1. Child Abuse

2. An acts of parents/guardians (and other adults) –Abuse –Maltreatment

3. Universal Definition Abused child: < 18 years old, has had serious physical injury inflicted by non-accidental means (includes sexual offences) Maltreated child:< 18, whose physical, mental, or emotional condition is in danger

4. NYS Definition of an abused child: An adult inflicts or allows to be inflicted upon the child a serious injury, or substantial risk of physical injury Commits or allows to be committed against the child a sexual offense defined in the penal law

5. NYS definition of a maltreated child Failure of a parent or legal guardian to exercise minimum degree of care Examples: –Alcohol/drug use –Inadequate food, clothing, shelter, education, medical care although financially able to do so –Improper supervision –Excessive corporal punishment

6. Mandated Reporters Physicians Nurses Dentists School officials How to report: Call NY State Child Abuse & Maltreatment Register (800-342- 3720)

7. When to Report When a mandated reporter has “reasonable cause” to suspect that a child whom the reporter sees in his/her professional or official capacity is abused or maltreated OR if the person legally responsible for the child states from personal knowledge that the child is being abused or maltreated

8. What is reasonable cause?

9. Obligations of mandated reporters Photographs and x-rays Take appropriate measures to protect a child’s life and health; when appropriate, taking protective custody of a child without the consent of the legal guardian (MD’s, hospital administrators, police officers)

10. Immunity Any person who in good faith makes a report has immunity from any liability civil and criminal that might be a result of such actions. Mandated reporters have confidentiality

11. Penalties for Failure to Report Legally: Any person required by law to report a case of suspected child abuse or maltreatment, who willfully fails to do so, may be guilty of a class A misdemeanor. May also be civilly liable for damages caused by the failure to report. Professionally: NYS Education Department can charge a professional with unprofessional conduct leading to potential license revocation after an investigation

12. 3 services when a report is made Investigation: to determine if evidence credible. –contacts child, siblings, parents, mandated reporter Determination: made within 60 days, indicated or unfounded Assessment/Service Planning: realistic plan for child/family is made, CPS may become involved

13. Behavioral & Environmental Characteristics of Abusers Parent abused or neglected as a child Lack of friendships or emotional support (lack of self-esteem) Marital problems Physical or mental health problems Life crises (unemployment)

14. Behavioral & Environmental Characteristics of Abusers Alcohol/substance abuse Adolescent parents Absence of nurturing child-rearing skills (violence for discipline) Delay or failure in seeking health care for child’s injury, illness, routine check-ups, immunizations Unreasonable expectations for child

15. Types of Abuse Physical Neglect Emotional Sexual

16. Physical Abuse Deliberate infliction of physical injury on a child usually by caregiver –Minor –Major

17. Indicators of Physical Abuse Injuries that are unexplained or are inconsistent with the parents/caretakers explanation Bruises, welts, bite marks on face, torso, back, buttocks, thighs Injuries to both eyes or cheeks Clustered, forming regular patterns reflecting shape of article used

18. Physical Indicators of Abuse Grab marks on arms or shoulders Lacerations or abrasions to mouth, lips, gums, eyes, external genitalia Burns: especially on soles, palms, back or buttocks, immersion burns (doughnut-shaped), patterned, rope burns Fractures Head injuries

19. Child Behavioral Indicators Wary of contact with parents or other adults Apprehensive when other children cry Behavioral extremes: (aggressive, withdrawn) Reports injury by parents Inappropriate clothes for the season

20. Neglect Physical neglect: Emotional neglect: Emotional Abuse:

21. Neglect Physical indicators: Failure to thrive Positive toxicology Lags in physical development Consistent hunger, poor hygiene Consistent lack of supervision Unattended physical problems or medical needs Chronic truancy

22. Neglect Behavioral indicators: Begging, stealing food Extended stays at school Constant fatigue, falling asleep in class Alcohol or drug abuse

23. Failure to Thrive (FTT) most common form of neglect Organic: result of physical cause (congenital heart defect) Nonorganic: result of psychosocial factors (knowledge deficit of parent, altered maternal/child attachment, abuse)

24. Other Factors Poverty Health beliefs Inadequate nutritional knowledge Family stress Insufficient breast milk

25. FTT Clinical manifestations Growth failure Developmental retardation Poor hygiene Withdrawn behavior, apathy Feeding or eating disorders No fear of strangers Avoidance of eye contact, minimal smiling Wide-eyed gaze and continual scan of environment

26. Diagnosis: weight & height < 5 th percentile Treatment: reverse the malnutrition Prognosis: depends on cause FTT

27. Sexual Abuse No universal definition In general: use, persuasion or coercion of a child to engage in sexually explicit contact –Incest –Molestation –Exhibition –Pornography –Prostitution

28. Sexual Abuse Physical indicators: difficulty in walking or sitting torn, stained or bloody underclothes pain or itching in genital area bruises or bleeding in external genital, vaginal or anal areas bruises to hard or soft palate STD’s (preteens), repeated UTI’s pregnancy (early adolescence)

29. Sexual Abuse Behavioral indicators: Unwilling to change for gym Withdrawal, fantasy or infantile behavior Bizarre, sophisticated or unusual sexual behavior or knowledge Poor peer relationships Reports sexual assault by caretaker Prostitution Forcing sex acts on other children Extreme fear of being touched Low self-esteem, general fearfulness

30. Munchausen Syndrome by Proxy Parent fabricates symptoms of illness in the child (usually under age 6 years) May be done to gain entry into medical system for own needs, thrives on medical attention Suspected when unexplained, recurrent, rare conditions occur, illness does not respond to treatment, symptoms are inconsistent

31. Munchausen Syndrome by Proxy CNS symptoms most commonly reported –Apnea, fever, seizure, N/V/D, blood in urine or stool Overdose on medications in order to cause side effects Child is fearful, anxious, uncooperative while parent appears knowledgeable, cooperative, calm, suggests treatment or diagnostic tests

32. Munchausen Syndrome by Proxy Abuser is usually the mother, is young, married, middle class, and often has a health care background Often was a victim of abuse Usually confirmed by covert video surveillance, collection of evidence

33. Hospitalization of the Abused Child Nursing Interventions: Verify that the case has been reported Promote a trusting relationship with child Integrate child into normal daily routine Observe all interactions between child and parents Remove child/parents from unit if necessary Participate in multidisciplinary meetings re: child progress/status Allow parents to verbalize, listen non- judgmentally, and avoid threatening questions

34. Interviewing the Child Indirect hints: “My brother wouldn’t let me sleep last night”. Response: “Can you tell me more”? Disguised Disclosure: “What would happen if a girl told someone her mother beats her”? Response: “What do you know about this girl”? Disclosure with strings attached: “If I tell you I have a problem can you promise not to tell anyone else”? Response: Let the child know you want to help, but it may be necessary to get special people involved.

35. Interviewing the Child Do: Conduct the interview in private Sit next to the child Tell the child that the interview is confidential Conduct the interview in language the child understands Ask the child to clarify words/terms which are not understood Tell the child if any further action will be required

36. Interviewing the Child Don’t: Allow the child to feel “in trouble” or “at fault” Suggest answers to the child Probe or press for answers the child is unwilling to give Display horror, shock or disapproval of parents, child or the situation Force the child to remove clothing

37. The nurse overhears a group of student nurses in the break room discussing the role of the nurse in suspected child abuse. The nurse concludes that the student who most accurately understands the role is the one who makes which of the following statements? 1.Nurses should only report abuse if they are certain 2.Nurses should tell the child’s doctor if child abuse is suspected 3.Only the physician can report child abuse 4.Nurses are required to report any case of suspected child abuse to child protective services

38. Case Study A 5-year-old female who is a victim of sexual abuse committed by her uncle is being admitted to your hospital unit for treatment of a urinary tract infection and labia lacerations.

39. As you admit the child to the unit, what will be your initial approach with her?

40. What measures can you take to promote a sense of security for the child?

41. The child tells you that she is “bad” because she told on her uncle. How would you respond?

42. The parents are arguing loudly in the child’s hospital room. What actions would you take?