Child Maltreatment/Abuse Wong’s Essentials pg. 401 – 404, 480 - 490. ATI Unit 3 pg. 606 - 610

1. Child Maltreatment/AbuseWong’s Essentials pg. 401 – 404, 480 - 490.ATI Unit 3 pg. 606 - 610 Dondi Kilpatrick, MSN, RN

2. Child Maltreatment Objectives • Define types of child maltreatment • Recognize S/S of child maltreatment • Describe contributors to child maltreatment • Discuss effects of child maltreatment • List cultural practices mimicking maltreatment

3. Child Maltreatment Definition: Intentional physical abuse or neglect emotional abuse or neglect or sexual abuse of children Wong’s Essentials of Pediatric Nursing 8th ed p480

4. Mental/Emotional Effects of Child Maltreatment bindler 245 • sleep disturbances • anxiety • hyperactivity conduct disorder • learning/memory problems • alcoholism • depression • drug abuse • eating disorders • post traumatic stress disorder • obesity • sexual promiscuity • suicide Videbeck 4th ed, Bindler

5. Physical Effects of Maltreatment • Fractures, bruises, lacerations, etc • Severe head trauma Bindler p 244

6. Predisposing Factors for Child Maltreatment • Exact cause unknown • 3 Contributing Factors • Child • Parent/Caregiver • Environment Wong’s Essentials of Pediatric Nursing 8th ed p 481

7. Characteristics of the child Children unintentionally contribute – THEY ARE NEVER TO BLAME • Behavior disorder • Ordinal position/position in family • Temperament • Less than 3 years old • Prematurity(NICU, have many needs) • Illegitimate, unwanted, brain damaged, hyperactive, or physically disabled child • Usually one child is the victim of abuse • Removal often places other siblings at risk Wong’s Essentials of Pediatric Nursing 8th ed p 481 - 482

8. Parental Characteristics • History of abuse /neglect themselves • Difficulty controlling aggressive behavior • Drug addiction/alcohol abuse • Social isolation/ inadequate support systems • Marital stress • Teenage mother-social network, many adjustments • Low self esteem • Inadequate knowledge of child rearing /inappropriate expectations for child’s developmental level Hockenberry p698

9. Environmental Contributors • Chronic stress • Poverty • Unemployment • Poor housing • Frequent relocation • Crowded living conditions • Re housing • Marital discord • Addition of a child • Child abuse spans all educational, social, and economic levels • Avoid Stereotyping Hockenberry p699

10. Types of Child Maltreatment • Neglect • Emotional abuse/neglect • Physical abuse • Sexual abuse

11. Neglect • Failure to provide for a child’s basic needs • Physical • Emotional • Educational • Most Common type of maltreatment ENPC 2004

12. Physical Neglect: ~Deprivation Of Necessities~ more details • Food • Clothing • Shelter • Supervision • Medical Care • Education

13. Neglect Signs and Symptoms • Unclean or inappropriate clothing • Poor personal hygiene • Failure to thrive (FTT) • Frequent injuries • Evidence of poor health care

14. Emotional Maltreatment Emotional Neglect: ~FAILURE to meet the needs of affection, attention, and emotional nurturance Emotional Abuse: ~DELIBERATE attempt to destroy or significantly impair a child’s self-esteem or competence

15. Failure to Thrive (FTT) • R/O neglect • FTT may be a result of: • Physical problems ex) HIV • Psychosocial issues • Poverty • Health beliefs • Family stress • Feeding issues http://emedicine.medscape.com/article/915575-media

16. Physical Maltreatment “DELIBERATE” infliction of physical injury

17. Injury from Abuse • Can occur from: • Punching • Beating • Shaking • Kicking • Biting • Throwing • Burning • Throwing • May result in: • Bruises • Bites • Burns • Lacerations • Pinch Marks • Swelling • Tenderness

18. Suspicious Injuries Suggestive of Abuse • Bruises • Varying stages of healing • Location • Number • Patterned bruises • Are they walking or not? Does the bruise match the child’s activity level

19. http://emedicine.medscape.com/article/915664-media

20. Suspicious Burns • Non-Accidental Patterns • Forced immersion burns • No Splash pattern Pattern from object

21. Inflicted burns may have a pattern or be circumferential

22. Suspicious Lacerations • Frenulum of upper lip • Frenulum- small fold of tissue that prevents an organ in the body from moving too far. • Ex: Forced fed = mouth injuries • Rectal area • Vaginal area

23. Suspicious Skeletal Fractures • May be single/multiple, new/old or a combination • Metaphyseal fractures • The metaphysis is the wider portion of a long bone adjacent to the epiphyseal plate. It is this part of the bone that grows during childhood • Rib, scapular, or sternal fractures • Transverse, oblique, or spiral • Bilateral or symmetrical • Greenstick is normal fx

24. Metaphyseal fracture: bucket- handle fracture http://www.medscape.com/features/slideshow/child-abuse?src=mp&spon=24&uac=135492FK

25. Rib fractures http://www.medscape.com/features/slideshow/child-abuse?src=mp&spon=24&uac=135492FK

26. Spiral fracture Child Abuse: Radiologic-Pathologic Correlation1 Gael J. Lonergan, Lt Col, USAF MC, Andrew M. Baker, MD, Mitchel K. Morey, MD and Steven C. Boos, Lt Col, USAF MC 2003

27. Anteroposterior Compression Fractures due to the squeezing pressure – NOT from CPR http://radiographics.rsnajnls.org/cgi/content/figsonly/23/4/811

28. Suspicious Abdominal Injuries • Injury inconsistent with history • Delay in seeking care • 2nd most common cause of death in child abuse

29. Suspicious Head Injuries • Head injury with bruising of upper extremities or ribs • Serious head injury with retinal hemorrhages • Shaken baby suspicion • History of injury inconsistent with injury • Skull fracture after tripping over dog • Keep in mind: does the injury match the child’s age • # 1 cause of death in child abuse

30. Shaken Impact Syndrome / Shaken Baby Syndrome • Signs/symptoms • poor feeding/eating • altered LOC • seizures • bruising of upper extremities or ribs • serious head injury with retinal hemorrhages, can become blind

31. Retinal hemorrhages http://emedicine.medscape.com/article/1176849-media

32. Common “Triggers” for Shaking • Crying • Toilet training • Feeding issues • Interrupting • What can you do to reduce abuse related to these triggers? • EDUCATE Serious Physical Abuse and SIDS Program 2005

33. Preventing Injuries Nursing Alert • Stress to parents the dangers of shaking infants • Advise against shaking as a method of burping or waking infant • Advise against tossing infant in the air • Advise against shaking infant when feeling angry or tense http://www.dontshake.org/sbs.php?topNavID=3&subNavID=24

34. Munchausen’s Syndrome By Proxy Illness that one person fabricates or induces in another to gain __ATTENTION__ from medical staff Wong’ s Essentials of Pediatric Nursing 8th ed p 481

35. Munchausen’s Syndrome by Proxy: • Caretaker may: • Present fictitious medical history • Chronically poison child • Suffocate child to cause apnea/seizure • Allege child has been sexually abused by someone else to gain recognition as child’s protector

36. Munchausen Syndrome By Proxy: Warning Signs • Unexplained, prolonged, recurrent or extremely rare illness • Discrepancies between clinical findings and history • Illness unresponsive to treatment • Signs/ symptoms only occurring in parent’s presence • Parents knowledgeable about illness, procedures, and treatments

37. Munchausen warning signs con’t • Parents very interested in interacting with health team members • Parents very attentive toward child (refuse to leave hospital) • Family members with similar symptoms Hockenberry p698

38. Munchausen by Proxy • Cause unknown • 10% of cases fatal • May lead to : • Chronic invalidism-many children may think that they have a chronic illness • Continued psychiatric trauma • REMEMBER: it’s the caretaker who has MBP not the child

39. Sexual Abuse The Use, Persuasion, Or Coercion Of Any Child To Engage In Sexually Explicit Conduct (Or Any Simulation Of Such Conduct) For Producing Any Visual Depiction Of Such Conduct, Or Rape, Molestation, Prostitution, Or Incest With Children (The Child Abuse And Prevention Act [Public Law 100-235])

40. Sexual Abuse • Typical abuser – male who victim knows • Offenders come from all levels of society • Coercion Methods: • Children are offered gifts or privileges • Adult tells child it is “O.K.” • Children enticed by adults who meet their needs for warmth and human contact • “Secret” relationship • Offender plays on child’s fears • Coercion-to force someone to do something that they do not want to do

41. Signs and Symptoms • Physical • Injury to/discharge from genitalia • Chronic dysuria “diff urinating”, enuresis “urinary incontinence”, constipation, or encopresis “involuntary bowel movement” • Sexually transmitted diseases • Difficulty walking or sitting • Pregnancy • Emotional/psychological • Sexual comments, behaviors or play • Regressive behavior i.e bed wetting • Resistance of child to remove clothes for exam

42. Health issues and/or practices mimicking maltreatment/abuse • Cultural practices • Mongolian spots- blue or purple-colored splotches on the baby's lower back and buttocks; common in darker-skinned babies. • SIDS-unexplained, sudden death of an infant up to 1 year of age. • Osteogenesis imperfecta- a genetic disorder that is also characterized by easily fractured bones “brittle bone disease” • Congenital anomalies of genitalia- an abnormality present at birth. • Diaper rash, erythema multiform- erythema multiform-red rash caused by hypersensitivity to a drug or disease or other allergen • Idiopathic thrombocytopenia purpura (ITP)- having a low platelet count (thrombocytopenia) of no known cause (idiopathic). • Leukemia- A cancer of developing blood cells in the bone marrow. • Accidental straddle injuries

43. Cultural Practices Cupping http://www.ethnomed.org/ethnomed/

44. Cultural Practices Coining http://www.ethnomed.org/ethnomed/

45. Mongolian Spots http://www.fwcc.org/mongolianspot.htm

46. Sudden Infant Death Syndrome (SIDS) • Sudden Death of an Infant < one year old • Death unexplained post autopsy, examination of the scene of death, and a review of the case Wong’s Essentials of Pediatric Nursing 8th ed p 401 National Institute Of Child Health And Human Development

47. SIDS • Etiology unknown • 3rd leading cause of death in children under 1 yr of age • Peak Age- 2-4 months of age • Occurs during sleep • Suspicion of co2 buildup • Usually peaks in the winter

48. Babies At Risk For SIDS • Maternal smoking • Poor prenatal care • Low maternal age • Prematurity or low birth weight • Intrauterine drug exposure • Multiple births-twins • Males • 2 or more SIDS victims in family • Winter months • Overheating the infant • Soft pillows, bedding in crib • Prone position for sleeping • Co-sleeping

49. Nursing Care of the Maltreated Child • Recognize • Protect-remove from situation • Treat physical injuries

50. Encourage child to verbalize feelings about incident • Refer to appropriate agencies • Prevent further abuse