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Interpreting Medical Evidence in Child Maltreatment J. Hatlevig Ph.D., RNC.

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Presentation on theme: "Interpreting Medical Evidence in Child Maltreatment J. Hatlevig Ph.D., RNC."— Presentation transcript:

1 Interpreting Medical Evidence in Child Maltreatment J. Hatlevig Ph.D., RNC

2 Types of Medical Diagnosis Shaken Baby Syndrome Failure to Thrive Methamphetamine Use around children SIDS SANE

3 Shaken Baby Syndrome (SBS) 2000 child abuse deaths per year in US from all causes SBS is leading cause of fatal physical abuse deaths 1200-1600 cases in the US each year Majority of children are under 1, some under 2 and unheard of after 5 years of age.

4 Shaken Baby Syndrome (SBS) Was not identified until 1946 Linked to “whiplash” injury in 1971(Guthkelch and Caffey) CT scans verified damage in 1970’s MRI used in 1980’s

5 Possible Causes Shaking Shaking and Slamming Impact Model Earthquake model

6 Definition of Shaken Baby Syndrome (SBS) Intracranial injury Retinal Hemorrhages Other injuries

7 Intracranial injury Brain swelling Diffuse Axonal Injury (DAI) Subdural/Subarachnoid/interhemispheric bleeding Shear injuries External head trauma

8 Subdural and Sub arachnoid

9 Shaken Baby Syndrome

10 Retinal Hemorrhages 75%-90% of all cases Usually many; diffuse; and may extend to periphery Occasionally retinal detachment occurs Visual impairment is usually a result of cortical damage and not retinal hemorrhages (which fade away) Rule out other causes

11 Retinal Hemorrhage


13 Other injuries Rib fractures Bruises or other broken bones Neck injury Preceding blows

14 Less Serious Injury: Lethargy / decreased muscle tone Extreme irritability Decreased appetite, poor feeding or vomiting for no apparent reason Grab-type bruises on arms or chest are rare No smiling or vocalization Poor sucking or swallowing Rigidity or posturing

15 Serious Brain Injury: Difficulty breathing Seizures Head or forehead appears larger than usual or soft-spot on head appears to be bulging Inability to suck or swallow Inability to lift head Inability of eyes to focus or track movement or unequal size of pupils

16 Medical-legal aspects: Severity Not caused by accidents, throwing child in air, jogging with backpack or bouncing on knee, etc. Pattern of trauma is comparable to falling from a three story building Severe injuries require repeated measures Spectrum of symptoms from gastroenteritis, vomiting, altered consciousness, to death

17 Medical-legal aspects: Timing Radiology may be able to date injuries, both old and new Dating of healing within a couple of days from injury Clinical dating Fatal cases

18 Recidivism 70% of SBS victims have evidence of prior abuse 33%have evidence of old intracranial injury Felony murder Other children

19 Diagnosis Index of suspician Eye examination Head imaging Skeletal survey CBC, PT, PTT Glucose and liver ensymes Medical photography Interviews

20 Treatment and Follow-up Medical Surgical Management Consultant medical evidence Child abuse report Legal action Developmental follow-up Support for surviving siblings

21 PURPLE crying Peak of Crying Your baby may cry more each day until they are about 8 weeks old. U Unexpected Crying can come go and you don't know why. R Resists Soothing Your baby won't stop crying no matter what you try. P Pain-like Face A crying baby may look like they are in pain, even if they are not. L Long Lasting Crying can last for 30-40 minutes and longer. E Evening Baby cries more in the late afternoon and evening. Ronald G. Barr, MDCM

22 Failure to Thrive Poverty Accidental Growth retardation –Psychological factors –Physical/organic/genetic factors FTT related to abuse –Targeted child

23 Ruling out underlying medical conditions Blood/X-rays for organic disorders Documentation of growth for past 2 months Parent’s role; where fed, sought advise? Evidence of physical or emotional abuse? Review parent’s statements to HC providers? Interview other contacts

24 Physical signs of FTT General appearance –Dull vacant stare –Poor hygiene –Passive or irritable infant Undress the baby –Protruding abdomen –Wasted buttocks –Thin limbs –Pale

25 Consequences of Non-organic FTT Acute –Slowed growth –Increased vulnerability to infections –Risk for developmental delays Chronic –Growth disturbance –Insecure attachments –Impaired cognitive abilities –Behavior problems

26 FTT Scene Investigation Medical information-appointments, RX Financial information-claims Overall condition of home Drugs or Alcohol Photos of children Victim’s belongings

27 Medical and suspect interviews Pre-existing medical conditions Review medical records Estimated time child deprived of food Review birth records Feeding history within the past 24 hours: who, what, when, where & child’s reaction When did child start losing weight? What was caretaker responses? 911? EMS?

28 Defenses in the FTT Cases Underlying medical condition Poverty Lack of parenting skills-ignorance Child wouldn’t eat Congenital Child health until just recently Another caretaker’s responsible

29 Possible defenses Competency or ignorance defense Poverty Transportation She just wouldn’t eat We are all short Recent weight loss

30 Sudden Infant Death Syndrome SIDS is the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history. (Willinger et al, 1991).

31 U.S. Annual SIDS Rate per 1000 Live Births

32 But my baby doesn't like sleeping on his back. Crying Spitting up Waking up Apnea Likely to choke CO2

33 StomachBack Cries more X Wakes moreX Harder to arouseX More likely to over-heatX Re-breaths moreX Increases carbon dioxideX Has more apneaX Spits up moreSame More likely to chokeSame Greater risk of SIDS deathX

34 Parents-To-Be Risk Factors 1.Get medical care early in pregnancy 2.Do not smoke, use cocaine, or use heroin. 3.Take care to prevent becoming pregnant during the teenage years. 4.Wait at least one year between the birth of a child and the next pregnancy.

35 Parents Risk Factors 1.Place infants to sleep on their backs, even though infants may sleep more soundly on their stomachs. 2.Place infants to sleep in a baby bed with a firm mattress. 3.Do not over-clothe the infant while he/she sleeps. 4.Avoid exposing the infant to tobacco smoke. 5.Breast-feed babies whenever possible. 6.Avoid exposing the infant to people with respiratory infections. 7.Consider using home monitoring systems (apnea/bradycardia monitors) in an attempt to prevent sudden death in high-risk infants.The risk of SIDS in the following groups exceeds that of the general population by as much as 5 to 10 times.

36 Continued Risk Factors 1.Infants born weighing less than 3.5 pounds. 2.Infants whose sibling died of SIDS. 3.Infants exposed to cocaine, heroin, or methadone during the pregnancy. 4.The second or succeeding child born to a teenage mother. 5.Infants who have had an apparent life- threatening event. 6.Discuss the advantages and disadvantages of home monitoring with the baby's doctor before making your choice.

37 Methamphetamine use around children 1919 Japanese scientist created drug WWII Given to troops in Japan 1950’s Truckers drug 1970’s Hell’s angels 1980’s SW California 1990’s Took off eastward 1995 Iowa and Minnesota

38 Effect of Meth on Human Body Increases and irritates heart Increases blood pressure Respiratory problems Anorexia Damages blood vessels in brain/placenta Cardiovascular Collapse Death

39 Dopamine Nicotene increases dopamine 200-225% for 15 minutes Cocaine increases dopamine 200-325% for ½ to 1 ½ hours Methamphetamine increases dopamine 1000% for 3-5 hours and is considered neurotoxic to dopamine receptors

40 Users 39% are 20-29 years of age 80% are white 47% are female 80% of meth admissions to hospital are white Increased sexuality & Hypersensitivity to touch, decreased inhibitions, increased self-confidence, increased unprotected sex, increase STD’s and pregnancy

41 Risks to children in utero Malnourished Prebirth stroke & bleeding Born Meth dependent, jittery, decreased sucking and swallowing ability Low BW, slow growth, hypersensitivity to touch. Neuro depletion of dopamine Test for meth toxicity at birth

42 Tests for Meth Use Neonatal meconium-Second trimester to birth and costs $77.00 Urine/Maternal/Neonate-2-3 days after birth and hard to get Neonatal/Maternal hair-one month history of use Large sample of blood or amniotic fluid-not recommended for neonate

43 Case Study 33 year old G6P4 female at 28 1/7 weeks gestation with twin prenancy Premature rupture of membranes. C- section performed at day 3 because of fetal compromise. Urine drug screen performed day 2 and 3. Mom’s urine was positive, meconium was negative.

44 Consequences No remorse-Rohaus case in California when man tortured and mutilated his 4 year old niece. 5.3% of US Pop 12+ report meth use at least once 2.2% 8 th graders,3.9% of 10 th graders, and 3.6% of 12 th graders Replacing the date rape drug

45 SANE Sexual Assualt Nurse Examination Step 1-19 Conducted in Emergency Room Considered an evidentiary exam

46 Step 1 Authorization Read the form Information you should know as a survivor of sexual assault/abuse –Provides information about sexual assault and offers options in prosecution etc. –Complete the consent for exam and release of evidence form

47 Step 2 Assault/Abuse History Form Asked client about the onset, frequency, duration, name of abuser, and patient information –Asks for specific information about vaginal, anal and oral contact; ejaculation, hygiene practices since assault, menstrual history and if client was menstruating during the assault.

48 Step 3 Collection of urine and blood samples for toxicological screeening for lab if it is possible it was a drug facilitated assault. This step is optional

49 Step 4 Clothing Collection –Intimate clothing such as underwear, bra, or any outer garments worn after the assault. –Undergarments are kept separately. –Do not shake garments

50 Step 5 Dried Stains –Ejaculation into the patient’s body, leakage from the patient’s body and the suspect’s use of his or her mouth on the body are examined. Swab all areas that fluoresce and also those with possible saliva.

51 Step 6 Cut Head Hair Standards –Use a clean sissors and cut 10-15 hairs from various parts of head

52 Step 7 Oral Swabs and Smear –Collect four oral swabs regardless of the assault/abuse history –Do not discard the swab. Label and seal

53 Step 8 Children ONLY: Oral culture for Gonnorhea –Culture the pharynx for gonorrhea –Non culture swabs such as ELISA and DNA may not be acceptable evidence

54 Step 9 Fingernail Scrapings/Cuttings –Scrape or swab under the patient’s nails using the orange stick or swabs provided in the nail scrapings envelope. Moisten the swabs to collect dry material. Clip fingernails if broken.

55 Step 10 Pubic Hair Combings or collect any stray hairs from the genital area –Comb directly into the envelope or use tweezers to collect stray hairs.

56 Step 11 Cut pubic hair standards –Using clean sissors, cut 10-15 hairs from various pubic hair. Cut as close to the skin.

57 Step 12 Anal/Perianal swabs and smear –Four anal swabs regardless of assault history.

58 Step 13 Children ONLY: –Anal/Perianal Cultures for gonorrhea and chlamydia. Cultures go to the lab

59 Step 14 Vaginal/Penile Swabs and Smear –If the patient has a tampon, collect –Swab external vaginal area and labia if cunningulus occurred –Collect regardless of history

60 Step 15 For children ONLY: Vaginal Penile Cultures for gonorrhea and chlamydia

61 Step 16 Blood Standard –Collect the patient’s blood standard wearing gloves. Pleace 2-3 drops of blood from a tube collected on the filter paper

62 Step 17 Complete Documentation of all injuries. –Take photos –Document injuries using anatomical outlines

63 Step 18 Give the patient the Document of care, after care information and resources and caring for yourself: A note to survivors; Give parent the document, Helping your child.

64 Step 19 Final instructions –Place original copy of all three pages of assault history form into the kit, –Follow instructions to seal specimens and kit

65 Luisa Luisa is a 4 year old hispanic child brought into the physician by her maternal grandmother because she is such a picky eater, oppositional, and sleeps very little. Her mother is a nurse and works crazy hours. Her father was a Cuban refugee with a history of murdering a man in a fight. Luisa tells the physician that she “sucks her daddy’s penis”. She is 25% underweight and screams to the physician that she is tired. Grandma suspects there is drug use in the house. She admits her daughter does not pay any attention to Luisa and may lock Luisa in her room at night. Her exam indicates that she has not had vaginal intercourse, possibly has had anal intercourse, has bruises on arms and is slightly neurologically impaired with numbness of face and arms and decreased reflexes. What are you planning to do?

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