Good Morning and Welcome Applicants!

1. Good Morning and Welcome Applicants! December 16, 2010

5. Physical Abuse • Second to neglect • 18% of total abuse • Underreported • Variations on definition • Training in recognition • Unwillingness to report • Professional bias

6. Physical Abuse • Long-term morbidity • More likely to die • More likely to develop behavioral and functional problems • More likely to have anxiety and/or depression • More likely to have social and relationship deficits

7. Risk Factors • Age • Adolescents are more likely to receive injuries from abuse • Infants <2y are more likely to have fatal abuse or serious injuries • Income • <$15,000/year • 3 times the number of fatalities • 7 times the number of serious inflicted injuries • 5 times the number of moderate inflicted injuries

8. Risk Factors • Maternal smoking • Presence of >2 siblings • Low infant birth weight • Unmarried mother • Living in household with unrelated adults • Disabilities • Domestic violence • Substance abuse

9. How does abuse present? • Individual sees a suspicious injury • Individual witnesses an abusive event • A caregiver observes symptoms and brings child for medical care unaware of abuse • Individual asks a child • The abuser thinks the injury requires medical attention • Disclosure

10. History • Use “quotes” • Mechanism of injury • Onset • Progression of symptoms • Developmental capabilities • Separate histories

11. When is the history concerning? • No explanation or vague history for a significant injury • An important detail changes dramatically • Inconsistent explanation • Pattern of injury • Developmental development • Different witnesses with different explanations

12. History • Behavior • Before, during and after • Access to caregiver • Caregiver activities • PMH • Trauma, hospitalizations, congenital, chronic illness • FH • Bleeding, bone, metabolic, genetic

13. History • Pregnancy • Unwanted, unplanned, PNC, complications, depression • Discipline patterns • Temperament • History of abuse • Substance abuse • Social and/or financial stressors • Violence in family

14. Physical Exam • Detailed • Body diagram • Pictures • Measurements • Look for other signs • Areas concealed by clothes

15. Physical Exam • Growth parameters • General appearance • HEENT • Neuro

16. Physical Exam • Skin • Bruises • Lacerations • Burns • Bites • Obscure sites • Ears, neck, angle of jaw, scalp, frenula

17. Physical Exam • Cranial Injuries • Leading cause of abuse fatalities • Younger patients • No or nonspecific symptoms • A normal neuro exam does not exclude need for imaging

18. Physical Exam • Cranial Injuries • Subdural hematomas • Subarachnoid hematomas • Retinal hemorrhages • Skull fractures • Multiple, complex, diastatic or occipital

19. Physical Exam • Thoracoabdominal Injuries • Rib fractures • Solid organ injuries • Spleen • Liver • Pancreas • Kidney • Hollow viscus • Intestinal

20. Physical Exam • Skeletal Injuries • Fracture • Grab marks • Metaphyseal • Spiral/oblique • Signs of OI

21. Work Up • Depends on . . . . • Severity of injury • Type of injury • Age of the child • Examination findings • The more severe the injury and younger the child, the more extensive the work up • Don’t forget about siblings

25. Follow up • Primary care physician • Child protective services • Complies with plan of care • Mental health and/or counseling • Medical passports

26. Role of the Pediatrician • Accurate identification • Reporting • Anticipatory guidance • Resource for unmanageable behavior