Child Abuse

1. Child Abuse Jan Bazner-Chandler RN, MSN, CNS, CPNP

3. What is Abuse? • Abuse is mental, emotional, physical or sexual injury to a child or failure to prevent such injury to a child.

4. Four Types of Child Abuse • physical abuse • sexual abuse • emotional abuse • neglect

5. Physical Abuse • Physical abuse, which is 19% of all substantiated cases of child abuse, is the most visible form of abuse and may be defined as any act which results in a non-accidental trauma or physical injury. Inflicted physical injury most often represents unreasonable, severe corporal punishment or unjustifiable punishment.

6. Physical Indicators • unexplained bruises (in various stages of healing) • welts, human bite marks, bald spots • unexplained burns, especially cigarette burns or immersion burns • unexplained fractures, lacerations or abrasions • swollen areas • evidence of delayed or inappropriate treatment for injuries

7. Behavioral Indicators • self destructive • withdrawn and/or aggressive - behavioral extremes • arrives at school early or stays late as if afraid to be at home • chronic runaway (adolescent) • complains of soreness or moves uncomfortably • wears clothing inappropriate to weather, to cover body • bizarre explanation of injuries

8. What is neglect? • Neglect includes: • Failure to provide a child with food, clothing, shelter, medical care. • Leaving a child in a situation where the child is at risk of harm.

9. Child Neglect • Neglect is a pattern of failing to provide for a child's basic needs, to the extent that the child’s physical and/or psychological well-being are damaged or endangered. In child neglect, the parents or caregivers are simply choosing not to do their job.

10. There are three basic types of neglect. • Physical • Educational • Emotional

11. Physical • Failure to provide adequate food, clothing, or hygiene. • Reckless disregard for the child’s safety, such as inattention to hazards in the home, drunk driving with kids in the car, leaving a baby unattended. • Refusal to provide or delay in providing necessary health care for the child. • Abandoning children without providing for their care or expelling children from the home without arranging for their care.

12. Educational • Failure to enroll a child in school • Permitting or causing a child to miss too many days of school • Refusal to follow up on obtaining services for a child’s special educational needs

13. Emotional • Inadequate nurturing or affection • Exposure of the child to spousal abuse • Permitting a child to drink alcohol or use recreational drugs • Failure to intervene when the child demonstrates antisocial behavior • Refusal of or delay in providing necessary psychological care

14. Signs of Neglect • Clothes that are dirty, ill-fitting, ragged, and/or not suitable for the weather • Unwashed appearance; offensive body odor • Indicators of hunger: asking for or stealing food, going through trash for food, eating too fast or too much when food is provided for a group • Apparent lack of supervision: wandering alone, home alone, left in a car • Colds, fevers, or rashes left untreated; infected cuts; chronic tiredness • In schoolchildren, frequent absence or lateness; troublesome, disruptive behavior or its opposite, withdrawal • In babies, failure to thrive; failure to relate to other people or to surroundings

15. Sexual Abuse • Behavior involving penetration – vaginal or anal intercourse and oral sex • Fondling – Touching or kissing a child's genitals, making a child fondle an adult's genitals. • Violations of privacy – Forcing a child to undress, spying on a child in the bathroom or bedroom. • Exposing children to adult sexuality – Performing sexual acts in front of a child, exposing genitals, telling "dirty" stories, showing pornography to a child. • Exploitation – Selling a child’s services as a prostitute or a performer in pornography.

16. Signs of Sexual Abuse • Inappropriate interest in or knowledge of sexual acts • Seductive behavior • Reluctance or refusal to undress in front of others • Extra aggression or, at the other end of the spectrum, extra compliance • Fear of a particular person or family member

17. Emotional Abuse • Verbal Abuse • Withholding Affection • Extreme Punishment • Corruption

18. Verbal Abuse • Belittling or shaming the child: name-calling, making negative comparisons to others, telling the child he or she is “no good," "worthless," "a mistake." • Habitual blaming: telling the child that everything is his or her fault.

19. Withholding Affection • Ignoring or disregarding the child • Lack of affection and warmth: Failure to hug, praise, express love for the child

20. Extreme Punishment • These are actions that are meant to isolate and terrorize a child, such as tying the child to a fixture or piece of furniture or locking a child in a closet or dark room.

21. Corruption • This involves causing a child to witness or participate in inappropriate behavior, such as criminal activities, drug or alcohol abuse, or acts of violence.

22. Causes of Child Abuse • Stress, including the stress of caring for children, or the stress of caring for a child with a disability, special needs, or difficult behaviors • Lack of nurturing qualities necessary for child care • Immaturity: a disproportionate number of parents who abuse their children are teenagers • Difficulty controlling anger • Personal history of being abused • Isolationfrom the family or community • Physical or mental health problems, such as depression and anxiety • Alcohol or drug abuse • Personal problems such as marital conflict, unemployment, or financial difficulties.

23. Reporting Child Abuse • California • Website: • http://www.dss.cahwnet.gov/cdssweb/PG20.htm

24. BRN – Registered Nurse • Under California law each person licensed by the Board of Registered Nursing is a “Mandated Reporter” for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Section 11166 and will comply with those provisions.

25. Physical Abuse

26. Soft Tissue Injuries • Bruises on face, lips, mouth, torso, back, buttocks, thighs • Especially in various stages of healing • Degree of bruising is greater than expected for the activity level of the child.

27. Bruises

28. Abnormal Bruising Patterns

29. Abdominal Trauma

30. Massive Bruising

31. Broken Teeth

32. Mouth Trauma

33. Scald Burns

34. Eye Trauma

35. Retinal Hemorrhage

36. Retinal Hemorrhage • A four-month-old Caucasian male who presented to the ER with a history of respiratory problems. Physical examination revealed multiple bruises, bilateral and frontal subdural hematomas by CT, and diffuse retinal hemorrhages and retinal folds on ophthalmic exam. Subsequently, the dad was charged with abuse. One month later after a prolonged stay in ICU he developed a seizure disorder and severe developmental delay. His retinal hemorrhages have not yet completely resolved.

37. Case Study #1 • 2 month old baby girl brought into the local ER with scalp swelling. • History: infant rolled off a sofa onto a carpeted floor.

38. Skull x-ray – multiple “egg shell” fractures

39. Case Study #2 7-month old baby is brought to the ER by mother, who came home from work and found him seizing.

40. CT scan of skull

41. CT Findings • Darker grey area in the right cerebrum indicates edema. • Subdural hematoma – blood collection between the two cerebral hemispheres. • Conclusion: Shaking is the typical cause of inter-hemispheric subdural hematomas.

42. Case #3 • 1-year-old brought in by ambulance comatose.

43. CT of Brain

44. CT Findings • Diffuse cerebral edema indicative of severe anoxic brain injury with resultant swelling. Small area of bleeding notes. • Conclusion: Child was violently shaken, causing severe brain injury as evidenced by diffuse cerebral edema.

45. Case Study #3 • 4 month old with cough, chest x-ray request for “rule out pneumonia”.

46. Chest X-ray

47. Chest X-ray Findings • Posterior rib fracture of the 7th rib. This fracture is less than 14 days old as there is no visible callus. Rib fracture is unrelated to child’s presenting complaint. • Conclusion: Rib fractures a common injuries in the young (less than 2 years). Typically, is part of violent shaking. Child is held very tightly around the chest and squeezed while shaking.

48. Case Study #4 • 3 ½ year old presents with 4 day history of persistent vomiting after eating and abdominal pain.

49. Upper GI Series

50. Upper GI Findings • Duodenal hematoma (blood collection) in the wall of the bowel. • Conclusion: This injury is almost always caused by direct trauma (assault, bicycle handlebar injury). Common injury in abuse and is typically seen in older children who are punched or kicked in the abdomen.