Child Abuse: Recognition and Reporting

1. Child Abuse: Recognition and Reporting Ryan Brown, M.D., FAAP Clinical Associate Professor University of Oklahoma College of Medicine Department of Pediatrics Section on Pediatric Emergency Medicine

2. 40th Annual OAPA Fall CME Conference Ryan Brown, MD, FAAP I have no financial relationships to disclose Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding financial relationships with commercial interests within the last 12 months.

3. Learning Objectives Upon completion of this presentation, participants should be able to improve competence, performance and patient outcomes by being able to: 1. Understand the epidemiology of abuse 2. Recognize appropriate findings of abuse. 3. Report appropriate findings of abuse.

4. Child Abuse and Neglect DEFINITION • Child maltreatment - abusive actions, or acts of commission…lack of action, or acts of omission, that result in morbidity or death. • Physical abuse • Sexual abuse • Emotional/Psychological abuse • Failure to thrive • Neglect • Prenatal maternal drug and alcohol abuse • Medical Child Abuse (Munchausen syndrome by proxy • Child Maltreatment 2010 US Department of Health and Human Services

5. NCANDS 2011 Common Types of Maltreatment

6. NCANDS 2011 Victims by Age, 2011

7. NCANDS 2011 Victims by Perpetrator Relationship, 2011

8. NCANDS 2010 Child Fatalities by Age, 2010

9. NCANDS 2010 Child Fatalities By Perpetrator Relationship, 2010 Child Maltreatment 2010 US Department of Health and Human Services

10. NCANDS 2011 Perpetrators by Age, 2011

11. NCANDS 2010 Deaths • 1,560 children died from abuse and neglect • 2.07 deaths/100,00 children

14. NCANDS 2010 Who Reported?

15. Child Maltreatment Epidemiology 67 % of abuse involved the mother Males are most common perpetrators of sexual abuse 10-40% of abusive parents were abused as a child Parents who abuse children have been reported from most ethnic, geographic, religious, educational, occupational, and socioeconomic groups Presence of Intimate Partner Violence increases chance that children are abused

16. It’s “All in the Family” • Compared to children living with married, biological parents, those whose single parent had a live-in partner had more than 8 times the rate of maltreatment overall, over 10 times the rate of abuse, and more than 6 times the rate of neglect. NCANDS 2010

17. Characteristics • One study found that children living in households with unrelated adults were approximately 50 times more likely to die of inflicted injuries than were children residing with 2 biological parents. Schnitzer PG, Ewigman BG. Child deaths resulting from inflicted injuries: household risk factors and perpetrator characteristics. Pediatrics. 2005;116(5).

18. Red Flags for Abuse • No explanation or vague explanation for a significant injury • An important detail of the explanation changes dramatically • An explanation that is inconsistent with the pattern, age, or severity of the injury or injuries • An explanation that is inconsistent with the child’s physical and/or developmental capabilities • Different witnesses provide markedly different explanations for the injury or injuries Evaluation of Suspected Child Physical Abuse, Committee on Child Abuse and Neglect, PEDIATRICSVolume 119, Number 6, June 2007

19. History Red Flags • Delay in seeking medical care • Unexplained apnea in children > 1 years old • Repeated drug or toxin exposure • Serious noncompliance with medical care • Cold injury • Injury resulting from discipline of a child • Bilateral, symmetric injuries

20. Physical Abuse

21. Epidemiology • Approximately 10% in injuries seen in ER are abuse • 15% of kids with burns are abused • 50% of kids with fractures under age 1 year are abused

22. Bruising Bruises Common childhood injuries Most common manifestations of physical abuse Pathophysiology of bruising T I M I N G

23. bruising

24. Bruising Pattern Injuries • Hand • Inflexible objects • Short linear bruises • Impact in one place and does not follow the curvature • May lead to larger ecchymoses that have no pattern

26. Bruising Pattern Injuries • Flexible objects • Bruising pattern follows the curvature of the extremity

28. Bruising Pinna Bruising Easy access to child’s head Rarely result of accidental injury

30. Bruising Can Bruises be Dated? • BariciakPediatrics 2003 • 50 children presented to ED with accidental bruising • Emergency physicians estimated age • Accuracy of estimation within 24 hours was 47.6% • Poor interobserver reliability

31. Bruising Can Bruises be Dated? • MunangJ ClinForensMed 2002 • 44 children identified in ED setting with bruising • 3 described same bruises in vivo and later by photograph • Only 31% of descriptions completely agreed with the later description of the photograph of the same bruise

32. Bruising Can Bruises be Dated? • Stephenson Arch Dis Child 1996 • 23 children evaluation with bruising • Blinded observer estimated age of injury as • Fresh (<48 hours) • Intermediate (48 hours – 7 days) • Old (>7 days) • Accuracy of estimation was 54.5%

33. Bruising Conditions Mistaken for Physical Abuse • Wardinsky 1995 • 7% initially diagnosed as child abuse but found to have other conditions • Wheeler 1988 • 3% found to have conditions mistaken for abuse

34. Bruising Differential Diagnosis Mongolian spots Phytodermatitis Erythema multiforme ITP Other coagulation disorders Ehlers-Danlos Syndrome Ink, dyes, paint, tatoos

35. Fractures Highly Specific NAT Classic metaphyseal lesions Rib fractures, particularly postero-medial Scapular, spinous process, and sternal

37. Fractures Moderately Specific NAT Multiple fractures, particularly bilateral Fractures of different ages Vertebral body compression fractures Digital fractures Complex skull fractures, bilateral, diastatic

38. Fractures Common, but Non-Specific Simple linear parietal skull fracture Torus fracture distal Toddler’s fracture (spiral hairline fracture distal tibial) Bending fracture of femur

39. Fractures Any fracture may be accidental. Spiral fractures may be accidental or inflicted. Toddler’s fracture presents with limp or swelling (NOT NAT). Supracondylar fractures and torus fractures may be unobserved (NOT NAT)

40. Fractures Healing of Fractures (not very exact)

41. When Multiple Fractures Occur Complete skeletal survey (if less than 2 yo) Eye exam CT or MRI CBC, CMP Serum 25-hydroxy-vitamin D if rickets is suspected

42. When Multiple Fractures Occur cont • Serum copper if radiographs support fracture • Liver functions, amylase, and lipase • UA • Bone densitometry • No age-related standards

43. Sexual Abuse

44. Sexual abuse • 1 in 4 females • 1 in 10 males • The majority of the time it is someone that is known to the victim • In Oklahoma, the age of consent is 16 • Age of consent is 18 if one of the participants is a teacher or a school employee

45. Examples of Sexual Behaviors in Children (ages 2-6 years old) Clinical Report : The Evaluation of Sexual Behaviors in Children, Nancy D. Kellogg and Committee on Child Abuse and Neglect, Pediatrics2009;124;992-998

46. Sexual Abuse General Discussion Exam – simple in prepubertal child Exam – takes less than 5 minutes Exam rarely confirms sexual abuse “Redness” down there is NOT a sign of sexual abuse Vaginal discharge is ALMOST NEVER a sign of sexual abuse Diaper rash is NOT a sign of sexual abuse

47. DEFINITION OF CHILD SEXUAL ABUSE (CSA) • Child sexual abuse involves a spectrum of activities ranging from non-contact to full sexual intercourse. • In Oklahoma, the age of consent is 16. • The age of consent is 18 if educational personnel is involved.

48. DEFINITION OF CSA CONTINUED • This spectrum of activities includes: • Exhibitionism (exposing children to adult sexual activity or pornography) • Use of the child for pornography or prostitution • Fondling of genitals, rectal area, or breasts directly or through clothing • Oral/genital contact • Attempted Intercourse - Intercourse

49. DEFINITION OF RAPE (ADULT SEXUAL ASSAULT) • Adult sexual assault includes any sexual act performed by one adult on another adult against that person’s will or without that person’s consent. • Can be drug induced • When is no NO?

50. DEFINITION OF RAPE CONTINUED • Frequent aspects of rape include anger, violence, sadism, power, control, intimidation and fear. • The sexual act is the weapon used to assault the victim. • In the majority of rape exams done, there are physical findings or evidence of trauma.