3What is Abuse?Abuse is mental, emotional, physical or sexual injury to a child or failure to prevent such injury to a child.
4Four Types of Child Abuse physical abusesexual abuseemotional abuseneglect
5Physical AbusePhysical abuse, which is 19% of all substantiated cases of child abuse, is the most visible form of abuse and may be defined as any act which results in a non-accidental trauma or physical injury. Inflicted physical injury most often represents unreasonable, severe corporal punishment or unjustifiable punishment.
6Physical Indicators unexplained bruises (in various stages of healing) welts, human bite marks, bald spotsunexplained burns, especially cigarette burns or immersion burnsunexplained fractures, lacerations or abrasionsswollen areasevidence of delayed or inappropriate treatment for injuries
7Behavioral Indicators self destructivewithdrawn and/or aggressive - behavioral extremesarrives at school early or stays late as if afraid to be at homechronic runaway (adolescent)complains of soreness or moves uncomfortablywears clothing inappropriate to weather, to cover bodybizarre explanation of injuries
8What is neglect? Neglect includes: Failure to provide a child with food, clothing, shelter, medical care.Leaving a child in a situation where the child is at risk of harm.
9Child NeglectNeglect is a pattern of failing to provide for a child's basic needs, to the extent that the child’s physical and/or psychological well-being are damaged or endangered. In child neglect, the parents or caregivers are simply choosing not to do their job.
10There are three basic types of neglect. PhysicalEducationalEmotional
11Physical Failure to provide adequate food, clothing, or hygiene. Reckless disregard for the child’s safety, such as inattention to hazards in the home, drunk driving with kids in the car, leaving a baby unattended.Refusal to provide or delay in providing necessary health care for the child.Abandoning children without providing for their care or expelling children from the home without arranging for their care.
12Educational Failure to enroll a child in school Permitting or causing a child to miss too many days of schoolRefusal to follow up on obtaining services for a child’s special educational needs
13Emotional Inadequate nurturing or affection Exposure of the child to spousal abusePermitting a child to drink alcohol or use recreational drugsFailure to intervene when the child demonstrates antisocial behaviorRefusal of or delay in providing necessary psychological care
14Signs of NeglectClothes that are dirty, ill-fitting, ragged, and/or not suitable for the weatherUnwashed appearance; offensive body odorIndicators of hunger: asking for or stealing food, going through trash for food, eating too fast or too much when food is provided for a groupApparent lack of supervision: wandering alone, home alone, left in a carColds, fevers, or rashes left untreated; infected cuts; chronic tirednessIn schoolchildren, frequent absence or lateness; troublesome, disruptive behavior or its opposite, withdrawalIn babies, failure to thrive; failure to relate to other people or to surroundings
15Sexual AbuseBehavior involving penetration – vaginal or anal intercourse and oral sexFondling – Touching or kissing a child's genitals, making a child fondle an adult's genitals.Violations of privacy – Forcing a child to undress, spying on a child in the bathroom or bedroom.Exposing children to adult sexuality – Performing sexual acts in front of a child, exposing genitals, telling "dirty" stories, showing pornography to a child.Exploitation – Selling a child’s services as a prostitute or a performer in pornography.
16Signs of Sexual AbuseInappropriate interest in or knowledge of sexual actsSeductive behaviorReluctance or refusal to undress in front of othersExtra aggression or, at the other end of the spectrum, extra complianceFear of a particular person or family member
18Verbal AbuseBelittling or shaming the child: name-calling, making negative comparisons to others, telling the child he or she is “no good," "worthless," "a mistake."Habitual blaming: telling the child that everything is his or her fault.
19Withholding Affection Ignoring or disregarding the childLack of affection and warmth: Failure to hug, praise, express love for the child
20Extreme PunishmentThese are actions that are meant to isolate and terrorize a child, such as tying the child to a fixture or piece of furniture or locking a child in a closet or dark room.
21CorruptionThis involves causing a child to witness or participate in inappropriate behavior, such as criminal activities, drug or alcohol abuse, or acts of violence.
22Causes of Child AbuseStress, including the stress of caring for children, or the stress of caring for a child with a disability, special needs, or difficult behaviorsLack of nurturing qualities necessary for child careImmaturity: a disproportionate number of parents who abuse their children are teenagersDifficulty controlling angerPersonal history of being abusedIsolation from the family or communityPhysical or mental health problems, such as depression and anxietyAlcohol or drug abusePersonal problems such as marital conflict, unemployment, or financial difficulties.
24BRN – Registered NurseUnder California law each person licensed by the Board of Registered Nursing is a “Mandated Reporter” for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Section and will comply with those provisions.
36Retinal HemorrhageA four-month-old Caucasian male who presented to the ER with a history of respiratory problems. Physical examination revealed multiple bruises, bilateral and frontal subdural hematomas by CT, and diffuse retinal hemorrhages and retinal folds on ophthalmic exam. Subsequently, the dad was charged with abuse. One month later after a prolonged stay in ICU he developed a seizure disorder and severe developmental delay. His retinal hemorrhages have not yet completely resolved.
37Case Study #12 month old baby girl brought into the local ER with scalp swelling.History: infant rolled off a sofa onto a carpeted floor.
41CT Findings Darker grey area in the right cerebrum indicates edema. Subdural hematoma – blood collection between the two cerebral hemispheres.Conclusion: Shaking is the typical cause of inter-hemispheric subdural hematomas.
42Case #31-year-old brought in by ambulance comatose.
44CT FindingsDiffuse cerebral edema indicative of severe anoxic brain injury with resultant swelling. Small area of bleeding notes.Conclusion: Child was violently shaken, causing severe brain injury as evidenced by diffuse cerebral edema.
45Case Study #34 month old with cough, chest x-ray request for “rule out pneumonia”.
47Chest X-ray FindingsPosterior rib fracture of the 7th rib. This fracture is less than 14 days old as there is no visible callus. Rib fracture is unrelated to child’s presenting complaint.Conclusion: Rib fractures a common injuries in the young (less than 2 years). Typically, is part of violent shaking. Child is held very tightly around the chest and squeezed while shaking.
48Case Study #43 ½ year old presents with 4 day history of persistent vomiting after eating and abdominal pain.
50Upper GI FindingsDuodenal hematoma (blood collection) in the wall of the bowel.Conclusion: This injury is almost always caused by direct trauma (assault, bicycle handlebar injury). Common injury in abuse and is typically seen in older children who are punched or kicked in the abdomen.
51Case Study #56 week old presents with sudden swelling of leg with no apparent trauma.
53QuestionsIs it developmentally possible for a six-week old to fracture a femur?Upon questioning the parents they report an incident when the infant was bumped against a door while carrying him in a padded infant carrier. The parents tell you it could not have been hard enough to cause a fracture.
54Family HistoryFather: 4 fractures 2 of which occurred with minor trauma.Paternal grandfather: 4 fractures from just “playing around”.Mother: scoliosis2 aunts: scoliosis
55What is the diagnosis? Osteogenesis imperfecta. Occult types tend to be autosomal dominantFamily history positive for fractures
56Does the injury match the history? In four of the case studies the presenting history did not match the physical / x-ray findings.In case study #5 a good family history provided a history of hereditary condition that can cause fractures.
57Shaken Baby Syndrome Prevention Act H.R. 2052Would enhance Federal efforts focused on public awareness and education about the risks and dangers associated with Shaken Baby Syndrome.
58Mandated ReporterCalifornia’s Child Abuse and Neglect Reporting Act: Reporting Rules for Health Care Providers.
60When are you required to submit an abuse report? “A mandated reporter shall make a report…whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child who the mandated reported knows or reasonably suspects has been the victim of child abuse or neglect.” Cal. Penal Code 11166(a).
61What if I am not sure that abuse has occurred? Confirmation of abuse is not required.Reporters must report whenever they have “reasonable suspicion” that abuse has occurred.
62Reasonable Suspicion“Reasonable suspicion” means “that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and expertise, to suspect child abuse or neglect.” Cal. Penal Code 11166(a)
63Board of Registered Nursing A BSN prepared nurse may apply for public health certification based on the fact the he / she has had content related to:Domestic AbuseChild AbuseGeriatric Abuse