by clinicians
  • Must have high index of suspicion
  • Mandated reporters must report suspicion of abuse
  • Complete careful histories and examinations
  • Document, document, document!
  • Avoid the misdiagnosis of abuse
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