ICANHELP: IV. Physical Abuse

1. ICANHELP:IV. Physical Abuse <Insert your name and affiliations> branchpartners.org

2. Learning Objectives • Discuss common forms of punishment, and engage colleagues in discussing which types might cross the line and cause harm. • Recognize historical and physical exam findings that raise a concern of child abuse. • Structure an appropriate evaluation for abuse when it is suspected. • Initiate management of abuse within the systems of the host country.

3. What type of hitting is too much?

8. Physical contact against children in Malawi Methods of inflicting corporal punishment: • Open hand on buttocks • Open hand on hand, leg or face (“love slap”) • Twisting arms • Hitting or whipping with small stick or strap – but leaving no marks • Hitting or whipping – and leaving welts, bruises • Poked with sharp object • Biting, pulling hair • Dipping hands into scalding porridge, or forcing to hold hot charcoal

9. Incidence and attitudes (World): • Ethiopia: 80% of grade school kids report being beatenKetsele, Ethiopian Medical Journal, 1997 • Hong Kong: 46.6% of adolescents had been hit in the last three months Lau, Child Abuse & Neglect, 1999 • Chile: 80% of public school students report physical punishmentVargas, Child Abuse & Neglect, 1995

10. The Arguments: “Hey, I was hit is a child, and I turned out ok!”

11. The Arguments: “He who spares the rod, hates his son”King Solomon, Proverbs 13:24

12. Sweden Norway Finland Denmark Germany Ukraine Cyprus Romania Latvia Switzerland* Canada* Incidence and Attitudes (World):Physical punishment of children is illegal in: • Austria • Croatia • Iceland • Ireland • Israel • Italy * Not illegal in this country, but government has adopted official position opposing corporal punishment

13. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

14. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

15. Bruise with recognizable shape

16. Bruise with recognizable shape

17. Bruise with recognizable shape

18. Bruise with recognizable shape

19. Bruise with recognizable shape

20. Bruise with recognizable shape

21. Burn with recognizable shape

22. Burn with recognizable shape • Tub Immersion Burn

23. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

24. Multiple InjuriesDifferent Ages

25. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

26. Epidemiology of Accidental Bruising

27. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

28. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

29. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Person Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

30. Inconsistency • Internal inconsistency • History changes with repetition • distinguish from changing medical history taking or documentation • Inter-historian inconsistency • Different history from different informants • distinguish from different perspectives or “telephone” errors

31. Inconsistency • Developmental Inconsistency • Child is reported to do something age inappropriate • Inconsistent cause • Epidemiologically unlikely • Biomechanically unlikely

32. Common fractures Clavicle Skull Others uncommon Fall Injuries • Uncommon head • Epidural • Small subdural • Death Rare

33. Visceral Injury Very rare Brain Injury Very rare Fall Injuries • General rules • Exceptions exist • Probabilistic • Not deterministic

34. 15-month-old brought for a “rash”

35. 15-month-old brought for a “rash”

36. 15-month-old brought for a “rash”

37. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Person Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

38. Algorithm to Recognize Inflicted Injuries Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Person Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

39. Summary Injury Evaluation Consider Physical Abuse Bruise or Burn with Recognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Inflicted Injury No Trauma History Inconsistencies in the Given History Minor Trauma with Severe Injuries Injury Complicated By Unreasonable Delay

41. References • Anderson, J. (1936). The young child in the home, a survey of three thousand american families : report of the Committee on Infant and Preschool Child. NYC, Century. • Berlin, L. J., J. M. Ispa, et al. (2009). "Correlates and consequences of spanking and verbal punishment for low-income white, african american, and mexican american toddlers." Child Dev 80(5): 1403-1420. • Blumberg SJ, e. a. (2000). "Design and operation of the National Survey of Early Childhood Health, 2000. ." Vital and Health Statistics. Ser. 1, Programs and Collection Procedures 40: 1-97.

42. Davis, J. (2003). General Social Survey 2002 [United States]. Princeton, NJ, Cultural Policy and the Arts National Data Archive, Princeton University. EPOCH-USA http://www.stophitting.com/index.php?page=epochboard Gershoff, E. T., A. Grogan-Kaylor, et al. (2010). "Parent discipline practices in an international sample: associations with child behaviors and moderation by perceived normativeness." Child Dev 81(2): 487-502. Goodenough, F. (1931). Anger in Young Children. Minneapolis, University of Minnesota Press. Graziano, A. M., J. L. Hamblen, et al. (1996). "Subabusive violence in child rearing in middle-class American families." Pediatrics 98(4 Pt 2): 845-848.

43. Gunnoe, M. L. and C. L. Mariner (1997). "Toward a developmental-contextual model of the effects of parental spanking on children's aggression." Arch Pediatr Adolesc Med 151(8): 768-775. Lau, J. T., J. L. Liu, et al. (1999). "Prevalence and correlates of physical abuse in Hong Kong Chinese adolescents: a population-based approach."Child Abuse Negl 23(6): 549-57. MacKenzie, M. J. e. a. (2011). "Who spanks infants and toddlers? Evidence from the Fragile Families and Child Well-Being Study." Child Youth Serv Rev. 33(8): 1364–1373. MacMillan, H. L., M. H. Boyle, et al. (1999). "Slapping and spanking in childhood and its association with lifetime prevalence of psychiatric disorders in a general population sample." CMAJ 161(7): 805-809.

44. McCormick, K. F. (1992). "Attitudes of primary care physicians toward corporal punishment." JAMA 267(23): 3161-3165. Montague, A., Ed. (1978). Learning non-aggression: the experience of non-literate societies, Oxford University Press. Sears, R., E. Macoby, et al. (1957). Patterns of Child Rearing, Stanford University Press. Straus, M. (1994). Beating the devil out of them: corporal punishment in American families. San Francisco, Jossey-Bass/Lexington. Straus, M. A., D. B. Sugarman, et al. (1997). "Spanking by parents and subsequent antisocial behavior of children." Arch Pediatr Adolesc Med 151(8): 761-767.

45. Vargas, N. A., D. Lopez, et al. (1995). "Parental attitude and practice regarding physical punishment of school children in Santiago de Chile." Child Abuse Negl 19(9): 1077-1082. Wissow, L. S. (2001). "Ethnicity, income, and parenting contexts of physical punishment in a national sample of families with young children." Child Maltreatment 6: 118-129. (1996) The short- and long-term consequences of corporal punishment., Elk Grove Village, Illinois, AAP. . Pediatrics. Oct;98(4 Pt 2):i-vi, 803-60.