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Physical Abuse of Children by Jim Carpenter MD,MPH,FAAP October 21, 2009.

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Presentation on theme: "Physical Abuse of Children by Jim Carpenter MD,MPH,FAAP October 21, 2009."— Presentation transcript:

1 Physical Abuse of Children by Jim Carpenter MD,MPH,FAAP October 21, 2009

2 Objectives  1.Develop a schema to identify the signs and symptoms of Child Physical Abuse(CPA)  2. Report reasonable suspicion of physical abuse to the appropriate agencies

3 Missed Diagnoses  Family Violence including child abuse, elder abuse and domestic violence  Mental health conditions including depression and anxiety disorders  Substance use and abuse

4 Definitions of Child Abuse  Physical injury inflicted intentionally upon a child  Neglect: “general” or “severe”  Sexual abuse including molest, assault and exploitation  Emotional abuse including willful cruelty, unjustified punishment and mental suffering

5 Prevalence  Second to neglect in reported cases of child maltreatment accounting for 18-20%.  26.4% of an adult cohort reported CPA.  1.3-15% of ED visits for child injury.  Underreported and misdiagnosed  31% of children with AHT were initially misdiagnosed  Due to lack of training, reluctance to report, failure to consult, and low index of suspicion

6 Fiscal Year 2006  3.3 million referrals to child protective services.  62% were screened in for investigation.  30% of reports found at least 1 child who was a victim.  60% of reports were not substantiated.

7 Who Reported? 56% of all reports were made by professionals.  Teachers: 16.5%.  Police, lawyers: 15.8%.  Social services: 10%.  Medical, mental health professionals: 12%.  Other professionals: 2%  2/3 of substantiated reports were made by professionals.

8 Who Were the Victims?  905,000 total  Birth to age 1 years: 24.4/1,000  Younger than 7 years: 55%  Race  White: 49%  African American: 23%  Hispanic: 18%  Other, unclassified: 10%

9 Types of Maltreatment  64%: Neglect  16%: Physical abuse  9%: Sexual abuse  7%: Emotional maltreatment

10 Child Abuse Fatalities  1,530 died.  Rate of death: 2.04 children per 100,000.  42% of deaths caused by neglect.  27% caused by combinations of maltreatment.  24% caused by physical abuse.  2.5% caused by medical neglect.  76% of deaths occurred in children younger than 4 years.

11 Perpetrators  79% were parents.  7% were other relatives.  Unrelated caregivers: 10%.  Women: 58%.

12 Sequelae of Physical Abuse  Mortality and Morbidity from the injury.  Behavioral and Functional problems including conduct disorder, aggression, school problems and failure, anxiety and depression, low self esteem, PTSD, criminality.  Subsequent generations of family violence.  ACE(Adverse Childhood Experiences) sequelae

13 ACE and Chronic Disease  ACE including all forms of child maltreatment increase the risk for:  Diabetes and Obesity  Hypertension  Depression  Substance Abuse  Ischemic Heart Disease  Risk taking behaviors ie. STI’s  Chronic Lung Disease

14 Risk Factors for Abuse  Age less than 2-3 years  Poverty  Single, isolated parent  Unrelated adult in home  Low birth weight  Substance use/abuse  Developmental delays in child  Family history of DV or child maltreatment

15 Medical History Concerning for Intentional Trauma  No or vague explanation for injury.  Details of injury change.  Explanation that is inconsistent with the injury.  Explanation is inconsistent with child’s physical or developmental abilities.  Different explanations by witnesses.  Delay in seeking care

16 Past Medical History  Pregnancy(prenatal care, planned, substance use, depression, support)  Family Hx(bleeding, metabolic or genetic disorders, violence, depression, substance use)  Medical(trauma, chronic illness, FTT,shot delay, developmental delays)  Social(poverty, stressors, support)

17 Physical Examination  ABC’s and VS including Ht, Wt and HC  Early Neurologic assessment  Skin(bruises, abrasions, patterned marks, burns, SQ fat, hygiene)  HEENT(swelling, contusions, alopecia, full fontanelle, hemotympanum, black eyes, slap or choke marks)

18 Cutaneous Injuries Key characteristics  Location  Pattern  Multiple ages of lesions  Failure of appearance of new lesions in new environment

19 Incidence and Prevalence  50% to 60% of all physical abuse cases have skin injuries, in isolation or in combination with other abusive injuries.*  Cutaneous injuries are the single most common presentation of physical abuse. *Johnson CF. Pediatr Clin North Am. 1990;37:791–814.

20 ACCIDENTALABUSIVE ShinsUpper arms Lower armsAnterior thigh Under chinTrunk ForeheadGenitalia HipsButtocks ElbowsFace AnklesEars Bony prominencesNeck Usual Locations of Bruises

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22 Slap Mark in 4-Month-Old Infant

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24 Strangulation Marks on Neck

25 ↑ ↑ The canine impressions are labeled with red arrows and have a distance of 4 cm between them. The 4 outlines of teeth between the arrows are from the incisors.

26 Aging of Bruises Visual aging of bruises is inexact.  Bruise with yellow is more than 18 hours old.  Red, blue, purple—present 1 hour to resolution.  Red color can be present anytime.  Bruises of same age on same person can vary in color.

27 Differential Diagnosis of Bruises

28 Typical Distribution of Slate-gray Nevi

29 Phytophotodermatitis

30 Cao Gio (Coin Rubbing)

31 Henoch-Schönlein Purpura

32 Forehead Bump With Migration

33 Abusive Burns

34 Bic Cigarette Lighter Burn

35 Iron Burn—Note Location

36 Immersion Burn

37 Differential Diagnosis of Burns Second degree  Bullous impetigo  Staphylococcal scalded skin syndrome (SSSS)  Toxic epidermal necrolysis  Epidermolysis bullosa

38 Staphylococcal Infection

39 Contact Dermatitis—Ex-Lax

40 Moxibustion

41 Abusive Head Trauma  Leading cause of CPA death and significant morbidity(blindness, CP, ADHD, retardation, seizures).  Survey showed 2.6% of mothers shake their children <2 yo for discipline.  Correlates with normal crying behavior.  Often is asymptomatic and easily missed by H&P.  Prevention works! Anticipatory guidance or Mark Dias MD Program or Period of Purple Crying Program

42 Period of PURPLE Crying  Peak of crying(second month)  Unexpected  Resists soothing  Pain-like face  Long-lasting(30-40 minutes and longer)  Evening crying

43 Suspicious Stories in Fatal Child Abuse Cases (Kirschner) 1. Child fell from low height. 2. Child fell onto furniture, floor, or object. 3. Child unexpectedly found dead (age and circumstances not suggesting SIDS). 4. Child choked; shaken to dislodge object. 5. Child turned blue; shaken to revive. 6. Child experienced sudden seizure activity.

44 Common Suspicious Stories 7. Resuscitation efforts caused injuries. 8. Caused by traumatic event a day or more prior. 9. Adult tripped or slipped while carrying child. 10. Child’s sibling did it. 11. Child left alone for short time. 12. Child fell down stairs.

45 Clinical Presentation  Poor feeding, vomiting  Lethargy, irritability  Seizures  Apnea or respiratory distress  Color change  Unresponsiveness  Hypothermia

46 Parietal Skull Fracture

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48 Retinal Hemorrhages  Dilated retinal exam by Ophthalmologist  Found in 80-90% of infants with severe shaking with or without impact.  Can occur from birth but are small and resolve by 2-4 weeks.  R/O vitamin K deficiency or glutaric aciduria type 1.

49 Chest Examination  Rib fractures(pain, crepitance, splinting,palpable callus, tachypnea, shallow breathing)  Rib fractures often occur in adults from CPR but rarely in children and almost never in infants.  Heart trauma is rare but if present is severe(hemopericardium and contusions)

50 Rib Fractures  Posterior fractures are most common.  Next most common is mid-axillary.  Overlying bruises may be seen, but are often absent.  Symptoms are usually absent.  Grating feeling may be present.

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53 Abdominal Injuries Abusive  Younger child (2.6 y)  Vague histories  Delayed medical care  Hollow viscera  Mortality rate: 53% Accidental  Older child (7.8 y)  90% credible accident history (eg, MVC, fall)  Prompt medical care  Solid organ  Mortality rate: 21%

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55 Signs and Symptoms  Abdominal tenderness  Abdominal distention  Absent bowel sounds  Obtundation  Low hematocrit  Blood in nasogastric drainage, hematuria  Bruising of abdominal skin

56 Extremity Examination  Observe for deformity, swelling, lack of use, discoloration, tenderness, ROM.  Skeletal survey is indicated in <2 yo with suspected CPA/neglect.  Repeat in 2 weeks in selected cases.  R/O rickets, scurvy, syphylis, and osteogenesis imperfecta(blue sclera, osteopenia,bad teeth, lax ligaments)

57 When to Suspect Abuse  Metaphyseal fractures in children younger than 2 years  Posterior rib fractures  Scapular fractures  Spine fractures  Sternal fractures  Multiple, especially bilateral fractures

58 When to Suspect Abuse  Fractures to hands or feet  Fractures in infants or young children  Fractures in children of poverty  Fractures in prematurely born children  Fractures in developmentally handicapped  Fractures with unexplained associated injuries

59 Diagnostic Testing for CPA  Bleeding screen(CBCD, platelets, INR, PT/PTT, VWF, Vit K, or other factors).  Abdominal screen(LFT’s, amylase, lipase, urinalysis, CT scan> KUB).  Fracture screen(skeletal survey, bone scan, 2 week f/u survey).  Cranial screen(MRI, CT, skull XR, urine organic acids, retinal exam).

60 Other Diagnostic Testing  Cardiac screen(troponin, CK-MB)  Osteogenesis imperfecta(FHx, skin bx for fibroblast culture, blood for DNA).  Other bone disorders:ie. rickets(Ca, Alk P, Phosphorus, Vit. D, PTH, Vit. C, RPR).  Tests to diagnose mimics of CPA.  Consider toxicology and forensics.

61 Diagnostic Studies

62 Documentation of CPA  Photography is recommended for all significant injuries.  Completion of the CalEMA 2-900 and SS8572 reporting forms.  Completion and review of all other medical records.  Inconsistencies in the record will haunt you if a case goes to prosecution.

63 Reporting of CPA  Mandated reporters are required to report suspected CPA to CFS/LE by phone as soon as possible and in writing within 36 hours.  Many cases are ambiguous so consult with pediatrician/supervisor to discuss management and need to report.

64 CalEMA 2-900 Reporting Form  7 pages  5 years in the making  Prompts for Hx, PE, forensics and diagnostics

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74 Reporting  All states have reporting laws of suspected child abuse by mandated reporters  Reports go to CPS and/or LE  Immediately by phone and in writing within 36 hours  To commence investigation, protect the child, and help the family

75 Mandated Reporters  Nurses  Doctors  EMT’s  Teachers  PT  OT  Firemen  Police  Childcare providers  Photo processors  CPS workers  Animal control  Clergy  Child visitation monitors

76 Reasonable Suspicion  “It is objectively reasonable for a person to entertain a suspicion, based on the facts that could cause a reasonable person in a like position, drawing when appropriate, on his or her training and experience, to suspect child abuse and neglect” (PC 11166a1)

77 Obstacles to Reporting  Denial  Fear of making a mistake  Deferring to another reporter’s lower index of suspicion  Fear the report will make things worse or make no difference  Fear of angry parents  Fear of court testimony

78 Penalties for Failure to Report  Misdemeanor punishable by up to 6 months in jail and/or $1000 fine  If GBI or death results- up to one year and/or $5000 fine  Civil liability  Potential loss of credential or license

79 Safeguards for Reporters  Immunity from criminal liability if report made in good faith  Supervisors may not impede or sanction reporters  Reports and reporter are confidential  Examination, photography and indicated tests do not require consent from potentially abusive parent.

80 Prevention of Child Abuse  Recognition and reporting  Home visitation  Parenting education  Substance abuse identification and treatment  Mental health diagnosis and treatment

81 Resources for CPA  Child and Family Services-(925-646-1680 or 877-881-1116) or CPS Alameda County(510- 259-1800)  Jim CrawfordMD/Center for Child Protection(510-428-3742)  Jim CarpenterMD/CCRMC (x210 or drjimcarpenter@yahoo.com)  Child Abuse Prevention Council - (925-798- 0546) or www.capc-coco.org.www.capc-coco.org  www.dontshake.org

82 Bibliography  Nursing Approach to the Evaluation of Child Maltreatment; Giardino & Giardino, 2003  Child Abuse:Medical Diagnosis & Management, 3rd edition: Reece & Christian; AAP; 2009  Visual Diagnosis of Child Abuse,3rd edition;Lowen & Reece; AAP  “The Relationship of Adverse Childhood Experiences to Adult Health, Well-being, Social Function, and Healthcare”; Felitti and Anda; AAP/San Francisco; 2007

83 Bibliography- continued  “Diagnostic Imaging of Child Abuse”; AAP Section on Radiology; Peds123:5, pp1430-35; 5/2009  “Abusive Head Trauma in Infants and Children”; Christian and Block; Peds123:5, pp1409-11; 5/2009  “Evaluation of Suspected Child Physical Abuse”; Kellogg; Peds119:6; pp1232-41

84 Thank You


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