1. Child Abuse Gloria Coats

2. Statistics In 2004, there were 2 million child abuse cases investigated and1,490 child fatalities from abuse and neglect confirmed by the U.S. Department of Health and Human Services in Administration for Children and Families. Of these deaths, 79% were under age 4 Children with disabilities are more likely to be abused. Girls are 3 times more likely to be sexually abused than boys. Child abuse includes:  Physical abuse  Sexual abuse  Emotional abuse

3. Physical, Sexual, Emotional Abuse Physical Abuse: Any act that results in nonaccidental physical injury. Injury frequently due to: shaking, striking, throwing, twisting limbs, biting, cutting, poking. Sexual Abuse: Involvement of a child in sexual activity, including inappropriate touching, intercourse, oral sex, any involvement with pornography Emotional Abuse: Verbal or mental including: belittling, embarrassing, blaming, rejecting, withholding love and affection

4. The History If abuse is suspected, make every effort to take the history without other family members present. Ask questions needed for a report to Child Protective Services: who, what, when, where Do not lead with questions Do not offer promises that can't be kept Control the natural response of shock Support the child/adolescent for telling you Use age-appropriate language Ascertain the words the child/adolescent uses to describe genital anatomy and give permission to use them

5. The history should asses for:  Injuries not explained or implausible, or the caregiver is vague  Explanation does not match type or mechanism of injury  Child or caregiver hides injury  Inconsolable crying  Toilet training accidents, sleeping, or discipline problems that may have led to a violent response by a caregiver  Child has a sophisticated knowledge of sexual activities  Promiscuity  A report of family crisis (financial problems or domestic violence)  Substance abuse problems in the family

6. Behavioral Signs Associated with Child Abuse Overly compliant or exhibits exaggerated fearfulness Wary of physical contact with adults Frightened of parents or of going home or both. Exhibits drastic behavioral changes in and out of parental or caregiver presence Depressed, hypervigilant, withdrawn, apathetic, antisocial, destructive behavior, promiscuity Overprotective of parents or caregivers Displays sleep or eating disorders.

7. Physical Findings Note location, type, and presence of multiple injuries Remember, the shins, elbows, and knees are the most common sites of accidental childhood injuries. Be aware of ethnic cultural remedies such as coining and cupping used by Russian-, Asian-, Mexican- American cultures and do not confuse these with child abuse.

8. Common Sites of Physical Abuse Head area  Bilateral black eyes  Pinch and pull marks on earlobes  Slap marks on cheeks  Lacerations on upper lip and frenulum Neck  Choke marks Trunk  Bite marks larger than 4cm diameter, finger marks on chest  Burn marks from cigarettes  Paddling and strap marks Genitals  Pinch marks  Bruising from intercourse or fondling  STIs Extremities  Grab marks on upper arms  Burns from emersion in hot liquids  Razor marks on feet  Fractures 56-60% of fractures under 1 year are not accidental. Suspicious fractures  Epiphyseal/metaphyseal chip at the end of a long bone due to shaking or jerking a limb  Spiral fractures of long bones  Evidence of fractures in various stages of healing

9. Shaken Baby Syndrome Signs and symptoms  Decreased LOC  Irritability  Lethargy and limpness  Vomiting  Increased RR, decreased HR  Coma with fixed and dilated pupils  Bruising of the head and face  Retinal bruises  Fractures of the ribs, collarbone, or long bones

10. Management Order appropriate diagnostic studies. Provide appropriate medical treatment for injury. Carefully document findings and any statements made by caregiver, parents, and child. Use the child’s own words. Avoid abbreviations, be clear and concise Secure photographic documentation of soft tissue injury. Take photographs from several angles. Make sure the child’s face is visible, if possible, for identification. As a mandated reporter, you must report abuse. Report to CPS and the Police department. The National Child Abuse hotline may be used to report abuse in any area: 1-800-422-4453

11. References Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N. B. & Blosser, C. G (2004). Pediatric primary care: A handbook for nurse practitioners (3 rd ed.) St. Louis, MO: Saunders. Riley, J. (2007). Do you know how to recognize child abuse? Nursing Made Incredibly Easy, 6(2 ), 54-62