Child Abuse Dr. Mansour Alqurashi

Objectives - Define Child abuse and Non Accidental Injury NAI. - Differentiate between types of Child abuse. - List the features in the history that should alert the physician to suspect child abuse. - List the features in clinical examination that should raise the suspicion of child abuse and NAI. - List the features in clinical examination that should raise the suspicion of child abuse and NAI. - Discuss the approach to discussing NAI with the family. - - Describe, briefly, the legal repercussion of diagnosis of NAI. - -To detail the epidemiology and long term effects of child abuse and neglect. - To review the role of pediatrics in the primary prevention of child abuse and neglect.

Child Abuse - - Abuse is ‘a violation of an individual’s human and civil rights by any other person or persons. - - Abuse and neglect are forms of maltreatment of a child, Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. - Children may be abused in a family or in an institutional or community setting, by those known to them or, more rarely, by a stranger. - They may be abused by an adult or adults, or another child or children.

RIGHTS ’ BASED APPROACH

PRIORITIES Right to Education Access to quality, free, compulsory primary education. Non-Discrimination in access to education (gender gap). Right to leisure, recreation and cultural activities.

Right to Health Access to quality health services. Rights of children with disabilities. Adolescents and reproductive health knowledge. Right to benefit from social security. Right to an adequate standard of living.

Right to Special Protection Protection from all forms of exploitation (economic, sexual). Violence against children (physical, psychological & sexual). Female Genital Mutilation & early marriage. Torture and deprivation of liberty for juvenile in conflict with the law Hazardous occupations. Smoking, substance abuse, and trafficking. Street children.

Child Abuse Definition: - Mental or emotional injury affecting growth, development, or psychological function. - Causing or permitting the child to be in a situation in which the child sustains injury or increases the risk for injury. - Failure to make a reasonable effort to prevent harm. - Harmful sexual conduct - Failure to prevent harmful sexual conduct. - Encouraging the child to engage in such conduct.

Child abuse :Failure of secondary prevention - Failing to remove a child from a harmful environment. - Failure to seek appropriate care. - Failure to provide appropriate care. - Failure to arrange appropriate care when returning home.

Another Definition “ Any behavior directed toward a child that endangers or impairs a child ’ s physical or emotional health and development ”

What are the types of Child Abuse ?

Physical Abuse Emotional Abuse Sexual AbuseNeglect Fabricated or induced illness

Physical Abuse

Physical Abuse may involve HittingShakingThrowingPoisoningBurning or scaldingDrowningSuffocatingOr any physical harm

Physical Abuse (cont.) The term ‘‘ battered child syndrome ’’ was coined to characterize the clinical manifestations of serious physical abuse in young children. This term is generally applied to children showing repeated and devastating injury to the skin, skeletal system or nervous system. It includes children with multiple fractures of different ages, head trauma and severe visceral trauma, with evidence of repeated infliction. Another form is the “ The shaken infant ”. Shaking is a prevalent form of abuse seen in very young children (less than 1 year). Most perpetrators of such abuse are males. Intracranial haemorrhages, retinal haemorrhages and chip fractures of the child ’ s extremities can result from very rapid shaking of an infant.

Corporal Punishment Corporal punishment of children --- in the form of hitting, punching, kicking or beating - -- is socially and legally accepted in most countries. In many, it is a significant phenomenon in schools and other institutions and in penal systems for young offenders.

Approach Suspected child abuse or neglect History The child’s age and stage of development The history given by the child (if they can communicate) The plausibility and/or reasonableness of the explanation for the injury Any background, e.g. previous child protection concerns, multiple attendances to A&E or general practitioner Delay in reporting the injury Inconsistent histories from caregivers Inappropriate reaction of parents or caregivers who are vague, evasive, unconcerned or excessively distressed or aggressive. Presentation of the child

Approach Suspected child abuse or neglect History Presentation of the child Physical symptoms and signs Psychological symptoms and signs A concerning interaction observed between the child and the parent or carer The child may tell someone about the abuse The abuse may be observed

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. -Understand legal requirements for reporting suspected child abuse.

General considerations (cont) - Case management should be a team approach Physicians and nurses Social services Law enforcement agencies - Document, document - Duty to report

Documentation - Extremely important to document correctly. - Use diagrams. - Measure with a ruler. - Document what you see, not what it implies. “Vaginal tears consistent with abuse”

Child Abuse Reporting Requirements “Any person having cause to believe that a child’s 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.

Identifying Physical Abuse... By the Doctor - Normal childhood development. - Conditions that may be confused with abuse. - Unintentional vs intentional injury.

Conditions that Mimic Child Abuse - Bruising - Mongolian spots - Congenital coagulopathy - Birth trauma - Accidental trauma - Fractures - Osteogenisis Imperfecta - Rickets - Scurvy - Syphilis - Copper Deficiency- Menke’s kinky hair syndrome

Recognizing Abuse Injuries... -Skin Injuries TEARS -Human Bite Marks -Hair Loss -Falls -Head, facial, oral injuries -Shaken baby Syndrome

Skin Marking - Normal Trauma Extensor surfaces to arms and legs Protruding bony surfaces of face - Protected area’s Inner arms ThroatAbdomen Lower back Inner thighs

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

Bruises - Generally speaking: fresh injury is red to blue 1-3 days deep black or purple 3-6 days color changes to green and then brown 6-15 days: green to tan to yellow to faded, then disappears - The younger the child the quicker the color resolves. - Document location, size, shape, color.

-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 <6 months of age should be considered suspicious for abuse. “If you’re not old enough to cruise, you’re not old enough to bruise”

Facial bruises Contusions are the most common injury seen in abused children and are the most common injury sustained to the head and face

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

Bruises from grabbing the upper arm

Slap marks across the face

Human Bites - Strongly suggest abuse. - Easily overlooked. - Location of bite marks on infants differ from sites on older children. - Swab wounds- 80% have ABO blood group identifiers

Pattern marks Injuries that occur from foreign objects will often leave specific patterns or markings - Ropes - Cords - Belts and belt buckles - Shoes - Iron - Kitchen tools

Discipline? Or Abuse?

AAP Guidelines for Effective Discipline (2002): Discipline is a multifaceted approach to assuring a child’s safety and successful development, involving positive as well as negative reinforcement. “Corporal punishment” is child abuse if: - It’s 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…).

Burns - - Accidental - irregular, indistinct margins, satellite splash lesions, “v-shape” - Suspected burns : Stocking/glovelikeBilateral Uniform degree of the burn Multiple burns Coexistent with trauma Cigar burns ~ 8mm

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?

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 -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

Intentional burn injuries

Skin protected by bottom of tub Skin Protected by skin folds

Protected Areas

Contact burns Typically leave a patterned mark - Cigarette lighters - Irons - Heaters

Head, Facial, Oral Injuries - Head is a common area of injury. - Approx. 50 % of physical abuse patients have head or facial injuries. - Injuries to the sides of the face, ears, cheeks, and temple area are highly suspicious for abuse. - Mouth/lip/teeth injuries

Upper frenulum and upper lip from external forces Frenulum under tongue internal force

Falls - In most cases, falls cause a minor injury. - If a child is reported to have had a routine fall but has what appear to be severe injuries, the inconsistency of the history with the injury indicates child abuse. - 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

Skeletal trauma(Fractures) - 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.

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

Skeletal Manifestations - 80% of abusive fractures are under age 18 months - Clavicle most common fracture of childhood – most common is the middle third (Lateral third more suspect). - - Buckethandle fractures of the metaphysis. -Rib fractures highly suggestive Multiple posterior fractures result from shaking Multiple posterior fractures result from shaking - Femur fracture highly suggestive - Tibial fracture Toddler’s fracture – non displaced oblique(normal). Toddler’s fracture – non displaced oblique(normal). Spiral fractures highly suggestive. Spiral fractures highly suggestive.

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.

Metaphyseal Fracture

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.

Spiral Fracture of Femur

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

Head Trauma Leading cause of non-accidental death in child abuse is head trauma. Where brain injury is suspected all children … -An immediate CT head scan followed later by a MRI head scan. -A skeletal survey to exclude fractures. -An expert ophthalmological examination to identify retinal hemorrhages. -A coagulation screen.

Head Trauma Accidental vs inflicted -Short vertical falls less than 4 feet (regardless of the landing surface) usually result in minimal or no injury. May cause small linear skull fractures (thus a few case reports of epidural hematomas). Much more significant force is required for depressed, stellate, complex, bilateral, or basilar skull fractures.

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.

S- Sagittal L- Lambdoidal P - Parietomastoid (squamosal) O - Occipitomastoid C- Coronal

Skull fractures

Shaken Baby Syndrome / Abusive Head Trauma

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.

Common “Triggers” for Shaking CRYING Toilet Training Feeding Problems Interrupting Dr. Jacy Showers, 1998

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

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

Shaken Baby Syndrome - Classically describe as occurring in infants less than 6 months. - Classic triad: Cerebral edema, subdural hematoma, retinal hemorrhages.

Head Injury -Most common head trauma in abuse is subdural bleeds and parenchymal injury (including DIA) -Increased risk of cervical cord injury because of the large head to body ratio Spinal cord contusions, subdural hematomas at the cervicomedullary junction

Retinal hemorrhages: Evidence of abuse or abuse of evidence? - Extraordinary force - Unilateral or bilateral hemorrhages are present in % of abusive head trauma - Common with birth trauma but resolve within 4 weeks - Other causes of retinal hemorrhages include: hematologic abnormalities, central nervous system vascular malformations, infections, high- altitude mountain climbing, during normal deliveries of newborns, and as a complication of general anesthesia

2 nd most common cause of death from child abuse. -Duodenal Injury common. - Spleen, liver. -Accidental vs Non-accidental Suspect in non-walking children Abdominal and Thoracic Injury

CHILD SEXUAL ABUSE Definition Child sexual abuse is the exploitation of a child or adolescent for the sexual gratification of another person.

Sexual Abuse - Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. - The activities may involve physical contact, including penetrative acts such as rape, buggery or oral sex, and/or non-contact activities, such as involving children in looking at or producing pornographic material or watching sexual activities or encouraging children to behave in sexually inappropriate ways.

- The assessment of sexual abuse is like a jigsaw puzzle. - Many different pieces of information need to be pieced together to make an informed opinion.

Some signs of sexual child abuse 1 BE AWARE!! Sexual abuse usually shows no signs unless MD is able to see marks or forced entry. However, there are clues to sexual abuse, including: -Inappropriate interest in or lots of knowledge of sexual acts -Seductive behavior in a child -Refusal to undress in front of others (grouped with other symptoms) -Extra aggression or, extreme compliance -Fear of a particular person or family member. -Children who use the Internet are also vulnerable to come-ons by adults online. Among the warning signs of online sexual child abuse are these: Your child spends large amounts of time online, especially atnight. Pornography on PC, frequent calls from unknown caller,or use of another members pass

Sexual abuse in children: types and warning signs 2 Sexual abuse, which accounts for about 10 percent of child abuse, is any sexual act between an adult and a child. Such acts include: - Behavior involving penetration – vaginal or anal intercourse and oral sex - Fondling –touching or kissing genitals or adult makes the child do this to them. - Violations of privacy – Forcing a child to undress, spying on a child in the bathroom or bedroom. - Exposing child to sex, in person or porn, dirty stories - Exploitation –making the child a prostitute or be on pornography Sexual abuse is never the child's fault. Guilt and loyalty issues Children can not mentally or physically handle sexual abuse, even toddlers have problems later with over stimulation.

Recognition The child or young person may: tell someone about the abuse be identified in pornographic material be pregnant (by legal definition this is due to sexual abuse for a girl under the age of 13 years) have a sexually transmitted infection with no clear explanation (but some sexually transmitted infections can be passed from the mother to the baby during pregnancy or birth). Physical symptoms Vaginal bleeding, itching, discharge Rectal bleeding. Behavioural symptoms Soiling, secondary enuresis Self-harm, aggressive or sexualised behaviours, regression, poor school performance. Signs There are few clearly diagnostic signs of sexual abuse on examination. Examination of children suspected of having been sexually abused.

Myths of Sexual Abuse -Perpetrators are strangers. -Perpetrators who touch boys don’t touch girls. -Children tell about the abuse immediately. -Children tell fantasies. -Any child victim with penetration will have an abnormal examination. -Disclosures in custody issues are all false allegations.

Emotional Abuse Is the persistent emotional maltreatment of a child resulting in severe and persistent adverse effects on the child’s emotional development. Is the persistent emotional maltreatment of a child resulting in severe and persistent adverse effects on the child’s emotional development. Worthless or unloved valued only insofar as they meet the needs of another person. Inadequate

Emotional Abuse (cont.) - It may feature developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and abnormal social interaction. It may involve seeing or hearing the ill treatment of another. - Some level of emotional abuse is involved in all types of maltreatment of a child, although it may occur alone.

Serious bullying that causes children to feel frightened or in danger. The exploitation or corruption of children.

Emotional Abuse (cont.) This damaging form of abuse is the hardest form of abuse to identify in a healthcare setting. Some clues may be found by noting how the parent or caregiver perceives the child. Is the child: - The ‘wrong’ gender - Born at a time of parental separation or violence - Seen as unduly ‘difficult’?

Emotional Abuse (cont.) There may be clues from the behavior of the child. This depends on the child’s age: Babies: – Apathetic, delayed development, non-demanding – Described by the mother as ‘spoiled, attention seeking, in control, not loving her’. Toddlers and preschool children: – Violent, apathetic, fearful. School children: – Wetting, soiling, relationship difficulties, non- attendance, anti-social behaviour.

Child Neglect

Neglect Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development.

Neglect It may involve a parent or carer failing to provide: - Adequate food and clothing - Shelter, including exclusion from home or abandonment - Protection from physical and emotional harm or danger - Adequate supervision, including the use of inadequate caregivers. - Access to appropriate medical care or treatment. - It may also include neglect or unresponsiveness to a child’s basic emotional needs.

Approach Suspected child abuse or neglect History Presentation of the child

Neglect Consider the possibility of neglect when the child: - Consistently misses important medical appointments -Lacks needed medical or dental care, immunisations or glasses -Seems ravenously hungry - is dirty - is wearing inadequate clothing in cold weather - is abusing alcohol or other drugs -Says there is no one at home to provide care. Consider the possibility of neglect when the parent / adult caregiver: -Appears to be indifferent to the child -Seems apathetic or depressed -Behaves irrationally or in a bizarre manner -Is abusing alcohol or other drugs.

Fabricated or Induced Illness

Munchausen by Proxy DSM IV – facticious disorder -Uncommon -Usually mother -Medically educated -Two types SimulatedProducedPoisoned Scratch (look like rash) -Treatment

This is a broad term to describe a group of behaviours by parents (or carers), but usually the mother (>80%), which cause harm to children. It fulfils the parents (or carers) own needs. It may consist of: Verbal fabrication parents fabricate (i.e. invent) symptoms and signs in the child, telling a false story to healthcare professionals, leading them to believe the child is ill and requires investigation and treatment. Induction of illness Suffocation of the child, which may present as an acute life-threatening event (ALTE) Administration of noxious substances or poisons Excessive or unnecessary administration of ordinary substances (e.g. excess salt) Excess or unnecessary use of medication (prescribed for the child or others) The use of medically provided portals of entry (such as gastrostomy buttons, central lines).

Fabricated or Induced Illness (cont.) Organic illness, may coexist with fabricated or induced illness in a child, making the fabrication more difficult to identify. It may manifest as overprotection, imposing unwarranted restrictions or giving treatment that is inappropriate or excessive.

hurts

Child Abuse Clues to history -Inconsistency with history and injury or developmental milestones -Delay in seeking treatment -Projection of blame to a third party

Physical Examinations Evaluations for the Diagnosis & Treatment of Child Abuse

History and Physical keys Overall health of child History keys Bed wetting Soiling pants Difficulty urinating

History and Physical keys Complete physical – may need to sedate - Particular attention to mouth (frenulum), nose, genitalia, rectum. -Irritation, pain, redness, bruises, burns, tears. - Hymen – age 0-2 under estrogen influences Start thick, pliable, elastic until age two, then becomes thin and delicate Intrusion without tear

History and Physical keys -Exam must correlate with the parents story. -Story must correlate with the child’s age. -Child must fit the developmental milestones. -When possible examinations should be completed by specially trained physicians to ensure that the examination is not more traumatizing then the incidences of abuse.

American Academy of Pediatrics -Developmentally appropriate interview. -Complete examination to include growth, development, social, and emotional state -Directed genital examination for specific signs or physical indicators -Laboratory evaluation, cultures for STI’s -- as indicated by history or physical

Physical Examination - Provides reassurance. - Examine for treatable conditions, STIs. - Collect legal evidence. - Chronic sequelae. - Assists in the protection of the child.

General Physical Examination Head to toe physical examination Attention to: - Abdominal Exam - Abdominal Exam - Skin- appropriate UV light source - Skin- appropriate UV light source - Bruising - Bruising -Ligature/control marks -Ligature/control marks - Oral - Oral -Sign of penetration -Sign of penetration - Sexually transmitted diseases - Sexually transmitted diseases

Physical Examination Genitals - Completed in a non-traumatic manner - External inspection A speculum is infrequently used in adolescents and rarely used in pre-pubertal children -Colposcope Tool for magnification and photo-documentation Does not see what is not there

Physical Signs and Symptoms -Bruises, scratches, bites -Abdominal pain -Genital bleeding – “blood on underwear” -Genital discharge, sexually transmitted disease -Genital or Anal Pain -Genital Skin Lesions -Genital/Urethral/Anal Trauma -Enuresis, Recurrent Urinary Tract Infections -Encopresis, Anal Fissures

Do Physician’s Recognize Sexual Abuse? - More than half could not recognize clear evidence of chronic sexual trauma. -More than half of primary care physicians could not identify major parts of a female child’s genital anatomy.

Physical Exam Findings diagnostic of trauma and/or sexual contact Examples: -Lacerations or bruising. -Hymenal transection (area of hymen torn through or nearly through the base). -Infection such as chlamydia > 3years old. -Pregnancy. -Sperm on sample taken from child’s body.

Why are exams normal? -Nature of assault may not be damaging -Perception of “penetration” -Disclosures often delayed -Complete healing can occur -The hymen changes with puberty

Mimickers of Sexual Abuse - Medical Conditions - Accidental Trauma

Differential Dx for Vaginal Bleeding -Sexual Abuse -Physiologic Endometrial Shedding -Lichen Sclerosus et Atrophicus -Labial Agglutination -Foreign body (Intermittent bloody discharge, Toilet paper ). -Accidental trauma. -Endocrine (Prepubertal Vaginal Bleeding): Hypothyroidism,Precocious puberty, Ovarian Cyst McCune-Albright Syndrome

Differential Dx for Vaginal Bleeding..cont -Tumors: Clear Cell Carcinoma,Rhadomyosarcoma,Ovarian, Adrenal -Urinary Tract: Urethral Prolapse,Hemorrhagic cystitis,Urate Crystals, Hematuria, UTI. - GI Tract: Hematochezia, Anal Fissure,Liver Cirrhosis Hematochezia, Anal Fissure,Liver Cirrhosis - Coagulopathy

On Summery - Child abuse is the responsibility of all doctors, and must not be avoided or ignored because it raises difficult issues and possible appearance in Court. -It takes various forms – physical abuse, emotional abuse, sexual abuse, neglect, fabricated or induced illness. -The interests of the child should be kept uppermost to ensure protection from harm. -In many instances it is uncertain whether or not the problem is one of child abuse. Good communication with the parents and child is vital.

Take home points - Child abuse is common, it will be in your practice! - Think about child abuse, especially when the story doesn’t fit. - Always consider the developmental age of the child - If you don’t think about the possibility of abuse, you will miss it every time - If you don’t think about the possibility of abuse, you will miss it every time - There are protocols for exams. - Consequences are vast and include death. - Reporting suspected abuse is imperative - There are strategies of prevention that you can include in practice – but overall prevention is a societal issue.