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Child abuse Dr. Ravi Nanayakkara. Definition Acts of commission or omissions leading to actual or potential damage to health and development and exposure.

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Presentation on theme: "Child abuse Dr. Ravi Nanayakkara. Definition Acts of commission or omissions leading to actual or potential damage to health and development and exposure."— Presentation transcript:

1 Child abuse Dr. Ravi Nanayakkara

2 Definition Acts of commission or omissions leading to actual or potential damage to health and development and exposure to unnecessary suffering.

3 Intermediate objectives Describe the different types of child abuse Discuss 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.

4 Contents Definitions 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.

5 Types of abuse Physical child abuse Sexual child abuse Child labour/child soldier Neglect Psychological and emotional abuse Munchousen’ syndrome by proxy Intentional poisoning

6 Physical child abuse Abusers Parent Guardian Consorts of either spouse Baby sitters Teachers Relation …..

7 Physical 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.

8 History Vague and conflicting history Different histories given by parent/guardian at different times Accidental fall Injury during play Assaulted by elder brother Punishment by teacher Some times children may be too young to express themselves

9 Examination Scared Avoid eye contact Sad Depressed Apathy

10 Injuries Usually inflicted by manually hitting with hands, shaking, throwing Weapons if used common household weapons canes, slicks Burns Hot water, heated objects Cutting and stabbing rare

11 Injuries Head and face Lip injuries Torn frenulum Nail marks Slap marks Bite marks Areas of alopecia following pulling of hair Scalp contusions

12 Eye injuries Black eyes Subconjuctival haemorrhage Bilateral vitreous haemorrhage Retinal, subretinal, preretinal haemorrhage Retinal detachments Anterior chamber haemorrhage Dislocated lens

13 Ear injuries Ruptured ear drum Chronic suppurative otitis media Cauliflower ear due to forceful slapping Tin ear syndrome unilateral ear bruising, ipsilateral cerebral oedema, haemorrhage retinopathy

14 Injuries Tram line contusions Grip marks Pinch marks Patterned injuries from belts, buckles Tying of penis to prevent frequent bed wetting Burn injuries with scalds Burn injuries with flame and heated objects

15 Injuries of different stages of healing fresh, healing, healed with scar Injury pattern and age of injuries inconsistent with the history

16 Bruises Most common indication of physical abuse Occurs in >50% of abused children Bruises are uncommon in infants < 6 months. – “Those who don’t cruise rarely bruise.” Two characteristics separate abusive from accidental bruises: LOCATION PATTERN

17 ACCIDENTALABUSIVE Shins Anterior thigh Lower arms Upper arms Under chin Neck ForeheadFace HipsButtocks ElbowsTrunk AnklesEars Bony prominences Genitalia Location

18 Bruises 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.

19 Bruises 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.

20 Location 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 punishment injuries). 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 of a child. More than 10 bruises in an actively mobile child should raise concern.

21 Differential Diagnosis of Bruising Accidental injury—commonly on bony surfaces, appropriate history. Artifact—dirt, paint, felt tip, or dye from clothing or footwear. Benign tumors—halo nevus, blue nevus, or hemangiomas. Vascular and bleeding disorders—thrombocytopenic purpura, Henoch–Schoenlein purpura, hemophilia, or purpura in association with infection (e.g.,meningococcal septicemia, seconday syphilis). Disturbances of pigmentation—café-au-lait patches or Mongolian blue spots. Erythematous lesions—erythema nodosum. Hereditary collagen disorders—osteogenesis imperfecta or Ehlers–Danlos syndrome. Allergic reaction

22 Bite 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.

23 Thermal 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.

25 Differential Diagnosis of Burns  Cellulitis, erysipelas  Sunburn  Contact dermatitis  Diaper rash  Drug reaction  Psoriasis  Infection—staphylococcal or streptococcal (impetigo or scalded skin syndrome).  Allergy—urticaria or contact dermatitis.  Insect bites.  Bullous diseases—porphyria or erythema multiform

26 Features of Thermal Injuries Suggestive of Child abuse Repeated burns. Sites—backs of hands, buttocks, feet, and legs. Types—clearly demarcated burns shaped like a particular object, immersion burns with a tide mark (clear edge) and no splash marks. The presence of other NAIs.

27 Fractures Any 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 traction or shaking of an arm. Humerus or femur transverse fractures from angulation, including a direct blow spiral fractures from axial twists with or without axial loading oblique fractures from angulation, axial twisting with axial loading.

29 Vertebral 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.

30 Other 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 when X-rays taken for other reasons

31 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.

32 Differential Diagnosis of Fractures Minor falls – Do not cause fractures in most instances – Studies show very low incidence of fractures from short falls Obstetrical/birth trauma – usually produces only humeral and clavicular fractures – no rib fractures Prematurity – Osteopenia can lead to fractures

33 DDX: Skeletal Fractures Congenital: – Osteogenesis imperfecta – Menke’s syndrome Nutritional / Metabolic: – Copper deficiency – Rickets – Scurvy – Renal osteodystrophy Infectious: – Congenital syphilis – Osteomyelitis Neoplasm: – Leukemia – Bony metastases Normal variant: physiological periosteal reaction (symmetric and smooth around the long bones of children from 6 weeks to 6 months). Neuromuscular disease: – Cerebral palsy

34 skeletal survey with healing left distal radius and ulna fractures skeletal survey with healing left distal radius and ulna fractures

35 Internal injuries Whiplash injuries, sub arachnoid, subdural haemorrhage (shaken baby syndrome) Cerebral contusion, bleeding, oedema Diffuse axonal injuries Neck injuries - contusions Chest – haemothorax Abdomen- intestinal tears, liver and spleen ruptures Any fatal injury…..

36 “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.” ) Shaken Baby Syndrome

37 Pathophysiology of SBS Forceful shaking causes shearing of the blood vessels in the brain, which can further cause subdural hemorrhage.

38 Pathophysiology of SBS Hallmark Sign: Absence of/or minimal evidence of external trauma to the head, face, and neck but serious intracranial or intraoccular bleeding.

39 Child sexual abuse Rape Anal intercourse in males and females Inter crural Oral intercourse Grave sexual abuse Incest

40 History Children rarely lie about sexual abuse Any complain by a child of sexual abuse is to be considered unless proven otherwise

41 Examination Vaginal penetration causes heavy bleeding and lacerations Attenuation of the hymen with enlargement of hymenal opening highly suggestive of recurrent vaginal penetration Hymenal tears – must extend to base, when healed usually seen as V shaped notch Reddening of labia (pruritus ?) Semen sometimes present

42 Anal tears, Bleeding Anal tags and fissures as it healed Minimal injuries if lubricant is used Semen may be seen Repeated penetration results lax anus with reduced tone

43 Inter crural intercourse usually leave no injuries Reddening of inner thigh, perineum or perianal areas may be seen Thickening and pigmentation in chronic cases Semen may be seen

44 Oral intercourse may not leave marks Forceful penetration causes injuries to lips, gums, floor of mouth Chronic cases ulceration mouth may be seen Semen may be seen

45 Kissing, 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)

46 Manifestations suggestive of child sexual abuse Sleep disturbances with nightmares Night wetting Discharge PV Pruritus ani, vulvi Painful defecation Recurrent urinary tract infections Masturbation Sexual explicitness (play, draw) Anxiety, eating disorders Behavioral problems in school

47 Child labour Employ children under 14 years (home or work place) is illegal Often associated with physical abuse, sexual abuse, neglect and psychological abuse

48 Procurement of armies (Child soldiers) Transport of drugs and illicit liquor

49 Child neglect Deprivation of care and attention to a child by their parents or guardian. Failure to provide Adequate food Clothing and warmth Proper lodging Health care Education

50 Exclude Poverty Ignorance Poor education Child neglect Repetition of neglect Negative consequences of child heath and development.

51 Diagnosis Poor, dirty clothing or naked Poor hygiene (body, oral, genital) Overgrown, mattered hair Head lice Dirty nails Features of starvation and malnutrition Skin infections (scabies, impetigo) Common respiratory and gastrointestinal infections Worm infestations Negligence of health care including vaccinations

52 Psychological abuse Sustained repetitive, inappropriate behaviour which damages or substantially reduces the creative and developmental potential of crucially important mental faculties and mental processes of a child. Include Intelligence, attention, imagination…

53 Psychological abuse Verbal abuse Threatening behaviour Punishment given excessive Intimidation Ridicule Being rejection and isolation

54 Features of Psychological abuse Depressed mood and other unusual emotional responses Poor eye to eye contact Aggressive behavior Unusual or unexplainable attachment patterns with care giver Any other physical or psychological findings which may arouse suspicion

55 Munchausen’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

56 Intentional poisoning and drugging To quite the crying child To control hyperactive child To form Munchausen's syndrome Child may be given substances of abuse or sedative medications

57 Child may be Drugged Given laxatives to create diarrhea Blood added to urine sample….

58 Diagnosis 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

59 Warning signs in the history Nature of presentation Delayed presentation for medical treatment History incompatible with the injuries seen History incompatible with the developmental age of the child Changing history from time to time

60 Behavioural / psychological Deteriorating school performance or school refusal Sudden onset unusual behaviours Attempted suicide or deliberate self- harm (older chilid) Sexualized behaviour Avoiding certain places or persons Children with sexually inappropriate behaviours eg. being unusually friendly with certain adults

61 Symptom pattern Somatic Vaginal discharge especially if blood stained or purulent Assumed menarche without sexual maturation Painful defecation with or without bleeding per rectum Skin lesions in the perineum&/or perianal region Somatization phenomena such as headache, abdominal pain, pseudo- seizures and ect.

62 Social Dysfunctional home environment eg. Broken families, parent/s employed abroad, substance abuse among family members Children without adult supervision

63 Physical examination – Evidence of neglect – Multiple injuries of different stages of healing – Unusual skeletal injuries Long bone fractures in infants(spiral fractures are very suspicious) Metaphysial fractures – chip and bucket handle fractures Posterior rib fractures – Bite marks – Burns & scalds eg. cigarette and fire brand injuries, incense stick burns, immersion injuries, peri-oral scalds – Association of retinal hemorrhages and finger tip bruises on the chest eg. shaken baby syndrome – Foreign body in the vagina – Multiple anal fissures or patulous anus, skin lesions in perineum/ perianal region – Ulcerations in oral cavity& torn frenulum

64 Diagnosis Do not be too dogmatic Look for risk factors Exclude differential diagnosis Do relevant investigations

65 Medico Legal Evaluation of Victim of Suspected Abuse History Physical Examination Laboratory and Radiologic Studies Differential Diagnosis Documentation

66 Risk factors of child abuse Multi-factorial – Child Characteristics – Parental Characteristics – Family/Environmental Factors – Triggering Situations Look them during history taking….

67 Risk factors Child characteristics Premature births Physical disabilities Developmental disabilities Chronic illness Behavioural problems Unwanted child

68 Risk factors Parental characteristics Psychiatric problems Low self esteem, depression, poor impulse control Alcohol and substance abuse abuse as a child Teenage parent Single parent Unrealistic expectations of child’s behaviour Negative view of themselves and their children

69 Risk factors Social factors Poverty Poor education Isolation Intimate partner violence Unemployment and financial problems

70 Triggers Excessive crying baby Child’s misbehaviour Family arguments Intimate partner violence

71 Intimate partner violence and Child abuse Physical Injuries to Children May Be: Accidentally caught in the crossfire Intentionally injured while protecting their mother Over-disciplined or abused by stressed, anxious, and depressed parent

72 Taking a history from the caretaker/parent Children should not be present Interview adults who are present separately

73 Physical Examination Emergent care first Complete head to toe evaluation Must look at all skin surfaces – Remove ALL clothing – Eyes, Ears, Neck, Mouth, Genitalia, Anus – Description of all skin findings

74 Diagnosis of Child Abuse Lab tests – Bruising – Haematological studies – If fractures, Ca, Phos, Alk Phos – Consider Vitamin D, PTH and Copper Radiology Studies – Skeletal survey All children < 2 years of age 2-5 years: selective survey Consider in children aged 2–4 years with severe bruising. Older children with severe injuries. Children dying in unusual or suspicious circumstances. – Bone scan – CTs / MRIs Ophthalmology ENT Orthopedic …..

75 The Skeletal Survey Skull: frontal and lateral views Spine: frontal, lateral thoracolumbar spine (including sternum) Chest: PA Extremities: Upper – AP, Lateral to include shoulders, arms, forearms and hands Lower – AP, Lateral to include lower lumbar spine, pelvis, Femur, Tibia/fibula, feet

76 Skeletal Trauma 80% cases in children < 18 months of age 50% children with fracture due to abuse have more than one fracture Refer radiologist for evaluation

77 Diagnosis of Abuse Indications for admission to a hospital: Medical/surgical/psychological treatment that cannot be provided as an outpatient To provide a place of safety Eg. Alleged/ suspected perpetrator living in the same environment If 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 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 physical injury and death than older children. The aim of recognition and early intervention is to protect the child, prevent mortality and morbidity, and diagnose and improve disordered parenting. Early intervention in families may prevent more serious abuse and subsequent removal of children into care.

79 Health consequences of child abuse Physical Abdominal and thoracic injuries External injuries Fractures and disability ocular and auditory damage Sexual STD Unwanted pregnancy Psychological Depression and anxiety Eating and sleeping disorders Hyperactivity Poor school performance Post traumatic stress disorder

80 effects Death 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.

81 Medico Legal Management

82 Medico legal management of abused child Aims of Management Provide immediate medical care in a secure environment Reduce re-traumatization Assess other children who may be at risk Work towards holistic recovery Prevent further abuse Assist legal process for justice

83 Objectives of Case Conference: – To prevent re- victimization – Inform other specialties about the victim – Plan further management – Follow up The Procedure the Case Conference – The JMO is responsible for coordinating the Clinical Case Conference. – The decisions will be documented in the BHT – Date, time & Case Conference will be decided – Invite the relevant parties

84 The participants at the Case Conference Medical administrator Pediatrician JMO Psychiatrist Relevant medical and nursing Officers from the Paediatric ward Child Probation officer designated as a case manager Police officer from the women’s & children’s Bureau of the police station from the area of residence Child Right Promotion Officer National Child Protection Authorityofficer of the area Community Physician / Medical Officer of Health Child, Parents/guardian of the child and any other relatives when indicated should be present at the time of the case conference. Any other

85 Details of child Date, time, venue Names of attendees with designations and signatures Decision Recommendations Placement Medical Management Psychosocial rehabilitation & re-integration School / vocational training Follow up plan

86 Medico legal investigation death suspected child abuse Detailed history Scene visit Identification Preliminary investigations Clothing examination General external examination Specific external examination Internal examination Samples for laboratory investigation Documentation

87 Conclusions Child abuse is very common Often missed by clinicians Must have high index of suspicion Mandated reporters must report suspicion of abuse Complete careful histories and examinations Document, document, document! Avoid the misdiagnosis of abuse

88 Physicians 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.

89 Summary Definitions Injury pattern History Examination Investigation Medico legal management Medico legal investigation of a death

90 Thank you.


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