Basic Child Abuse Curriculum

1. Basic Child Abuse Curriculum For Health Professionals

2. Developed by the ISPCAN Medical Curriculum Development Taskforce • Members: Dr. Steve Boos (Chair), Dr. Evelyn Eisenstein (Co-Chair), Dr. Moh Sham Kasim, Dr. Randa Youssef, Dr. Patricia Lai Sheung Ip, Dr. Tufail Muhammad, Dr. Margaret Lynch and Dr. Randall Alexander • Dr. Howard Dubowitz, Facilitator and Editor • ISPCAN Staff Support

3. Vignette 1 Infant Male: USA Economically stressed family Fussy baby Bottom bruises “Otitis media” Subdural hematoma Extensive retinal hemorrhages

4. Vignette 1 Fussy infantSource: AAP

5. Discussion What is child abuse? How common are child maltreatment, child physical abuse, abusive head trauma? Were Bobby’s injuries due to child abuse? What is Bobby’s diagnosis? Why didn’t the doctor suspect child abuse at Bobby’s two week well-baby-check?

6. What is Child Maltreatment?

7. Child Maltreatment All forms of physical &/or emotional ill treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to a child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power. (World Health Organization 1999)

8. Incidence of Child Maltreatment Rate per 1000

9. Incidence of Child Maltreatment Rate per 1000

10. Known cases are just the tip of the iceberg

11. Rates of Harsh Physical Punishment Source: WHO WorldSAFE study Runyan DK. Pediatrics. 2010;126:e701-11

12. Rates of Psychological Punishment Source: WHO WorldSAFE study

13. Abusive Head Trauma Shaking of children < 2 years Keenan: ICU admissions & deaths Theodore: parental report Keenan, et al. JAMA. 2003;290:621-6 Theodore, et al. Pediatrics. 2005;115:e331-7

14. Rates of child maltreatment are higher than what most “official” statistics suggest But is child maltreatment more common than other childhood conditions??

15. Comparison to Other Childhood Conditions * Denotes prevalence. All others are incidence rates

16. Are Bobby’s Injuries Due to Child Abuse?

17. Differential Diagnosis • #1 - Trauma • #2 - Trauma • #3 - Trauma

18. Differential Diagnosis Subdural Hemorrhage • Non-inflicted trauma • Bleeding disorder • Ruptured aneurysm • Ehlers-Danlos • Glutaric aciduria type I

19. Differential DiagnosisRetinal Hemorrhage • Normal newborn • Aneurysm • Bleeding disorder • CPR • High blood pressure • Infection • Metabolic disorder • Above rarely cause extensive hemorrhage!

20. Differential Diagnosis of Rib Fractures • Non-inflicted trauma: should be history of severe trauma (eg, MVC, direct blow) • Birth injury: history of difficult delivery • Metabolic bone disease:OI, rickets, etc. • Extreme prematurity

21. Rib Fractures • HIGH SPECIFICITY FOR ABUSE • Especially if posterior or lateral • Usually occult • Acute rib fractures often missed, esp. if anterior or lateral • Easier to see on X-ray when healing, after 1-2 wks.

22. Rib Fractures - Mechanism of Injury • Compression of the chest causes leverage of posterior ribs over spine. • Compression places tension along inner aspects of the rib head and neck regions, causing fracture. • Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO: Mosby, Inc. 1998. p116.

23. What is Bobby’s Diagnosis?

24. ABUSIVE HEAD TRAUMA IS… ANY INFLICTED INJURY TO THE HEAD OF A CHILD

25. Shaken Baby Syndrome Shaking Impact Syndrome Abusive Head Trauma Inflicted Traumatic Brain Injury iTBI

26. Definition • Abusive head trauma – any inflicted injury to the head of a child • Encompasses “shaken-baby syndrome” and “shaking-impact syndrome” • Contact and/or non-contact injury

27. Epidemiology • Occurs most commonly in infants • Shaking injury reported in children up to 5 years of age • At least 2/3 of serious head injuries in infants

28. Diagnostic Findings • Subdural hemorrhage • Retinal hemorrhage • Brain injury • Fractures – especially rib and metaphyseal

29. Potential Triggers • Crying • Toilet training • Perceived misbehavior • None

30. LESS SEVERE Lethargy Irritability Poor appetite Vomiting MORE SEVERE Seizures Unconsciousness Breathing difficulty Death Signs and Symptoms

31. Why didn’t the doctor suspect abuse at his 2 week well child visit?

32. Contributors to Child Maltreatment Society Community Family Parents Child Professionals Belsky, Psychological Bulletin. 1993;114:413

33. Child Risk Factors • Age - younger children • Gender- • - girls: higher risk for infanticide, sexual abuse, educational and nutritional neglect. • - boys: higher risk for physical abuse • Special Characteristics – twins, children with handicaps, prematurity, unwanted pregnancy

34. Parent/Caregiver Risk Factors • Young age • Single parent • Unwanted pregnancy • Poor parenting skills • Substance abuse • Physical or mental illness

35. Family Risk Factors Overcrowded living circumstances Poverty Social isolation Major stress Domestic violence

36. Community/Societal factors No/poorly enforced child protection laws Limited value of children Social acceptance of violence (family, community or society – including war) Cultural norms Social inequities - poverty

37. Professional Factors Failing to: Acknowledge that child maltreatment exists Identify and address child maltreatment Offer necessary services to children and families Help prevent maltreatment By promoting health, development and safety By addressing major risk factors

38. Discussion Why didn’t the doctor suspect child abuse when Bobby returned with symptoms? Assuming abuse, what do you think are the consequences of Bobby’s child abuse? Why do you think abuse might have happened in this family?

39. Why didn’t Bobby’s doctor suspect abuse when he returned with symptoms?

40. Teaching Points Physicians look to the history for the answer; disregarding the history is hard. Thinking of abuse is uncomfortable, particularly in families who are “nice,” sympathetic Inflicted trauma is often occult

41. Clinical Presentation Non-specific findings + Absent or misleading history _______________________ Missed diagnosis

42. Missed Diagnosis • More common in families who are: • White • Have married parents • Higher income

43. Mental retardation Severe brain damage Learning disabilities Seizures Hearing and speech impairment Visual impairment Behavioral disorders Death Outcome for Victims

44. Why do you think abuse might have happened in this family?

45. Vignette 2 Maria - teenage mother, Brazil Found unconscious, possible suicide attempt 3 month old and 4 year old children – dirty, hungry, developmental concerns Elena - 4 year old girl is masturbating frequently – physical exam is normal Maria was sexually abused as a child

46. Discussion Was Elena sexually abused? How does Elena’s physical examination influence your impression? What were the consequences of child abuse for Maria?

47. Discussion Have Elena and her brother been neglected? What is the relationship between Maria’s experiences and the neglect and sexual abuse of her children?

48. Was Elena sexually abused?

49. Child Sexual Abuse Involvement of a child in sexual activity that he/she: does not fully comprehend, is unable to give informed consent to, is not developmentally prepared, violates laws and taboos of society Children can be sexually exploited by an adult or other child who by virtue of age or development is in a position of responsibility, power or trust (From ISPCAN & WHO in, “Preventing Child Maltreatment”, 2006)

50. Child Sexual Abuse Often a ‘hidden’ assault All forms of sexual activity are included, not just intercourse and other physical types Includes child prostitution and exposure to pornography