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Child Abuse

Violence occurs more frequently within the family than any other place in our society. During the six weeks that we were involved in the Gulf War, more children were killed by their parents than soldiers died in the field. Definitions of child abuse have expanded over the years from an initial focus on physical injuries inflicted by caregivers to today's broader conceptualization. Today, child maltreatment refers to any act or omission that endangers or impairs a child's physical or emotional health and development. There are four major categories of child maltreatment: physical abuse, sexual abuse, neglect and emotional maltreatment child abuse, child maltreatment, childabuse

Physical abuse is what generally comes to mind when we hear the words "child abuse" and that refers to any act of harm or threatened harm against a child by a caregiver which results in physical or mental injury to the child. So, examples would include cuts, bruises, burns, fractures, abrasions. Here we see marks on a child who has been tied to his bed for long periods of

Sexual abuse is any contact or interaction between a child and another person in which the child is sexually exploited either for the gratification or profit of the perpetrator. So things like fondling, exhibitionism, voyeurism, all those would be examples of sexual abuse. Neglect refers to a condition in which a caregiver either deliberately or by extraordinary inattentiveness fails to meet a child's basic needs. It is an act of omission that places a child at risk for physical harm. Deprivation of clothing, food, shelter, lack of supervision, abandonment. All of those would be examples. Here is a child with alopecia as a result of neglect.

The fourth category of child maltreatment is emotional maltreatment. This can be an act or an omission on the part of a caregiver that causes or can cause serious behavioral, cognitive, emotional or mental disorder in a child. There are two types of emotional maltreatment. There is emotional abuse

Emotional neglect refers to omissions that result in a failure to meet a child's emotional needs. These would include such things as depriving a child of proper stimulation, responsiveness, refusing to recognize that a child has an emotional disturbance and/or failure to respond to that emotional disturbance. Physical abuse, sexual abuse, neglect, emotional abuse and emotional maltreatment are all forms of child maltreatment.

The incidence and prevalence of child maltreatment. There were 2.7 million reported cases of child maltreatment in 1993. We have to remember that incidence relies on reported cases and this can vary dramatically depending upon our willingness to recognize the problem. I suspect that the actual incidence is higher than that. We tend to think of child maltreatment as something that occurs most frequently in young children and, indeed, physical abuse is the leading cause of head injury in infants. But physical and emotional abuse appear to be increasing steadily with age. According to the Department of Health and Human Services, teens are estimated at twice the risk of children under the age of three when it comes to physical and

Now, a misconception that I hear quite frequently is that child maltreatment is a problem of the cities. In actuality, there are no urban/rural differences in the rates of sexual abuse or physical abuse and I think that's particularly important for family physicians to know since many of you practice outside

There is a strong correlation between domestic violence and child maltreatment. More and more research is being done in this area and we know now that child abuse has been reported to occur in 33-54% of the families where domestic abuse is occurring. We also know that about 28% of battered women emotionally abuse their children.

Looking at the incidence and prevalence of sexual abuse, it is estimated that between 100,000 and 500,000 children are sexually abused each year. 30-46% of these children have been sexually abused on more than one occasion. As I noted earlier, it cuts across all socioeconomic groups and also

Now, we also have to consider the consequences of child maltreatment. Obviously, the most extreme consequence is death and unfortunately that occurs much too frequently. But what about those children who survive? There has been a fair amount of research done in the area of physical and sexual abuse survivors. With regards to physical abuse, we know that children who are subjected to this form of abuse tend to be more aggressive

The rate of abuse in families where parents have been abused is six times higher and I don't think that should surprise any of us. When you think about the primary role model for parenting, that's our own parents. Families that are experiencing high levels of stress are at higher risk and also

Looking specifically at sexual abuse, there is no classic profile of the offender. What we do know, however, is that 90% of the offenders are males. Up to 20% are adolescents and most of these adolescents have been sexually abused themselves. Adult women are offenders in 1 out of every 5 sexually abused males and 1 out of every 20 sexually abused females. Most often the offender is someone that is closely related to the child. In 40% of the cases, they are family members. In another 40% of the cases, they are known to the family. Children who are living in homes where mom is

Premature birth refers to children that are born prior to the due date but there are no known physical or mental problems. We're not certain for sure why these children are at greater risk but we think it has something to do with the fact that they tend to be more hypersensitive and they tend to have

If any of you have ever dealt with a colicky child, I don't think I need to explain that one. Children with congenital deficiencies or abnormalities are often a source of embarrassment for families. They certainly alter family patterns and frequently strain family resources. Wrong sex children, particularly those families that very much wanted a male and the child ends up being female. Hyperactive kids. Unwanted pregnancies with the

Children who are vulnerable to sexual abuse include those who lack confidence, they are indiscriminate in their trust of others and they are frequently

Emotional and behavioral signs and symptoms in children who are maltreated including the following. The child who is unusually fearful of adults, perhaps one sex more than others. They seem frightened of their parents. A child who doesn't want to go home with their parents when you see them in the clinic. They are resistant to being touched by any adults. A variety of school performance problems – delinquency, vandalism, those kinds of

When looking for signs of physical abuse, there are certain parental or caregiver behaviors to pay attention to and, again, I think these you are familiar with. The unexplained delay in bringing the child. Oftentimes home remedies are tried first to try to forestall medical attention. The implausible explanations. You know, the child who can't sit independently and yet the parents tell you that they rolled off the couch or they fell off the chair or whatever. The accounts that change. They tell you this story and then they tell you that story or there are conflicting stories. One parent tells you one

When looking for physical findings, the location and the type of injury can help differentiate between accidental and nonaccidental causes. Looking first at specific physical findings, you need to be wary of burns, particularly cigar or cigarette burns that are found on the bottoms of feet, on backs, buttocks. Immersion burns with splash burns. You know, those glove-like on the hands or the stocking-like burns on the feet that you see there or the

Lacerations. Particularly location. If you find them on face, lips, mouth, ears. Here is a child who his mouth has been taped for long periods of time. Sometimes you will see the bruises on the corner of the mouth. Oftentimes that's indicative of gagging, either as punishment or the child's been crying

Fractures. Skull fractures almost always indicate some kind of direct impact. Jaw fractures, rib fractures. Now, there are those of your colleagues who feel that posterior rib fractures in infants are pathognomonic of child abuse because it is impossible to fracture a child's rib with CPR unless there

Abdominal injuries. These are the second leading cause of death in abused children. Duodenal, jejunal hematomas, intestinal perforations, kidney/bladder injuries. Here is a child with significant hematomas.

Head injuries. This is the leading cause of death from child maltreatment. Subdural hematomas. Subarachnoid hemorrhages. Retinal hemorrhages. These are oftentimes easy to miss on initial exam so you need to look closely for those.

Now, again, there are colleagues of yours who feel very strongly that if you see retinal hemorrhaging in children under the age of 3 without external evidence of some significant trauma, that it is pathognomonic of child abuse. There are others that argue that CPR with chest compressions can

I would be remiss if I didn't mention the two syndromes that are suggestive of abuse and neglect in infants and toddlers. There is the battered child syndrome generally seen in children under the age of 3. Again, with a variety of potential signs and symptoms – subdural hematomas, failure to thrive, soft tissue swelling. Then there is the shaken baby syndrome generally seen in children under the age of 2. Here is oftentimes where you see the retinal hemorrhages, some kind of cervical spinal cord injury or subdural/subarachnoid hemorrhaging.

Just looking at the signs of sexual abuse, just some overall guidelines. First of all, the signs are going to vary according to age and developmental stage and I would focus more on developmental stage. Age oftentimes doesn't tell us a whole lot about a child. Keep in mind that these signs are

Contrary to popular belief, sexual abuse may leave few, if any, physical effects. You know, if you stop to think about it, fondling or oral copulation is not going to leave any signs at all. Last, but certainly not least, don't overlook sexual abuse in males. We tend to think of sexual abuse occurring in females, and obviously the incidence is much higher, but 1 in 10 victims of sexual abuse are boys.

Again, according to developmental stage, I'm not going to go through all of these. I've got those in your outline. Appetite changes, sleep disturbances, severe anxiety. In your preteen school age kids – conversion disorders, sudden weight gain or weight loss. School failure. Running away. Among your teens, sexual promiscuity. The other one is adolescent girls often exhibit significant rebellious behavior towards their mothers. The reason for that is they feel that mom is not doing an adequate job of protecting them.

I just want to point out a couple of things with regards to sexualized behavior. If you're not very familiar with what's normative, I would recommend that you read an article that is found in Pediatrics. It is Volume 88, one of the 1991 editions, pages 456 to 464. This does a very nice job of going over normative sexualized behavior.

The other thing that I want to point out is that sexual behavior in younger children must be viewed in the context of the family, the culture and the history. Cultures and families within given cultures vary widely in their attitudes and their behavioral responses to nudity and sexuality. Obviously these differences affect children's behavior so you need to keep those in mind.

I think the thing to remember is that the absence of any sexualized behavior does not confirm that sexual abuse did not occur any more than the presence of sexualized behavior conclusively demonstrates that it did occur.

Physical findings. Again, I'm not going to go through all those. With regard to STDs, oftentimes the assumption is made that these diseases can result only from sexual contact. We do know that some genital infections like gonorrhea and chlamydia can be transmitted perinatally so just keep that in mind.

Signs of neglect. Parental behavior that is suggestive of neglect includes the parent that appears to be very indifferent towards the child, is very apathetic, very depressed or tends to behave very irrationally. Behaviors in children that may be indicative of neglect would be discipline problems or poor school performance. Physical findings of neglect would be poor hygiene, inadequate clothing.

The symptomatology that is displayed by the child may be global or it may reflect just a particular area of neglect. For example, you may have a child who is very well-clothed, very well-fed, clean, but has a chronic illness and receives no care for that chronic illness. That potentially could be neglect if they are not getting any care for the chronic illness.

Emotional maltreatment can be very difficult to detect but I think primary care physicians are in a much better position to recognize it because you are following this child over time. So you can observe a child that is not developing well which is a common characteristic that we see in children of emotional maltreatment and also the failure to thrive.

Parental behaviors. Here is a child, obviously with significant facial wasting as a result of treatment. Parental behaviors that may be indicative of emotional maltreatment would be the parent that constantly belittles or blames the child, who is totally unconcerned about the child or may just overtly reject the child. Behaviors of children that may be indicative of emotional maltreatment. Again, sleep disturbances. The child who is inappropriately

So that's identifying. Your second task is assessing and that involves obtaining a history and performing a physical examination. The history is a keystone to making a diagnosis of child sexual abuse and I really can't overemphasize that. You are going to want to interview the child and the parent together initially. Again, these things are outlined in your handout so I'm not going to go over all of these. But I want to make sure that you understand the parent's concern, the symptoms and injuries of the child. Gather a detailed history. Explain that you are going to need to speak to the child alone and be honest about that.

Phrase questions in a non-confrontational way. You want to ask, "How did that bruise occur?" Not, "Why did you cause that bruise?" Convey an

Two important questions to keep in mind as you're doing your physical examination: Is the history consistent with the observed injury? Could this child have received this injury in the manner that has been described? If you suspect physical abuse, a couple of things to keep in mind. Again, do a

When do you collect forensic evidence? Obviously, if the history suggests that there's been sexual contact that involves penetration or ejaculation on the body within the past 72 hours, you want to collect forensic evidence, do a forensics exam. Also you want to do a forensics exam when the indications are not clear. For example, if you've got a preverbal child or you've got a child who is comatose, it is better to go ahead and do the

There are some conditions that can mimic child maltreatment and I need to point out those because we have to be careful not to misdiagnose. Some children fail to thrive because of congenital abnormalities and not every unexplained injury is child abuse. There are some conditions that can mimic physical abuse. The Mongolian spots that you see here. Usually they are found on the lower back or the upper buttocks. Impetigo can be confused with cigarette burns. Coining. Are you all familiar with that practice? That's where they rub the back and the chest with coins in warm oil. Oftentimes it's a treatment for colds. But that can leave lines and it can leave bruises. Osteogenesis imperfecta and osteomyelitis both can mimic intentional

There are also some things that can mimic sexual abuse. Perianal Streptococcus and vaginitis due to Streptococcus or Shigella, Crohn's disease, urethral prolapse. Again, just keep those things in mind.

One of the difficulties in assessing the presence of child maltreatment is the distinction between physical punishment and physical abuse. Personal beliefs, experiences, cultural beliefs and cultural values all are going to affect one's decision as to when punishment becomes abuse. I think obviously

When do you report? Well, obviously if a family member has committed an act of maltreatment or if parents have not provided a safe place for the