Child Abuse

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Child Abuse

• James L. Lukefahr, MD

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General considerations

• Suspect abuse with any unusual physical or
  psychological complaint
• Is the injury consistent with the history?
• Identify signs and symptoms of suspected abuse
• Maintain a safe environment for the child
• Maintain objectivity
• Understand legal requirements for reporting
  suspected child abuse

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General considerations (cont)

• Case management should be a team approach
• Physicians and nurses
• Social services
• Law enforcement agencies
• Document, document, document
• Document some more

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INCIDENCE OF ABUSE

• 15/1000 Children Confirmed
• Each Year as Abuse Victims
• 1996 Validated CPS Cases
• True Incidence 22-30/1000
• 1993 Natl Incidence Study

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Injuries associated with non accidental trauma
can involve many different organ systems

• Soft tissue/skin
• Head and neck injury
• Chest injury
• Abdominal injury
• Skeletal trauma
• Genitalia

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Bruises

• Common to all children
• Accidental injuries typically occur on the
  forehead and extremities
• Bruising can occur secondary to medical
  conditions
• Leukemias
• Idiopathic thrombocytopenia purpura (ITP)
• Coagulopathies (bleeding disorders)
• Suspicious injuries
• Occur in different planes of the body
• Different stages of healing
• Central distribution
• Injuries to the back
• Pattern injuries

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• Bruising and other soft tissue injury is
  extremely uncommon in children younger than 6
  months of age and increases in frequency as
  children becomes older and more mobile
• Any bruising on an infant be considered suspicious for abuse

If youre not old enough to cruise, youre not
old enough to bruise
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Facial bruises

• Contusions are the most common injury seen in
  abused children and are the most common injury
  sustained to the head and face

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Handmarks

• Bruising occurs in the tissues between the
  fingers, where tissue is squeezed or compressed
• Slap marks
• Grab marks
• Knuckle marks

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Bruises from grabbing the upper arm
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Slap marks across the face
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Pattern marks

• Injuries that occur from foreign objects will
  often leave specific patterns or markings
• Ropes
• Cords
• Belts and belt buckles
• Shoes
• Kitchen tools

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Discipline? Or Abuse?
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Discipline? Or Abuse?

• AAP Guidelines for Effective Discipline (2002)
• Discipline is a multifaceted approach to assuring
  a childs safety and successful development,
  involving positive as well as negative
  reinforcement.
• Corporal punishment is child abuse if
• Its performed when the adult is angry or out of
  
• control
• The intention is to inflict pain
• Involves anywhere other than the clothed
  buttocks or
• backs of the thighs
• Leaves a mark for more than a few minutes
• An object is used (belt, cord, paddle)

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Burns

• Thermal injuries can be caused by accident,
  abuse, or neglect
• Pattern of injury is important
• Burns secondary to falling or splashing of hot
  liquid should have a non specific pattern
• Inflicted injuries typically involve many
  different planes
• Thermal injuries with a stocking glove
  distribution represent immersion injuries
• Is the injury consistent with the history?

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Intentional burn injuries

• Inflicted injury
• Extent of the burn depends on
• Water temperature
• 117 F is the threshold for scald injuries
• Duration of exposure
• 3rd degree burns occur on adult skin after
• 1 minute in 127 F water
• 30 seconds in 130 F water
• 2 seconds in 150 F water
• Presence or absence of clothing and material
• Area of body exposed
• Soles and palms tend to have thicker skin than
  other parts of the body

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Skin Protected by skin folds
Skin protected by bottom of tub
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Contact burns

• Typically leave a patterned mark
• Cigarette lighters
• Irons
• Heaters

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Iron floor
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Iron butt
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Curling iron
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Head and neck injuries

• Bruises and contusions
• Injuries to the oral cavity
• Shaking injuries
• Injuries to the neck
• Most serious injuries are related to direct
  trauma
• Shaking injuries
• Blunt force trauma

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Shaken Baby Syndrome / Abusive Head Trauma
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SBS is a form of AHT

• SBS is a form of Abusive Head Trauma that occurs
  when a frustrated caregiver violently shakes
  and / or slams a child head against a
  stationary object, usually to stop them from
  crying or to get a child to respond to the
  expectations of the caregiver.
• There are usually no outward signs of trauma, but
  there is significant injury to the brain and
  often the eyes

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AAP Policy Statement on SBS

• the act of shaking leading to Shaken Baby
  Syndrome is so violent that individuals observing
  it would recognize it as dangerous and likely to
  kill the child.

American Academy of Pediatrics Policy Statement,
Vol. 108, Number 1 July 2001
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Common Triggers for Shaking
CRYING
Feeding Problems
Toilet Training
Interrupting
Dr. Jacy Showers, 1998
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• Example Of Shaking
• The child is grasped by trunk or arms
• They are violently shaken back and forth
• Chin impacts chest
• Back of head impacts upper back

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Symptoms of SBS / AHT

• Mild cases
• Irritability
• Poor Feeding
• Vomiting
• Lethargy

• Severe cases
• Respiratory distress
• Cardiac arrest
• Seizures
• Coma
• Death

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Timing and Onset of Symptoms in SBS / AHT

• Mild Cases
• Immediate onset of symptoms will occur with any
  injury but the symptoms may be vague
• These symptoms can be missed by medical
  professionals
• (C. Jenny, JAMA, 1999, 281621-626)
• Severe or fatal cases
• Immediate onset of symptoms
• No lucid interval (normal behavior) following
  traumatic insult to the brain

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Medical Diagnosis

• Subdural hemorrhage
• Retinal hemorrhage
• Cerebral edema (Brain swelling)

Subdural Bleeding
The Big 3
Retinal Bleeding
Brain Swelling
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History Given by Caregivers

• The history provided by caregivers is frequently
  absent or attributed to a common, low energy
  accidents such as a fall down the stairs or off a
  couch, or rough-housing with another young child

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Skeletal Trauma (Fractures)
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Skeletal trauma

• Consider the mobility and developmental level of
  the child
• Fractures in small infants and non-mobile
  children are highly suspicious for non-accidental
  trauma
• History should be consistent with physical
  findings
• Multiple fractures, especially if they are of
  differing ages are highly suspicious of abuse
• Skeletal trauma often accompanies abusive head
  and abdominal trauma

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Imaging recommendations

• An initial skeletal survey should be performed in
  all infants under 2 years of age that are
  suspected of having been abused or severely
  neglected.
• All films should be reviewed by a pediatric
  radiologist
• In seriously-abused children, follow-up skeletal
  films should be performed two weeks later for
  evaluate for occult or hidden fractures

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Types of fractures

• Metaphyseal and Epiphyseal fractures
• Referred to as Corner or Bucket Handle
  fractures
• Occur from a pulling or jerking type motion of
  the limb as well as rotational forces that can be
  applied during shaking of a child
• Considered to be pathognomonic (diagnostic) of
  abuse

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Metaphyseal Fracture
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Long bone fractures

• Commonly seen in accidental and non accidental
  trauma
• Most common site for abusive trauma in the arm is
  the humerus
• Most common sites for abusive trauma in the leg
  is the femur and tibia

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Spiral Fracture of Femur
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Skull fractures

• Skull fractures in abused children can be
  produced by a direct blow to the head or by the
  child being thrown onto a hard object
• Skull fractures can be simple or complex
• Depressed skull fractures in young children are
  indicative of trauma
• Simple linear skull fractures can be caused by
  accidents or abuse, but it is rare to have
  associated brain injury or retinal hemorrhages
• Is the history consistent with the injury

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Skull fractures
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Child Abuse Reporting Requirements

• Any person having cause to believe that a
  childs physical or mental health or welfare has
  been or may be adversely affected
• must report their concern to Child Protective
  Services or to a law enforcement agency.

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Why should I report?

• Health care professionals are especially expected
  to report, given our expertise and influence.
• A child with unrecognized abusive injury has a
  50 chance of sustaining a 2nd serious injury.
• Failure to report child abuse is a class B
  misdemeanor (up to 1000 fine, 180 days in jail).

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How do I report?

• Texas Child Abuse
• Reporting Hotline
• 1-800-252-5400
• Or
• https//reportabuse.ws

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What happens when I report?

• CPS intake worker evaluates risk, assigns
  priority
• Priority 1 local CPS makes contact within 24
  hours.
• Priority 2 contact within 10 days.
• CPS can take emergency custody if reason to
  believe child is in danger.
• Custody hearing before a judge within 14 days,
  then every 60-90 days.
• Final order 1 year after initial hearing.

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What do I tell the family?

• Honesty is the best policy. People know when we
  act sneaky.
• Parents know were required to report.
• We dont accusewe take care of kids.
• Im really concerned about your childs injury.
  You may know Im required by law to report
  injuries like this to Child Protective Services.
• CPS appreciates us informing the parents easier
  to have rapport if parents are expecting them.
• Exception if youre worried about your safety,
  or safety of child or family.

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What do I tell the family?

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What about parental permission and release of
medical records?

• Texas Family Code says parental permission is not
  required to examine a child if abuse is
  suspected. This includes taking pictures.
• A health care provider who makes a report of
  child abuse may release medical records to CPS or
  law enforcement without parental consent if they
  are relevant to the investigation of the reported
  abuse. (Supersedes HIPAA)

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Preventing Child Abuse

• Individual patients, families
• Parenting education
• Treat mental illness
• Recognize high-risk families
• Community efforts
• Education
• Healthy Families Initiative

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Healthy Families Initiative

• Community collaboration
• Identify high-risk families
• Support, empower parents to change risky
  lifestyles

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Conclusions

• Child abuse occurs frequently in our society
• Always consider the developmental age of the
  child
• Is the history consistent with the injury
• If you dont think about the possibility of
  abuse, you will miss it every time
• Reporting suspected abuse is imperative
• Prevention is difficultimpossible for one of us,
  possible for all of us