Child Abuse

Child Abuse

Central elements in maltreatment

·        Parent‟s strong negative and irrational engagement with the child, featuring a distorted perception of the child

·        Parent‟s lack of ability to engage positively with the child

·        Child is continually left in a state of worry or anxiety

General History

·        History of injuries – how, who, when, where. Note details of different caregivers, change over times, etc. Clarify custody arrangements well 

·        Developmental history

·        PMH, especially previous injuries (do you need notes from hospital, other GPs etc)

·        Social history: supports, domestic violence, other stresses, previous CYFS referral

·        What are parent‟s expectations of toddler behaviour, etc

Physical Abuse

·        Non-accidental injury to a child or young person

·        Includes: bruises, cuts, fractures, head injuries, injuries to internal organs, suffocation, poisoning, burns

·        Risk factors:

o   Hard to parent child: eg handicapped or behaviourally difficult

o   Poor parenting skills/experience

o   Unrealistic expectations of the child

o   Poor mental health of the parents

o   Reduced social support

o   Alcohol or substance abuse

o   Domestic violence

o   History of child abuse in the abuser

o   Triggering event precipitating loss of control by the perpetrator

·        Be suspicious when:

o   No history is given for the injury

o   The history changes

o   History is partial

o   Unbelievable explanation

o   Unreasonable delay in seeking help

o   Previous similar episodes

o   Parents affect or behaviour is abnormal

·        Questions to include in history taking:

o   When, where and how did the injury occur

o   What was the child doing at the time

o   Who saw it

o   What is the child‟s developmental level

o   Is a scene examination necessary

·        Patterns of injury suggesting non-accidental injury:

o  Fractures: multiple sites or different ages, rib fractures, any fracture in a child < 2: consult radiologist. Look for missing teeth 

o  Head injuries: any child < 1, unexplained coma, retinal haemorrhages (from shaking). Usually closed head injury rather than a fracture 

o  Bruises: on face or back, non-mobile baby, fingertip pattern bruises, other pattern bruises (strap, belt), yellowing Þ older than 18 hours. If suspicious, referral immediately to a paediatrician (who can arrange for evidential photos to be taken). Tell mum you need to refer so they can be checked for other injuries 

o  Burns: Child will withdraw hand or foot before a burn is full thickness, pattern burns (eg held in hot bath, cigarette burns), burns on back

·        Examination:

o  Normal general assessment: growth, consciousness, play and behaviour, language 

o  Carefully full survey: looking for bruises, tenderness, acute abdomen (eg splenic rupture), genital bleeding (leave full genital exam for an expert)

o  Developmental assessment

o  Systems Review – any other possible cause for the injuries 

o  Document everything carefully, use a body chart and measure lesions, ask for explanation of each injury 

·        Investigations:

o  FBC and coagulation

o  Referral for specific investigations: X-ray, ophthalmologist, ENT surgeon, CT

o  Consider urine toxicology

·        Differential to physical abuse:

o  Bruising: Mongolian spots, coagulopathies, coin rubbing

o  Cigarette burns: bites or vesicles

o  Hot fluid burns may be non-intentional

o  Fractures: osteogenesis imperfecta, spiral fractures of the tibia in toddlers

Sexual Abuse

·        Any act resulting in sexual exploitation of a child – whether consensual or not, including:

o  Non-contact abuse: exhibitionism, suggestive behaviours, exposure to pornography

o  Contact abuse: fondling, masturbation, oral sex, object or penis penetration

·        Risk factors:

o  Family dysfunction

o  Female sex

o  Pre-adolescence

o  Previous victimisation: don‟t think they‟re worth it – won‟t say no

o  Non-biological parent

o  Developmental delay: don‟t understand, scarred to say no 

·        Alleged perpetrators are all ages. If < 10 years, are they acting out abuse to them. 60% are family members

·        History taking:

o  Evidential interview is the job of the police and CYPFS – usually videoed 

o  If child discloses to a doctor, record questions and answers carefully. Don‟t ask leading questions. Qualify notes with “the above history was taken in order to direct the exam and does not necessarily constitute a full or detailed history”. If not acute, leave questions for police 

·        Presentation:

o  Behavioural indicators: non-specific so don‟t over interpret.  They‟re the same for anything that‟s 

o   upset them, eg parents separating: sleep disturbance, change in appetite, regression, running away, fear (specific or generalise), anger, ¯concentration, sexualised behaviour 

o  Adolescence: self-harm, suicidal ideation, alcohol/drug abuse, eating disorders, unprotected consensual sex, promiscuity, school failure, loss of peer group

o  Vaginal discharge in a pre-pubertal child is common:

§  Non-specific eg irritant/allergic

§  Infection: Gp A strep, shigella, Candida (uncommon once out of nappies)

§  Foreign bodies

§  Polyps

§  Systemic illness eg measles, chickenpox

§  Vulvar skin disease

o   Vaginal bleeding: accidental straddle injury, vaginitis, foreign body, precocious puberty

·        Normal sexual development:

o   0 – 2: genital exploration, masturbation (boys > girls), learning names

o   3: talk about sexual differences, genital interest increases, masturbation common 

o   4: Play doctors and nurses, mothers and fathers, games involving undressing, exhibitionist activities, demand privacy for themselves, interested in others bodies 

o   5 – 6 years:  familiar with and has less interest in sexual differences, likely to be more modest

o   Sexualised behaviour:

§  Masturbation is normal, but inappropriate if older and still public

§  Sexual play: if > 5 shouldn‟t be touching other genitals

·        Physical findings in abuse:

o   > 50 % of disclosures will have no physical findings

o   Urgent forensic exam only if incident < 72 hours ago 

o   Perpetrator usually doesn‟t want to hurt the victim, otherwise won‟t have continued access Þ physical injuries less common 

·        Investigations:

o   Pre-pubertal: don‟t screen for STD‟s unless symptomatic.  HIV testing in time if high risk

o   Adolescents: screen for STDs and ?pregnancy test 

·        Prognosis: 25% have no adverse psychological sequalae. The more invasive the abuse, the more severe the effects long term

Neglect

·        = Act or omission that results in impaired physical functioning or development, or injury. Includes physical neglect, neglectful supervision, medical neglect, abandonment, refusal to assume parental responsibility 

·        Risk factors:

o   Poor attachment

o   Parental psychiatric illness

o   Maternal depression

o   Isolated unsupported parent

o   Poverty

·        Presentation:

o   Often associated with physical and emotional abuse 

o   In an infant: failure to thrive, frequent attendance at A&E, severe nappy rash, unexplained bruising, cold injury, developmental delay, attachment disorder 

o   Pre-schoolers: short stature, unkempt and dirty, delayed language, very disorganised play (eg aggressive and impulsive, indiscriminate friendliness) 

o   School children: short stature, poor hygiene (including teeth), unkempt, learning difficulties, ¯self esteem, disordered/few relationships, unusually patterns of defecation or urination

Emotional Abuse

·        = Act or omission that impairs the psychological, social, intellectual or emotional development of a child or young person. Includes: Rejection, isolation, oppression, deprivation of affection, inappropriate criticism, threats or humiliation, exposure to violence, involvement in illegal or anti-social activities, negative impact of substance abuse or mental/emotional condition of parent or caregiver 

·        Risk factors:

o   Poor attachment

o   Parental psychiatric illness

o   Maternal depression

o   Isolated unsupported parent

o   Parental alcohol and/or drug addiction

o   Domestic violence

·        Presentation: 

o   Socio-emotional indicators: can‟t enjoy themselves, refuses to defend self, cheats, steals, bizarre or extreme behaviours, failure to accept responsibility for behaviour, low self-esteem, withdrawal, defiance, compulsivity, seeks love and acceptance outside the home, apathy 

o   Cognitive indicators: learning problems, short attention span, hypervigilance, hyperactivity, developmental delay, lack of curiosity 

o  Physical indicators: Failure to thrive, accident prone, self destructive behaviour, eating disorders, GI and bowel problems, poor posture, sleep disorders, ¯energy 

·        Differential: Munchausen‟s by proxy

Management of Abuse

·        Paramount principle: The interests, safety and well being of the child should be the paramount concern (Section 6, Children, Young Persons and Their Families Act)

·        Doctor‟s role is medical management, not the assessment of child abuse

·        If child abuse is suspected:

o  Trust your instincts

o  Look for signs of abuse

o  Document the facts

o  Recognise and treat medical sequalae

o  Prevent pregnancy

o  Provide ongoing support, and watch for and help behavioural sequalae 

o  Contact CYPFS immediately and discuss your concerns. You cannot be guaranteed anonymity, but when reporting to CYPFS or the police you are protected from court action if acting in good faith 

o  Mother/other person can also contact CYPS [good approach if you consider this is really a custody issue. Alternatively advise the mother to get a lawyer] 

o  There is no legal requirement to contact CYPFS or to give a CYPFS social worker information if they contact you. There is likely to be an ethical obligation, and referral guidelines will exist and should be followed. 

·        Investigation and management is multi-disciplinary: should involve paediatrician, social worker, police, psychologist

·        If a child discloses abuse:

o  Listen to the child but do not interview them

o  Well being of the child comes before the interests of any other person

o  Write down what the child says

o  Reassure them they‟ve done the right thing 

o  Tell them that they will get help – but don‟t make promises. Say it‟s got to stop but that you‟ll need to tell someone else who will help

o  Tell your manager/supervisor as soon as possible

o  Look after yourself: discuss the matter with someone you trust

o  If nothing seems to be happening, contact CYPFS again

o  Complete an ACC M45 form and forward to the Sensitive Claims Unit at ACC

·        Care for mother: may be domestic violence, depression, addiction, etc 

·        Care for perpetrator: talk with intake social worker about help for them (eg violence prevention programmes)