Injuries or illnesses that occur to children as result of family dysfunction. In practice, child abuse is considered non-accidental injury of children at the hands of their caregivers.

Physical abuse is leagally defined by state laws.

Physical

Sexual

Emotional

Neglect

Physical

Emotional

Medical

Medical

Physical

Emotional

Epidemiology:

Abuse may occur in families from any socioeconomic class, ethnicity, or community

Epidemiology:

The recognition of child abuse physical abuse begins with the clinician's ackowledgement that child abuse occurs commonly

Epidemiology:

Parents who were abused as children are at a greater risk for abusing their own children. it is estimated that 30% go on to be abusive parents

Incidence:

Children <3- highest rates of maltreatment

In 2008, there were 3.3 million referrals to child welfare agencies in the US for child abuse and neglect

Incidence:

~702,000 children were determined to be victims of child maltreatment

The child abuse victimization rate was 9.3 per 1,000 children in the national population

Almost 1,800 abusive deaths per year, by conservative estimates

Difficulty walking or sitting- sexual, Physical

Failure to Thrive- neglect, physical, emotional

Depression/suicide- sexual, physical, emotional

Incidental findings on routine exam- physical, sexual

Recurrent UTI's- sexual

Poor bonding- emotional, neglect, physical

Precocious sexual behavior

Parental Probelms

"Elevated Care Child"

Poor Social Support

Family Crisis

Historical features that should raise the questions of ___

History provided does not correlate with findings

Child's development is not compatible with mechanism described

History of even changes with time

Unexpected delay in seeking care

No history of trauma is provided

Disclosure that injury was inflicted

Event of behavoir by a child that triggers a loss of control by the caregiver

History of abuse in the caregiver's  childhood

Innappropriate affect of the caregiver

Pattern of increasing severity or number of injuries of no intervetion

Social or physical isolation of the child or caregiver

Stress or crisis in the family or caregiver

Unrealistic expectations of caregiver for the child

Behavior changes of child

Bruises on uncommonly injured body surfaces

Blunt-instrument marks or burns

Human hand marks or bite marks

Cigarette burns

Multiple injuries at different stages of healing

Evidence of poor care or failure to thrive

Circumferential immersion burns

Unexplained retinal hemorrhages

Assess for:

Growth failure

Bruisees

Burns

Oral injuries

Palpable rib fxs

Abdominal injuries

Genital injuries

Retinal hemorrhages

Are the findings explained by any medical condition?

Abusive head trauma

Associated with abuse can be located anywhere around the brain but are often found in the posterior interhemispheric fissure

Bone injuries: Posterior rib fx, metaphyseal (bucket-handle or corner)

fracture, scapula, sternal, or spinous process fxs

Long bond fxs- spiral, bucket handle (metaphyseal)

Scapular fxs

Rib fxs (esp posterior)

Spinous Process fxs

Skull (esp. non-linear)

Sternal fxs

Multiple fxs

Physical Abuse-Diagnostics

For children with bruising or bleeding

CBC, PLT count

Prothrombin time/partial thromboplasatin time, INR

PLT function evaulation

LFTs

Amylase, lipase

UA

Creatine kinase

LP

Toxicology screen

Skeletal survery

Clavicle, long bone shaft and linear skull fxs are common accidental fxs that have low specificity for physical abuse

CT and MRI

Report any suspicious cases to local child welfare agency

Report abuse to law enforcement when injuries warrant police investigation

Consult social worker

You, as a professional, are obligated by law to call CPS!!!

Hospitalization to ensure the protection of the child during initial investigation is sometimes necessary

Epidemiology and Risk Factors:

Risk increases with multiple care takers

Children at all ages may be victimized with a peak age of vulnerability between 7 and 13 years

Epidemiology and Risk Factors:

Girls are victimized more than boys, although abuse of boys is thought to be underreported.

African American > Caucasian

Low socioeconomic status

Children with disabilities

History:

Should be conducted with the child separate from family members; diagnosis often depends on the history obtained from the child.

History:

Ask open-ended, non appropriate language

Special questions:

Identity of alleged perpetrator/relationship to child

Time of last possible contact

Method of disclosure

Specific types of secual contact included in the abuse

Previous official reports to the abuse

Review of systems including genital pain, bleeding, dyuria, painful bowel movements and behavior changes.

Most ___ children have normal genital examinations

Abuse may not have caused injury to tissues

Mucosal injuries heal quickly and may be resolved by the time child is examined

Prepubertal children require detailed external genital inspection only

Genital exam can be done with child in supine frog-leg position

Use of the techniques of labial separation and traction will allow complete examination of vulvar structures

Adolescent girls usually do not require a full pelvic exam

Prepubertal girls should not have a speculum exam without anesthesia

These include the presence of semen, acute genital/anal injuries without an adequate accidental explanatino, syphilis and N. gonorrhea

Look for acute genital injuries and marked disruptions of hymenal tissue

Testing for N. gonorrhoeae and C. trachomatis

Forensic evidence collection

Prophylactic antibiotics against common STI

Consider pregnancy prevention
Tetanus booster

Hep B vaccination

Sitz bath for comfort

Report!!!

Prevention:

Teach children to protect themselves and their "private parts"

Failure to provide necessary food, clothing, shelter and safe environment

Often associated with poverty or ignorance

History:

Evaluate psychosocial history and family dynamics

Social servies evaluation of home and family

Failure to thrive/growth failure

Phsycial Exam:

Absence of subcutaneous fat in cheeks, buttocks, and extremities

Physical Exam:

Poor nutrient and vitamin intake manifestations

Depression

Physical Exam:

Short stature/deprivation dwarfism (in older children)

Normal head circumference

Diagnostics:

FFT work up

Assessment of growth curv

CBC, electrolyte panel, thyroid and liver function test

Skeletal survery

Munchausen syndrome by proxy

Caregivers simulates or creates symptoms or signs of illness in a child

Medical Care Neglect and Abuse

May present with:

SxS of whatever illness is factitiously produced or simulated

Long list of medical problems or bizarre, recurrent complaints

Persistent doctor shopping and refuse to acceptance that the child is healthy

ON PE check for Signs of sexual abuse

It's your job and your responsibility

On any type of suspected abuse, it's good to get your supervising physician to check. It's always good to have a second opinion.

Good documentation

Most emergency departsment have sexual assault team, Use them!!!

 DON'T LET THE KIDS DOWN, YOUR VOICE MAY BE THEIR ONLY ESCAPE