RECOGNIZING CHILD ABUSE: WHEN THE HISTORY DOESN’T FIT!

1. RECOGNIZING CHILD ABUSE: WHEN THE HISTORY DOESN’T FIT! Sharon W. Cooper, MD, FAAP Developmental & Forensic Pediatrics, PA University of North Carolina Chapel Hill School of Medicine USA

2. CHILD MALTREATMENT PREVENTION • The morbidity of the 21st century is resting upon educational, behavioral, and maltreatment problems for children • As informed consumers, it is important to recognize when the history doesn’t fit

3. THE GROWING DIAGNOSIS • Neglect: chaotic v global • Physical abuse: nonaccidental trauma, battered child syndrome, inflicted injuries • Emotional abuse: VICTORI • Verbally assaulting • Ignoring • Corrupting • Terrorizing • Over pressuring • Rejecting • Isolating

4. THE GROWING DIAGNOSIS • Sexual Abuse –from voyeurism to assault, sadistic abuse and bestiality • Pediatric condition falsification – broader parameters than MSBP • Child Sexual Exploitation

5. THE GROWING DIAGNOSES & THE CONCEPT OF CO-MORBIDITY

6. CHILD ABUSE AND EMOTIONAL ABUSE • Most forms of child physical abuse have an emotional impact (fractures, burns, beatings) • Child sexual abuse has psychological impact in>85% of chronic cases (abuse lasting more than 6 months) • Neglect often has psychodevelopmental impact which often has emotional components • Exposure to violence has clear cause and effect factors

7. CARE PROVIDER FACTORS • Intimate partner violence • Substance abuse • Poverty and lack of education in child rearing • Intergenerational factors associated with child maltreatment (sexual abuse) • Criminality • Mental health concerns

8. PARENTAL MISCONCEPTIONS • Unrealistic Expectations • Lack of empathy • Vested belief in the value of punishment • Need for power and control • Parent child role reversal • BAVOLEK, 1992

9. NEGLECT • The absence of critical organizing experiences at key times during development. • Global neglect exists when a history of relative sensory deprivation in more than one domain is obtained (e.g. minimal exposure to language, touch, and social interactions). • Chaotic neglect is present when there is physical, emotional, social or cognitive neglect.

10. LINDA THE ROOTS OF VIOLENCE

11. Global Neglect • 1833 Kasper Hauser was abandoned near 2 years of age, and lived until he was 17-years-old in a dungeon, experiencing relatively complete sensory, emotional and cognitive neglect. • His emotional, behavioral and cognitive functioning was, as one would expect, very primitive and delayed.

12. Clear and Convincing Evidence • At autopsy, Hauser’s brain had a very small cortex, with few and non-distinct cortical gyri consistent with cortical atrophy. • Cortical atrophy has been reported in children as recently as 1997, following severe total global neglect during childhood.

13. The Girl in the Closet (2001) • In Dallas, a mother was sentenced to life after her 8-year-old daughter was found having been confined to a closet from 3 years of age. • When discovered, the child was near death, weighed 25 pounds, and demonstrated severe global developmental delay. Her brain MRI revealed cortical atrophy. • She had been noted to be normal by foster parents before being given to her biological mother shortly after 2-years of age.

14. Chaotic Neglect • This form of neglect is far more common than global neglect. • It is present when there is consistent physical, emotional, social and cognitive neglect. • Children’s experiences are chaotic, inconsistent and episodic. • Mild sensory deprivation is much less clinically significant than sensory chaos.

15. THE UNQUESTIONABLE ROLE OF ADDICTION

16. ADDICT • Any individual who has a psychological and physical dependency on a chemical agent, which is usually illegal or illicit • Stereotype is an impoverished, minority, unemployed adult male or female who has chosen to become addicted to drugs and who could “stop at any time”

17. THE COMPULSION TO USE DRUGS TAKES OVER A LIFE • Addiction often involves not only compulsive drug taking • Also a wide range of dysfunctional behaviors • Addiction also can place people at increased risk for a wide variety of other illnesses

18. THERAPY • Behavioral therapy • Medications • The combination

19. SUBSTANCE ABUSE & NEGLECT • Pregnancy and substance abuse (10-24%) • Increased obstetrical problems • Risk for HIV • Alcohol and teratogenesis • Cocaine and IUGR

20. SUBSTANCE ABUSE AND NEGLECT CASE STUDY NEGLECT & CHILD FATALITY

21. CHILD FACTORS • Premature delivery and medical fragility • Special needs • Behavioral problems • Inability to measure up to parent’s desires (gender, IQ, etc.) • Nonbiological relationship (foster care, adopted, etc.)

22. ENVIRONMENTAL FACTORS • Poverty (sexual exploitation) • Religious communities (cults, sexual abuse) • Cultural traditions (foreign national children)

23. FACTS V MYTHS IN CHILD MALTREATMENT • Abuse is more common in out of home care providers • The most common perpetrator of physical abuse is a father • Non-offending parental attitude is an important factor in assuring child safety

24. FACTS V MYTHS IN CHILD MALTREATMENT • Disabled children are safe from abuse or neglect • The most common cause of death in infants and toddlers is motor vehicle accidents • The most common reporters of abuse are pediatricians

25. FACTS V MYTHS IN CHILD MALTREATMENT • Biological family members are the most common cause of abusive deaths • The most common type of child maltreatment is neglect • Rib fractures in infants are often secondary to birth trauma

26. FACTS V MYTHS IN CHILD MALTREATMENT • When considering adolescent sexual abuse, consensual sex with an adult is a factor which could lead to court dismissal • Divorce and custody are common situations for false allegations of child sexual abuse

27. FACTS V MYTHS IN CHILD MALTREATMENT • Sexual abuse of males is very rare • Sexual abuse of females has + physical findings in 20% of cases • Toddlers cannot recall abuse

28. Rhesus Monkey Model • From a genomic perspective, this animal and humans are 90% identical. • Used for a multitude of human “alternative” studies to include in vitro fertilization, Parkinson’s disease, ageing, aggression, and parent child psychological dynamics, to name only a few.

29. Neurodevelopmental Trauma • “I’m at my spot, looking out the window, and I feel her there, standing behind me, all in her monster face and stuff, just waiting for me to turn around so she can practice putting on her human face. That’s how monsters play. But I don’t fall for that ‘cause I know she’s not nice.” (Antwone Fisher, Finding Fish, 2001- memory at 4 years of age)

30. MEMORIES AND TRAUMA • “Down to the basement we go, where she ties us to a big pole that stands from the floor to ceiling – a stanchion, they call it, because it holds the house up. She ties us to it back-to-back with rope and leaves us here in the dark. After a few minutes, Dwight whispers, “Don’t be scared.” I say nothing, ‘cause I am scared. There’s monsters and bad things happen down here. Dwight and I know we’ll be in more trouble if she hears us talking, so we sit there quiet, except for our short, frightened heartbeats and the sounds of unseen creatures in the dark.”(Antwone Fisher, Finding Fish, 2001 – 7 year old memory)

31. DISABILITIES • 21.3/1000 children without disabilities are maltreated annually • 35.5/1000 children with disabilities suffer the same fate • Highest risk disabilities are serious emotional disturbance, learning disabilities, and impaired speech and language

32. DISABILITIES • Omaha study looked at all children in schools as well as the birth-3 population receiving early intervention services • 9% prevalence of maltreatment in the nondisabled child • 31% prevalence of maltreatment in the disabled child

33. “I ONLY SHOOK HIM ONCE” LIKE THIS!

34. IF THE SHOE DOESN’T FIT….. MOTOR SKILLS AND CHILD ABUSE

35. THE MEDICAL HISTORY IN ABUSE • Inconsistent history renditions • Inconsistent mechanisms of injury • Inconsistent caregiver behavior

36. INCONSISTENT HISTORY • Changes in minor details from the 911 call, to the paramedic history and possibly the emergency room providers • Note that non-offending caregivers may give a very detailed history, but were never present and were not eye witnesses • Carefully scan the record and talk to other responders re: history

37. INCONSISTENT MECHANISM OF INJURY • Offenders often offer implausible explanations for the cause of the injury (e.g. 24” fall leading to a toddler’s death) • Inaccurate sequence of events (e.g. she collapsed and was unresponsive and I shook her to revive her) • Implication of siblings as the perpetrator of the injuries

38. INCONSISTENT CAREGIVER BEHAVIOR • Inconsistent behavior with a severe accident • Same “start” injuries from an accident v abuse have much different outcomes (e.g. abusive head or abdominal injuries have far more morbidity and mortality) • Failure to seek medical care in a timely fashion is the rule more so than the exception • The non-offending parent is often allowed to “discover” the injured or deceased child

39. You’re hurting me too! “IF I WAS A KID…..”

40. CHILD SEXUAL ABUSE Where Are We Today?

41. Neurobiology of Trauma • Trauma research reveals that abuse of children early in life may have a significant impact upon the neuroarchitecture of the brain • Sexual abuse in very young children may have long term effects, primarily associated with posttraumatic stress symptoms

42. THE BASICS • The medical evaluation is often based upon the age of the victim • Children who are preverbal (<30 months) will have less interview time, more observational time, and the need for an excellent supportive historian • Infants and toddlers will require physical findings typically to move a case forward

43. SEXUALIZED BEHAVIORS • In very young children, the association of sexualized behaviors is more likely to be noted with: • Length of time in daycare • Family violence • Stressful life circumstances • Family nudity habits, co-sleeping, co-bathing and pornography exposure (Friedrich et al 1998)

44. PRESCHOOL AGED CHILDREN • This group requires the most developmental understanding and care in the interviewing process • The suggestibility concerns are typically one on one points, not a lengthy dialogue of what may have happened in a suggested circumstance • Behaviors are a critical part of this evaluation

45. ELEMENTARY AGED CHILDREN • Sometimes these kids are the masqueraders; If very resilient they may show few symptoms • More often however, they are traumatized victims with predictable symptomology • Abuse, when chronic, may not be deemed “abnormal” to the child until they are older • Physical findings are present in <20%

46. ELEMENTARY AGED CHILDREN • May recant due to family pressures • The nature of the recantation is important • “I wish I never told and I won’t talk anymore about this” is not the same as “I lied and it never happened”. • Really require support and counseling especially if removal from the home is one of the outcomes

47. Robert and the Staircase “Just being complete” or Which came first, the chicken of the egg?

48. Behavioral Problems • Maternal stress and nonsupport of the child victim has a higher association with child behavioral problems in CSA (Everson, Hunter, Runyan,Edelsohn & Coulter, 1989) • Adolescents SA victims are more likely to run away from home, use drugs, and become bulimic (Hibbard et al, 1990) • Adolescent mothers with a history of SA are more likely to abuse their children or have them removed by CPS (Boyer & Fine, 1991)

49. A Need to Know • At times, a professional may be called upon to provide a victim impact statement at sentencing • Being able to place a given case in one’s years of experience, assists a judge or jury on the severity of the long term expression of the child’s dysfunction

50. Facts • In a prospective, longitudinal, general population study, it was found that CSA was associated with posttraumatic stress and depression. (Boney-McCoy & Finkelhor, 1996) • Impact of CSA affects children both in the short term (Kendall-Tackett, Williams, & Finkelhor, 1993) as well as later in terms of adult functioning (Fergusson, Horwood, & Lynskey 1996)