Child Abuse: A Problem in Our Community?!

1. Child Abuse:A Problem in Our Community?! Lisa Piercey, MD Jackson Clinic Pediatrics Medical Director, Madison County CAC

2. Child Maltreatment • Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm • National Clearinghouse on Child Abuse and Neglect

3. History of Child Maltreatment • 1865 – Society to Prevent Cruelty to Animals • 1874 – Society to Prevent Cruelty to Children • 1930’s – Social Security Act, gov’t recognized interest in protecting children from abuse • 1962 – C. Henry Kempe, Battered Child Syndrome • 1967 – All 50 states passed mandated reporting laws • 1970’s – Reporting laws expanded to sexual abuse • 1980’s – Increase in child abuse prosecutions • 1985 – NDAA created National Center for Prosecution of Child Abuse • Late 1980’s to present – Child Advocacy Centers

4. A History of Denial:Gonorrhea in Childhood • Childhood sexual abuse was recognized but considered “rare” in the late 1800’s and most of the 1900’s • Surveys of MD’s in the 1920-1930’s reported that only 4-7% of children with GC were felt to have been victims of sexual assault • Per the AAP and CDC, detection of gonorrhea in childhood is “diagnostic” of sexual abuse (can’t be transmitted any other way)

5. A History of Denial:Gonorrhea in Childhood • “An overwhelming proportion of the cases of vulvovaginitis in young girls is gonorrheal and innocent in origin…” Findley (1908) • “Even girls from middle class families are infected…therefore there must be an innocent source…” Huffman (1981) • Fomite (object) transmission was considered the overwhelming reason for such infections • Toilet seats, bedsheets, etc.

6. “Fomite transmission” • Toilet seat design evolved from “innocent spread” of GC • Split front required in public restrooms to prevent spread of infection. • Height of toilet itself was dictated to prevent children from “sliding” across infected secretions.

7. Child Maltreatment: Public Health Threat

8. Child Maltreatment is a Public Health Problem • An estimated 1.5 million children experience non-fatal child maltreatment each year in the U.S. • Different types of child maltreatment • ALL are under-reported!

9. Child Abuse Fatalities • Over 1,400 child fatalities from child abuse and neglect in 2002 • Estimated 50-60% of deaths resulting from child abuse and neglect are not recorded • Vast majority of victims are ≤ 3 years old

10. Local Child Abuse Statistics:Tennessee • Every day, more than 100 children are reported as abused or neglected. • Over 37,000 CPS reports/year • Increase of 6.9% in last 5 years • 8,500 cases of indicated (founded) abuse • 18 child abuse fatalities in 2002

11. Adverse Childhood Experiences • Impact of cumulative exposure to child abuse and family dysfunction (ACE’s) on future outcomes • ACE • Physical abuse • Sexual abuse • Verbal/emotional abuse • Household substance abuse • Mental illness in household • Incarcerated household member • Parental separation or divorce

12. Adverse Childhood Experiences • Children exposed to 4 or more forms of ACE’s were 4 to 12 times more likely to experience alcoholism, drug abuse, depression, and suicide attempts. • There was a dose-response relationship between exposure to child maltreatment and the presence of adult diseases, including heart disease, cancer, COPD, skeletal fractures, and liver disease.

18. Child Sexual Abuse QUIZ

19. True or False • Girls can be born without a hymen. • Vigorous sporting activities (bicycling, horseback riding, gymnastics) can injure the hymen. • A newborn baby girl with vaginal bleeding is usually not suspicious for sexual abuse. • Masturbation is normal beginning in late infancy and does not signal sexual abuse.

20. True or False • A large vaginal opening indicates sexual penetration. • Anal penetration by an adult penis often leaves scars or laxity of the anus. • Sexual intercourse always tears the hymen.

21. Why it’s “normal to be normal”! • Only 3-5% of all children evaluated for alleged sexual abuse had ABNORMAL exams • Berenson (2000), Heger (2002) • Only 6% of PREGNANT adolescents had definite exam findings of penetration!! • Kellogg (1998)

22. Why it’s “normal to be normal”! • Many children do not disclose a history of sexual abuse until months or years later, allowing time for acute injuries to heal. • Most types of child sexual abuse do not involve a great amount of physical force by the perpetrator, therefore not severely damaging the anogenital tissues. • Genital and anal tissues of children can heal completely with little to no sign of previous trauma.

23. Why it’s “normal to be normal”! • Picking a child’s nose • Finger is bigger than nostril opening • Hurts for a minute • Rarely gets scratched, bleeds, or bruises

24. The Bottom Line:“IT IS NORMAL TO BE NORMAL!” • A child’s credible history of sexual abuse should not be discounted because the child has a normal genital examination. • The diagnosis of child sexual abuse is rarely made on the basis of the physical examination findings alone.

25. Suspicious Findings for Child Maltreatment

26. Guiding Principles • Children should be SEEN and HEARD and BELIEVED! • If you do not ASK, you will never KNOW! • The problem does not cease to exist because we choose to ignore it. • We cannot STOP child abuse if we run away from reality. • “Unto the Third Generation”, Victor Vieth

27. Do you suspect abuse? • Suspicious perpetrator • Can have risk factors • Low SES, drug abuse, unemployment, mental illness, poor coping skills, lack of social support • Presence of domestic violence • History of abuse as a child • May look completely “normal” • Reverse discrimination

28. Pick the Perp

29. Different faces of child abuse Exploitation of a minor Prostitution of a child Sexual battery of a child Child pornography Sodomy of a child Aggravated rape of a child

30. You CAN’T TELL by LOOKING!

31. Red Flags of Child Abuse • Disclosure • Most common manifestation of sexual abuse is a positive history • Injury inconsistent with history or developmental stage of child • Fall from sofa causing multiple fractures • Pattern burn with splash history • Bruises in nonambulatory infant • Accusing sibling as perpetrator of major trauma

32. Delay in seeking treatment History of lack of supervision Injuries with different ages/stages of healing Multiple or changing stories Recurrent injuries Lack of routine well child care/immunizations Sexually transmitted infection, especially outside newborn period Prior DCS reports Drug exposure Sexually acting out More Red Flags

33. Case presentations

34. Case # 1 • 18 mo boy brought to ED with nosebleed, facial bruising, and extensive bruising over back • Mom reports baby “fell off couch onto coffee table” • Skeletal survey, consult Child Protection Team

35. Case # 1 • While in xray, labs come back: • Anemia, extremely low platelet level • Diagnosis: • ITP (Idiopathic Thrombocytopenic Purpura)

36. Case # 2 • You are babysitting your neighbor’s newly adopted child so the parents can “get a break”. • While changing the child into her pajamas, you notice. . .

37. Case # 2

38. Case # 2 • Child was just adopted from China; orphanage reported child having cold symptoms one week prior to adoption • Diagnosis: • Coining (cao gio) • Hot oil rubbed with coin or spoon to open “wind” channel

39. Case # 3 • 2 yo boy transferred for work-up of suspected non-accidental trauma • Mother’s boyfriend picked up child at daycare yesterday and then kept child overnight while mom worked a double shift. • Mom gives no history of trauma but states that the child “gets on my boyfriend’s nerves”

40. Case # 3 • Admit to hospital for protection • Labs from outlying hospital: • Slightly anemic, but all other labs normal • All xrays normal • Head CT reported as normal • Physical exam otherwise normal

41. Case # 3 • Discharged home next day to foster parents • Has increased bruising and eye bulging/swelling during next 1-2 weeks in foster care • Diagnosis: • Neuroblastoma

42. Case # 4 • 3 mo baby noticed by family member to be “black and blue all over” • Mom has 3 other kids and says, “One of her older sisters must have done it. . .”

43. Case # 4

44. Mimics of Child Maltreatment • Accidental injuries • History is important • Weird things DO happen! • Congenital findings • Birthmarks (Mongolian spots) • Injuries during delivery/birth • Metabolic/genetic disorders • “Brittle bone disease”

45. Mimics of Child Maltreatment • Cultural practices • Coining, cupping; caida de mollera • Medical conditions • Drug rashes, bleeding disorders, tumors • Common genital abnormalities

46. What do I do if I suspect child abuse or neglect?

47. Tennessee Law • Now, EVERY PERSON in Tennessee is a “mandated reporter” • Cannot report to supervisor, social worker, etc. • Misdemeanor charge, with fines up to $2500 • Reporters who "act in good faith" are immune from any civil or criminal liability.

48. Steps to Take • Report to Department of Children’s Services (Central Intake) • Phone (877) 237-0004 • Admit to hospital if immediate protection of child required • Consult social worker/Child Protection Team • Take care of medical issues or refer • CPT, CAC, Emergency Department/SANE

49. What happens next?? • Central Intake assigns DCS investigator • Is child in immediate danger? • Interviews, home visit • Disposition • Home, foster care, etc. • Forensic interview and/or medical exam at Child Advocacy Center • Involvement of law enforcement • Services for child and family • Counseling, education/prevention • Exchange Club Carl Perkins Center for Prevention of Child Abuse

50. Local Child Abuse Resources