2DefinitionActs of commission or omissions leading to actual or potential damage to health and development and exposure to unnecessary suffering.
3Intermediate objectives Describe the different types of child abuseDiscuss the detailed medico legal investigation of a case of suspected child abuse and further management.Discuss how you would express your opinion in relation to medico legal aspects of the case and fill MLEF and MLR.
4ContentsDefinitions of different types of child abuse, predisposing factors, history, physical examination and investigations done in suspected case.Characteristic injury pattern in child physical abuse.Management of victims, rehabilitation and case conference.
5Types of abuse Physical child abuse Sexual child abuse Child labour/child soldierNeglectPsychological and emotional abuseMunchousen’ syndrome by proxyIntentional poisoning
6Physical child abuse Abusers Parent Guardian Consorts of either spouse Baby sittersTeachersRelation …..
7Physical abuse is characterized by the infliction of physical injury as a result of punching, beating, kicking, biting, burning, shaking or otherwise harming a child. The parent or caretaker may not have intended to hurt the child; rather, the injury may have resulted from over-discipline or physical punishment.
8History Vague and conflicting history Different histories given by parent/guardian at different timesAccidental fallInjury during playAssaulted by elder brotherPunishment by teacherSome times children may be too young to express themselves
13Ear injuriesRuptured ear drumChronic suppurative otitis mediaCauliflower ear due to forceful slappingTin ear syndromeunilateral ear bruising,ipsilateral cerebral oedema,haemorrhage retinopathy
14InjuriesTram line contusionsGrip marksPinch marksPatterned injuries from belts, bucklesTying of penis to prevent frequent bed wettingBurn injuries with scaldsBurn injuries with flame and heated objects
15Injuries of different stages of healing fresh, healing, healed with scarInjury pattern and age of injuries inconsistent with the history
16Bruises Most common indication of physical abuse Occurs in >50% of abused childrenBruises are uncommon in infants < 6 months.“Those who don’t cruise rarely bruise.”Two characteristics separate abusive from accidental bruises:LOCATIONPATTERN
18Bruises in Physical Child Abuse Fingertip bruises consisting of circular or oval bruises from squeezing, gripping, or grabbing injuries.Linear petechial bruises in the shape of a hand caused by capillaries rupturing at the edge of the injury from the high-velocity impact of the hand slap.Pinch marks consisting of paired, crescent-shaped bruises separated by a white line.
19Bruises in Physical Child Abuse High-velocity impact causing a rim of petechiae outlining the pattern of the inflicting instrument, e.g., parallel sided marks from sticks—“tramline bruising”Higher velocity impacts causing bruising underlying the injury in the shape of the object used, (e.g., wedge-shaped bruises from kicks with shoes).Pressure necrosis of the skin from ligatures, causing well-demarcated bands partially or fully encircling limbs or the neck.Coarse speckled bruising from impact injuries through clothing.
20Location Commonly associated with physical child abuse • Facial—soft tissues of the cheek, eye, mouth, ear, mastoid, lower jaw,frenulum, and neck.• Chest wall.• Abdomen.• Inner thighs and genitalia (strongly associated with sexual abuse).• Buttock and outer thighs (commonly associated with punishmentinjuries).• Multiple sites.Commonly associated with accidental injury:• Bony prominences.• On the front of the body. Numbers:• The number of accidental bruises increases with increased mobility ofa child.• More than 10 bruises in an actively mobile child should raise concern.
21Differential Diagnosis of Bruising • Accidental injury—commonly on bony surfaces,appropriate history.• Artifact—dirt, paint, felt tip, or dye from clothing orfootwear.• Benign tumors—halo nevus, blue nevus, or hemangiomas.• Vascular and bleeding disorders—thrombocytopenicpurpura, Henoch–Schoenlein purpura, hemophilia,or purpura in association with infection(e.g.,meningococcal septicemia, seconday syphilis).• Disturbances of pigmentation—café-au-lait patches orMongolian blue spots.• Erythematous lesions—erythema nodosum.• Hereditary collagen disorders—osteogenesis imperfectaor Ehlers–Danlos syndrome.Allergic reaction
22Bite Marks A bite mark is a mark made by teeth alone or in combination with other mouth parts and may be considered a mirror image of the arrangement and characteristics of the dentition. Human bite marks rarely occur accidentally. Children can be bitten in the context of punishment, as part of a physical assault, or in association with sexual abuse. Children can also be bitten by other children.
23Thermal injuries• Scalds—immersion, pouring or throwing a hot liquid onto a child. The affected skin is soggy, blanched, and blistered. The shape of the injury is contoured. The depth of the burn is variable. • Contact burns—direct contact of a hot object with the child. Characteristically, the burn is shaped like the hot object, with sharply defined edges and usually of uniform depth. The burn may blister.
24•Fire burns—flames from fires, matches, or lighters in close or direct contact with the skin, causing charring and skin loss with singeing of hairs.• Cigarette burns—inflicted direct contact leaves a characteristically well-demarcated circular or oval mark with rolled edges and a cratered center, which may blister and tends to scar. Accidental contact with a cigarette tends to leave a more superficial, irregular area of erythema with a tail.• Chemical burns—the chemical in liquid form is drunk, poured, or splashed onto the skin, or in solid form is rubbed on the skin. The skin may stain, may have the appearance of a scald, and may scar.
25Differential Diagnosis of Burns Cellulitis, erysipelasSunburnContact dermatitisDiaper rashDrug reactionPsoriasisInfection—staphylococcal or streptococcal (impetigo or scalded skin syndrome).Allergy—urticaria or contact dermatitis.Insect bites.Bullous diseases—porphyria or erythema multiform
26Features of Thermal Injuries Suggestive of Child abuse • Repeated burns.• Sites—backs of hands, buttocks, feet, andlegs.• Types—clearly demarcated burns shaped like a particular object, immersionburns with a tide mark (clear edge) and no splash marks.• The presence of other NAIs.
27FracturesAny fracture can occur as a result of NAI, but some have a high specificity for abuse• Metaphyseal—a shaking, pulling, or twisting force applied at or about a joint, resulting in a fracture through the growing part of the bone.• Epiphyseal separation—resulting from torsion of a limb, particularly in children younger than 2 years old.• Rib—resulting from severe squeezing or direct trauma; posterior rib fractures virtually pathognomonic of NAI and commonly associated with shaking injury.
28• Scapular—resulting from direct impact. • Lateral clavicle—resulting from excessive tractionor shaking of an arm.• Humerus or femurtransverse fractures from angulation, including a direct blowspiral fractures from axial twists with or without axial loadingoblique fractures from angulation, axial twisting withaxial loading.
29Vertebral fractures—resulting from hyperflexion injuries, impact injuries, or direct trauma. • Digital fractures—resulting from forced hyperextension or direct blows.• Skull fractures—resulting from blunt-impact injuries, particularly occipital fractures and fractures that are depressed, wide (or growing), bilateral, complex, crossing suture lines multiply, or associated with intracranial injury .• Periosteal injury—resulting from pulling or twisting of a limb separating the periosteum from the surface of the bone, leading to hemorrhage between the periosteum and the bone and subsequent calcification.
30Other features of skeletal injury suggestive of abuse include the following: • Absence of an appropriate history.• Multiple fractures.• Fractures of differing ages.• Fracture in association with other features of NAI (e.g., bruising at other sites).• Unsuspected fractures (recent or old) found whenX-rays taken for other reasons
31Dating Fractures • Resolution of soft tissues — 2 to 10 days Dating Fractures • Resolution of soft tissues — 2 to 10 days. • Early periosteal new bone — 4 to 21 days. • Loss of fracture line definition — 10 to 21 days. • Soft callus — 10 to 21 days. • Hard callus — 14 to 90 days. • Remodeling — 3 months to 2 years.
32Differential Diagnosis of Fractures Minor fallsDo not cause fractures in most instancesStudies show very low incidence of fractures from short fallsObstetrical/birth traumausually produces only humeral and clavicular fracturesno rib fracturesPrematurityOsteopenia can lead to fractures
33DDX: Skeletal Fractures Neoplasm:LeukemiaBony metastasesNormal variant:physiological periosteal reaction (symmetric and smooth around the long bones of children from 6 weeks to 6 months).Neuromuscular disease:Cerebral palsyCongenital:Osteogenesis imperfectaMenke’s syndromeNutritional / Metabolic:Copper deficiencyRicketsScurvyRenal osteodystrophyInfectious:Congenital syphilisOsteomyelitis
34skeletal survey with healing left distal radius and ulna fractures
36Shaken Baby Syndrome“Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome (SBS) or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma.”)
37Pathophysiology of SBS Forceful shaking causes shearing of the blood vessels in the brain, which can further cause subdural hemorrhage.
38Pathophysiology of SBS Hallmark Sign: Absence of/or minimal evidence of external trauma to the head, face, and neck but serious intracranial or intraoccular bleeding.
39Child sexual abuse Rape Anal intercourse in males and females Inter cruralOral intercourseGrave sexual abuseIncest
40History Children rarely lie about sexual abuse Any complain by a child of sexual abuse is to be considered unless proven otherwise
41Examination Vaginal penetration causes heavy bleeding and lacerations Attenuation of the hymen with enlargement of hymenal opening highly suggestive of recurrent vaginal penetrationHymenal tears – must extend to base, when healed usually seen as V shaped notchReddening of labia (pruritus ?)Semen sometimes present
42Anal tears, BleedingAnal tags and fissures as it healedMinimal injuries if lubricant is usedSemen may be seenRepeated penetration results lax anus with reduced tone
43Inter crural intercourse usually leave no injuries Reddening of inner thigh, perineum or perianal areas may be seenThickening and pigmentation in chronic casesSemen may be seen
44Oral intercourse may not leave marks Forceful penetration causes injuries to lips, gums, floor of mouthChronic cases ulceration mouth may be seenSemen may be seen
45Kissing, fondling, sucking, masturbation, touching of genital and para-sexual areas may not leave any marks.Digital penetration of vagina or anus may leave bruises and tears.Pornography video and photographs using children (Non contact abuse)
46Manifestations suggestive of child sexual abuse Sleep disturbances with nightmaresNight wettingDischarge PVPruritus ani, vulviPainful defecationRecurrent urinary tract infectionsMasturbationSexual explicitness (play, draw)Anxiety, eating disordersBehavioral problems in school
47Child labourEmploy children under 14 years (home or work place) is illegalOften associated with physical abuse, sexual abuse, neglect and psychological abuse
48Procurement of armies (Child soldiers) Transport of drugs and illicit liquor
49Child neglectDeprivation of care and attention to a child by their parents or guardian.Failure to provideAdequate foodClothing and warmthProper lodgingHealth careEducation
50ExcludePovertyIgnorancePoor educationChild neglectRepetition of neglectNegative consequences of child heath and development.
51Diagnosis Poor, dirty clothing or naked Poor hygiene (body, oral, genital)Overgrown, mattered hairHead liceDirty nailsFeatures of starvation and malnutritionSkin infections (scabies, impetigo)Common respiratory and gastrointestinal infectionsWorm infestationsNegligence of health care including vaccinations
52Psychological abuseSustained repetitive, inappropriate behaviour which damages or substantially reduces the creative and developmental potential of crucially important mental faculties and mental processes of a child.IncludeIntelligence, attention, imagination…
53Psychological abuseVerbal abuseThreatening behaviourPunishment given excessiveIntimidationRidiculeBeing rejection and isolation
54Features of Psychological abuse Depressed mood and other unusual emotional responsesPoor eye to eye contactAggressive behaviorUnusual or unexplainable attachment patterns with care giverAny other physical or psychological findings which may arouse suspicion
55Munchausen’s syndrome by proxy Usually mother takes the child to various doctors and hospitals with bogus complains of illness which very often requires extensive investigations sometime even surgery.Separation from the mother results improvement of the child.Father may unaware the symptoms
56Intentional poisoning and drugging To quite the crying childTo control hyperactive childTo form Munchausen's syndromeChild may be given substances of abuse or sedative medications
57Child may beDruggedGiven laxatives to create diarrheaBlood added to urine sample….
58Diagnosis of child abuse The most important first step in the diagnosis of child abuse & neglect is a high degree of suspicion and prompt recognition. Warning signs in the history Warning signs of examination
59Warning signs in the history Nature of presentationDelayed presentation for medical treatmentHistory incompatible with the injuries seenHistory incompatible with the developmental age of the childChanging history from time to time
60Behavioural / psychological Deteriorating school performance or school refusalSudden onset unusual behavioursAttempted suicide or deliberate self-harm (older chilid)Sexualized behaviourAvoiding certain places or personsChildren with sexually inappropriate behaviours eg. being unusually friendly with certain adults
61Symptom patternSomaticVaginal discharge especially if blood stained or purulentAssumed menarche without sexual maturationPainful defecation with or without bleeding per rectumSkin lesions in the perineum&/or perianal regionSomatization phenomena such as headache, abdominal pain, pseudo- seizures and ect.
62SocialDysfunctional home environment eg. Broken families, parent/s employed abroad, substance abuse among family membersChildren without adult supervision
63Physical examinationEvidence of neglectMultiple injuries of different stages of healingUnusual skeletal injuriesLong bone fractures in infants(spiral fractures are very suspicious)Metaphysial fractures – chip and bucket handle fracturesPosterior rib fracturesBite marksBurns & scalds eg. cigarette and fire brand injuries, incense stick burns, immersion injuries, peri-oral scaldsAssociation of retinal hemorrhages and finger tip bruises on the chest eg. shaken baby syndromeForeign body in the vaginaMultiple anal fissures or patulous anus, skin lesions in perineum/ perianal regionUlcerations in oral cavity& torn frenulum
64DiagnosisDo not be too dogmaticLook for risk factorsExclude differential diagnosisDo relevant investigations
65Medico Legal Evaluation of Victim of Suspected Abuse HistoryPhysical ExaminationLaboratory and Radiologic StudiesDifferential DiagnosisDocumentation
66Risk factors of child abuse Multi-factorialChild CharacteristicsParental CharacteristicsFamily/Environmental FactorsTriggering SituationsLook them during history taking….
68Risk factors Parental characteristics Psychiatric problems Low self esteem, depression,poor impulse controlAlcohol and substance abuseabuse as a childTeenage parentSingle parentUnrealistic expectations of child’s behaviourNegative view of themselves and their children
69Risk factors Social factors Poverty Poor education Isolation Intimate partner violenceUnemployment and financial problems
71Intimate partner violence and Child abuse Physical Injuries to Children May Be:Accidentally caught in the crossfireIntentionally injured while protecting their motherOver-disciplined or abused by stressed, anxious, and depressed parent
72Taking a history from the caretaker/parent Children should not be presentInterview adults who are present separately
73Physical Examination Emergent care first Complete head to toe evaluationMust look at all skin surfacesRemove ALL clothingEyes, Ears, Neck, Mouth, Genitalia, AnusDescription of all skin findings
74Diagnosis of Child Abuse Lab testsBruising – Haematological studiesIf fractures, Ca, Phos, Alk PhosConsider Vitamin D , PTH and CopperRadiology StudiesSkeletal surveyAll children < 2 years of age2-5 years: selective surveyConsider in children aged 2–4 years with severe bruising.Older children with severe injuries.Children dying in unusual or suspicious circumstances.Bone scanCTs / MRIsOphthalmologyENTOrthopedic …..
75The Skeletal Survey Skull: frontal and lateral views Spine: frontal, lateral thoracolumbar spine (including sternum)Chest: PAExtremities:Upper – AP, Lateral to include shoulders, arms, forearms and handsLower – AP, Lateral to include lower lumbar spine, pelvis, Femur, Tibia/fibula, feet
76Skeletal Trauma80% cases in children < 18 months of age50% children with fracture due to abuse have more than one fractureRefer radiologist for evaluation
77Diagnosis of Abuse Indications for admission to a hospital: Medical/surgical/psychological treatment that cannot be provided as an outpatientTo provide a place of safetyEg . Alleged/ suspected perpetrator living inthe same environmentIf parents/guardians refuse admission:Medical Officer OPD should inform the JMO immediately to obtain a court order through the police irrespective of the time of the day.
78• Physical abuse often overlaps with other forms of abuse. Assessment of a physically abused child• Physical abuse often overlaps with other forms of abuse.• Abuse may involve other siblings and family members.• Abuse may recur and escalate.• Younger children and infants are more at risk of physicalinjury and death than older children.• The aim of recognition and early intervention is to protectthe child, prevent mortality and morbidity, and diagnoseand improve disordered parenting.• Early intervention in families may prevent more seriousabuse and subsequent removal of children into care.
79Health consequences of child abuse PhysicalAbdominal and thoracic injuriesExternal injuriesFractures and disabilityocular and auditory damageSexualSTDUnwanted pregnancyPsychologicalDepression and anxietyEating and sleeping disordersHyperactivityPoor school performancePost traumatic stress disorder
80effectsDeath or disability in severe cases. • Affective and behavior disorders. • Developmental delay and learning difficulties. • Failure to thrive and growth retardation. • Predisposition to adult psychiatric disorders. • An increased risk of the abused becoming an abuser.
82Medico legal management of abused child Aims of ManagementProvide immediate medical care in a secure environmentReduce re-traumatizationAssess other children who may be at riskWork towards holistic recoveryPrevent further abuseAssist legal process for justice
83Objectives of Case Conference: To prevent re- victimizationInform other specialties about the victimPlan further managementFollow upThe Procedure the Case ConferenceThe JMO is responsible for coordinating the Clinical Case Conference.The decisions will be documented in the BHTDate, time & Case Conference will be decidedInvite the relevant parties
84The participants at the Case Conference Medical administratorPediatricianJMOPsychiatristRelevant medical and nursing Officers from the Paediatric wardChild Probation officer designated as a case managerPolice officer from the women’s & children’s Bureau of the police station from the area of residenceChild Right Promotion OfficerNational Child Protection Authorityofficer of the areaCommunity Physician / Medical Officer of HealthChild, Parents/guardian of the child and any other relatives when indicated should be present at the time of the case conference.Any other
85Details of childDate, time, venueNames of attendees with designations and signaturesDecision RecommendationsPlacementMedical ManagementPsychosocial rehabilitation & re-integrationSchool / vocational trainingFollow up plan
86Medico legal investigation death suspected child abuse Detailed historyScene visitIdentificationPreliminary investigationsClothing examinationGeneral external examinationSpecific external examinationInternal examinationSamples for laboratory investigationDocumentation
87Conclusions Child abuse is very common Often missed by clinicians Must have high index of suspicionMandated reporters must report suspicion of abuseComplete careful histories and examinationsDocument, document, document!Avoid the misdiagnosis of abuse
88Physicians may be involved in a range of child protection activities, including the following: • Recognition, diagnosis, and treatment of injury. • Joint interagency activity. • Court attendance. • Ongoing care and monitoring of children following suspected abuse. • Support for families and children. • Prevention. • Teaching, training, supervision, and raising awareness.
89Summary Definitions Injury pattern History Examination Investigation Medico legal managementMedico legal investigation of a death