Basic Child Abuse Curriculum

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Basic Child Abuse Curriculum

• For Health Professionals

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Developed by the ISPCAN Medical Curriculum
Development Taskforce

• Members Dr. Steve Boos (Chair), Dr. Evelyn
  Eisenstein (Co-Chair), Dr. Moh Sham Kasim, Dr.
  Randa Youssef, Dr. Patricia Lai Sheung Ip, Dr.
  Tufail Muhammad, Dr. Margaret Lynch and Dr.
  Randall Alexander
• Dr. Howard Dubowitz, Facilitator and Editor
• ISPCAN Staff Support

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Vignette 1

• Infant Male USA
• Economically stressed family
• Fussy baby
• Bottom bruises
• Otitis media
• Subdural hematoma
• Extensive retinal hemorrhages

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Vignette 1 Fussy infantSource AAP
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Discussion

• What is child abuse?
• How common are child maltreatment, child physical
  abuse, abusive head trauma?
• Were Bobbys injuries due to child abuse?
• What is Bobbys diagnosis?
• Why didnt the doctor suspect child abuse at
  Bobbys two week well-baby-check?

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What is Child Maltreatment?
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Child Maltreatment

• All forms of physical /or emotional ill
  treatment, sexual abuse, neglect or negligent
  treatment or commercial or other exploitation,
  resulting in actual or potential harm to a
  childs health, survival, development or dignity
  in the context of a relationship of
  responsibility, trust or power.
• (World
  Health Organization 1999)

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Incidence of Child Maltreatment

• Rate per 1000

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Incidence of Child Maltreatment

• Rate per 1000

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Known cases are just the tip of the iceberg
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Rates of Harsh Physical Punishment
Source WHO WorldSAFE study Runyan DK.
Pediatrics. 2010126e701-11
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Rates of Psychological Punishment
Source WHO WorldSAFE study
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Abusive Head Trauma

• Shaking of children lt 2 years
• Keenan ICU admissions deaths
• Theodore parental report

Keenan, et al. JAMA. 2003290621-6 Theodore, et
al. Pediatrics. 2005115e331-7
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Rates of child maltreatment are higher than what
most official statistics suggest

• But is child maltreatment more common than other
  childhood conditions??

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Comparison to Other Childhood Conditions
Denotes prevalence. All others are incidence
rates
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Are Bobbys Injuries Due to Child Abuse?
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Differential Diagnosis

• 1 - Trauma
• 2 - Trauma
• 3 - Trauma

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Differential Diagnosis Subdural Hemorrhage

• Non-inflicted trauma
• Bleeding disorder
• Ruptured aneurysm
• Ehlers-Danlos
• Glutaric aciduria type I

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Differential DiagnosisRetinal Hemorrhage

• Normal newborn Aneurysm
• Bleeding disorder CPR
• High blood pressure Infection
• Metabolic disorder
• Above rarely cause extensive hemorrhage!

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Differential Diagnosis of Rib Fractures

• Non-inflicted trauma should be history of
  severe trauma (eg, MVC, direct blow)
• Birth injury history of difficult delivery
• Metabolic bone disease OI, rickets, etc.
• Extreme prematurity

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Rib Fractures

• HIGH SPECIFICITY FOR ABUSE
• Especially if posterior or lateral
• Usually occult
• Acute rib fractures often missed, esp. if
  anterior or lateral
• Easier to see on X-ray when healing, after 1-2
  wks.

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Rib Fractures - Mechanism of Injury

• Compression of the chest causes leverage of
  posterior ribs over spine.
• Compression places tension along inner aspects of
  the rib head and neck regions, causing fracture.

• Kleinman, PK. Diagnostic Imaging of Child Abuse,
  2nd ed. St Louis, MO Mosby, Inc. 1998. p116.

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What is Bobbys Diagnosis?
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• ABUSIVE HEAD TRAUMA
• IS
• ANY INFLICTED INJURY TO THE HEAD OF A CHILD

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Shaken Baby Syndrome
Shaking Impact Syndrome
Abusive Head Trauma
Inflicted Traumatic Brain Injury
iTBI
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Definition

• Abusive head trauma any inflicted injury to the
  head of a child
• Encompasses shaken-baby syndrome and
  shaking-impact syndrome
• Contact and/or non-contact injury

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Epidemiology

• Occurs most commonly in infants
• Shaking injury reported in children up to 5 years
  of age
• At least 2/3 of serious head injuries in infants

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Diagnostic Findings

• Subdural hemorrhage
• Retinal hemorrhage
• Brain injury
• Fractures especially rib and metaphyseal

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Potential Triggers

• Crying
• Toilet training
• Perceived misbehavior
• None

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Signs and Symptoms

• LESS SEVERE
• Lethargy
• Irritability
• Poor appetite
• Vomiting

• MORE SEVERE
• Seizures
• Unconsciousness
• Breathing difficulty
• Death

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Why didnt the doctor suspect abuse at his 2 week
well child visit?
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Contributors to Child Maltreatment
Society
Community
Family
Parents
Child
Professionals
Belsky, Psychological Bulletin. 1993114413
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Child Risk Factors

• Age - younger children
• Gender -
• - girls higher risk for infanticide, sexual
  abuse, educational and nutritional neglect.
• - boys higher risk for physical abuse
• Special Characteristics twins, children with
  handicaps, prematurity, unwanted pregnancy

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Parent/Caregiver Risk Factors

• Young age
• Single parent
• Unwanted pregnancy
• Poor parenting skills
• Substance abuse
• Physical or mental illness

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Family Risk Factors

• Overcrowded living circumstances
• Poverty
• Social isolation
• Major stress
• Domestic violence

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Community/Societal factors

• No/poorly enforced child
  protection laws
• Limited value of children
• Social acceptance of violence (family, community
  or society including war)
• Cultural norms
• Social inequities - poverty

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Professional Factors

• Failing to
• Acknowledge that child
  maltreatment exists
• Identify and address child
  maltreatment
• Offer necessary services to
  children and families
• Help prevent maltreatment
• By promoting health, development and safety
• By addressing major risk factors

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Discussion

• Why didnt the doctor suspect child abuse when
  Bobby returned with symptoms?
• Assuming abuse, what do you think are the
  consequences of Bobbys child abuse?
• Why do you think abuse might have happened in
  this family?

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Why didnt Bobbys doctor suspect abuse when he
returned with symptoms?
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Teaching Points

• Physicians look to the history for the answer
  disregarding the history is hard.
• Thinking of abuse is uncomfortable, particularly
  in families who are nice, sympathetic
• Inflicted trauma is often occult

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Clinical Presentation

• Non-specific findings
• Absent or misleading history
• _______________________
• Missed diagnosis

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Missed Diagnosis

• More common in families who are
• White
• Have married parents
• Higher income

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Outcome for Victims

• Mental retardation
• Severe brain damage
• Learning disabilities
• Seizures

• Hearing and speech impairment
• Visual impairment
• Behavioral disorders
• Death

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Why do you think abuse might have happened in
this family?
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Vignette 2

• Maria - teenage mother, Brazil
• Found unconscious,
  possible suicide attempt
• 3 month old and 4 year old
  children dirty, hungry, developmental
  concerns
• Elena - 4 year old girl is masturbating
  frequently physical exam is normal
  
• Maria was sexually abused as a child

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Discussion

• Was Elena sexually abused?
• How does Elenas physical examination influence
  your impression?
• What were the consequences
  of child abuse for Maria?

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Discussion

• Have Elena and her brother been neglected?
• What is the relationship between Marias
  experiences and the
  neglect and sexual abuse of
  her children?

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Was Elena sexually abused?
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Child Sexual Abuse

• Involvement of a child in sexual activity that
  he/she
• does not fully comprehend,
• is unable to give informed consent to,
• is not developmentally prepared,
• violates laws and taboos of society
• Children can be sexually exploited by an adult or
  other child who by virtue of age or development
  is in a position of responsibility, power or
  trust
• (From ISPCAN WHO in, Preventing
  Child Maltreatment, 2006)

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Child Sexual Abuse

• Often a hidden assault
• All forms of sexual activity are included, not
  just intercourse and other physical types
• Includes child prostitution and exposure to
  pornography

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Perpetrator Characteristics

• No typical profile
• Many appear normal, successful and have no
  criminal record
• Most are male
• Most are familiar to the child many in position
  of trust, authority
• 20 - 40 adolescents
• Many (not all) were abused themselves

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Child Characteristics

• About 85 female (cases known to system)
• Peak ages
• Girls and boys early school age 5-7 years
• Girls 14-15 years
• Vulnerable, needy

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Ways Children May Be Identified

• Physical signs injury or infection
• Childs disclosure to another
  child, parent, therapist, or trusted
  adult
• Child sexually abuses another child
• Child uses sexually explicit language, behavior
  beyond normal development

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Does Elenas normal exam rule out the possibility
of sexual abuse?
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The Medical Exam - Findings

• Its normal to be normal
• More than 95 of referred children have normal
  exams
• Why???
• Abusive acts may leave no injury (e.g. fondling)
• Causing injury increases risk of disclosure
• Injuries often heal without scars before
  disclosure and medical evaluation

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The Medical Evaluation Whats Not Normal

• Genital injury
• Acute - tears, bruises, bite marks
• Sub-acute, chronic healed hymenal tears, scars
• Sexually transmitted infections
• Pregnancy
• Forensic evidence sperm, semen, etc.

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Sexualized Behavior in Children

• Possible causes
• Sexual abuse
• Poor understanding of societal norms
• E.g. child with developmental disabilities
• Sexual curiosity/exploration
• Exposure to explicit sexual activities
• Witnessed activity in home, on TV, movies
• Viewing pornography
• May be inadvertent, neglectful, or abusive

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Common Behaviors - 2-9 years (unlikely to be
related to abuse)Friedrich WN. Normative sexual
behavior in chidren. Pediatrics. 1998 101e9

• Boys
• 1) Touches sex parts at home
• 2) Touches breasts
• 3) Stands too close
• 4) Tries to look at other people when they are
  nude
• 5) Touches sex parts in public
• 6) Masturbates with hand

• Girls
• Touches sex parts at home
• Touches breasts
• Tries to look at other people when they are nude
• Stands too close
• Masturbates with hand
• Touches sex parts in public

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Common Behaviors - 10-12 years (unlikely to be
related to abuse)Friedrich WN. Normative sexual
behavior in chidren. Pediatrics. 1998 101e9

• Boys
• 1) Very interested in opposite sex
• 2) Wants to watch TV nudity
• 3) Tries to look at pictures of nude people
• 4) Knows more about sex
• 5) Talks about sex acts
• 6) Touches sex parts at home

• Girls
• Very interested in opposite sex
• Knows more about sex
• Stands too close
• Wants to watch TV nudity
• Touches sex parts at home
• Talks about sex acts

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Uncommon Behaviors _at_ 2-12 years (more likely to
be related to abuse)

• Puts mouth on sex parts
• Asks to engage in sex acts
• Masturbates with object
• Inserts objects in vagina/anus
• 5) Imitates intercourse

• Makes sexual sounds
• Tries to french kiss
• Undresses other people
• Asks to watch explicit TV
• 10) Imitates sexual behavior with dolls

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Behaviors that Raise Concern

• Excessive focus on sexuality, knowledge beyond
  normal development
• Inappropriate behavior despite redirection
• Sexual behavior/exploration/coercion with much
  older/younger children
• Inflicts injury to own or others genitals
• Disturbing toileting behavior
• Drawings with genitals predominating
• Sexual contact with animals

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What were the consequences of sexual abuse for
Maria?
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Impact of Sexual Abuse Physical Health

• Short term
• Acute injuries
• STDs
• Long term
• GI problems (irritable bowel)
• Chronic pain (headache, abdominal, back, or
  pelvic pain)
• Obesity, failure to thrive
• Somatization

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Impact of Sexual Abuse Mental Health

• Behavioral problems withdrawal, acting out,
  delinquency
• Depression
• PTSD other anxiety disorders
• Substance abuse
• Eating disorders anorexia, bulemia
• School failure
• Low self esteem, interpersonal difficulties

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Have Elena and her brother been neglected?
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Child-Centered Definition of Neglect

• Neglect occurs when a childs basic needs are
  not met, resulting in potential or actual harm.
• Basic needs include adequate
• Food - Clothing
• Supervision - Protection
• Health care - Education
• Love nurturance - Home

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What is the relationship between Marias
experiences and the neglect and sexual abuse of
her children?
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Teaching Points

• All forms of maltreatment increase with social
  risk factors, especially poverty
• Sexual abuse is the least related
• Neglect is the most related
• All forms of abuse happens in every ethnic,
  social and economic group

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Additional Teaching Points

• False allegations are rare
• False denials are common
• Sexually abused children often grow up to be
  unsympathetic witnesses
• Runaways
• Street children
• Delinquents

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Teaching Points

• Neglect failure to meet a childs basic needs
  (rights)
• Emotional
• Nutritional
• Housing
• Safety
• Health
• Education

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Teaching Points

• Neglect may seem benign
• Its not
• It has serious potential effects
• Physical eg, poor growth, ingestions, death
• Cognitive eg, developmental delay, learning
  problems
• Mental health eg, emotional and behavioral
  problems
• Social Juvenile delinquency and criminal
  behavior

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Vignette 3

• Middle-aged man China
• Physical and psychosomatic
  ailments
• Tobacco and alcohol abuse
• Beaten as a child
• Witnessed domestic violence
• Broke off relationship with mentor
• Socially isolated

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Discussion

• What adverse childhood
  experiences can you identify
  or do you suspect?
• What do you think happened between
  Lao Zhang and his mentor?
• Could it have been sexual abuse?

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Discussion

• What possible behavioral consequences may be
  related to Lao Zhangs
  childhood experiences?
• What medical consequences have occurred, or might
  occur, in a patient like Lao Zhang?

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Impact of Maltreatment on Children

• Every child is affected extent varies
• Several factors determine the impact
• Nature of maltreatment
• Childs personality
• Protective factors
• Consequences can be
• Physical
• Psychological
• Behavioral
• Societal

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Physical Consequences

• Injuriesi.e fractures, burns, injury to internal
  organs, lacerations, head injury
• Impaired brain development
• Short and long-term disability
• Death

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Odds of Ischemic Heart Disease By Number of
Adverse Childhood Experiences
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Psychological Consequences

• Common
• May include
• Immediate issues of isolation, fear and lack of
  trust
• lifelong problems of depression, low self-esteem,
  relationship difficulties
• Impaired cognitive development

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Suicide Risk by ACE Score
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Teaching Points

• Many older people suffered abuse
  that they may not see as
  abuse, or, may not
  discuss
• This is particularly true of
  sexual abuse in boys
• Witnessing domestic violence can seriously affect
  children

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Teaching Points

• Adverse childhood experiences may have long
  term health effects
• Health problems (eg, heart disease)
• Mental health problems (eg, depression,
  suicidality)
• Vulnerability due to stress, social isolation?

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Vignette 4

• Six-year old girl
• At seven-months of age
• Symptomatic femur fracture
• Old and new rib fractures
• classic metaphyseal lesions
• Protected
• Family treated
• Reunified

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Discussion Questions

• What do you think caused Palwashas many
  fractures?
• What might have happen to Palwasha when she was
  removed?
• What services might be
  helpful to Palwasha and
  her family?

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What are possible causes of Palwashas many
fractures?
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Differential Diagnosis of Long-bone Fractures

• Child abuse
• Non-inflcited (accidental injury)
• Medical disorders that increase
  risk for fractures
• Osteogenesis imperfecta
• Rickets

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Long Bone Fractures

• Low specificity for abuse
• EXCEPT IN INFANTS (pre-ambulatory children)
• Spiral or oblique fracture non-specific
• Indicates torsional (twisting) force

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Long Bone Fractures Femur

• Common non-inflicted patterns
• Running falling, especially with twisting
  motion
• Twisting against a planted foot with a fall
• Femur fractures very suspicious for abuse in
  infants not yet walking

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Long Bone Fractures Humerus

• Shaft fractures
• Consider age of child hx of injury
• Supracondylar fx
• Due to fall on elbow
• Mostly not inflicted
• Abuse more likely in infants

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Long Bone Fractures Tibia

• Toddlers fracture
• Oblique, non-displaced fracture of distal tibia
• History of minor or no trauma
• In infants toddlers who have just begun to
  cruise or walk
• NON-INFLICTED

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Long Bone Fractures Classic Metaphyseal
Lesion (CML)

• Corner or bucket-handle depending on view
• Mechanism twisting or pulling of extremity or
  acceleration/deceleration forces during shaking
• HIGHLY SPECIFIC FOR ABUSE

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SUMMARY DIAGNOSISSpecificity of Fractures
HIGH MODERATE LOW
CML Multiple fx, esp. bilateral Subperiosteal new bone
Rib Fx of different ages Clavicle
Scapula Epiphyseal separation Long bone shaft
Spinous process Vertebral body Linear skull
Sternum fx Fingers/toes
Complex skull fx
Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO Mosby, Inc. 1998. P 9. Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO Mosby, Inc. 1998. P 9. Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO Mosby, Inc. 1998. P 9.
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What might have happened to Palwasha when she was
removed?
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Discussion

• What system exists in your community to protect
  abused children?
• How do you activate that system?
• What services exist in your community to treat
  abused children, their non-abusive family
  members, and those who abuse children?

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Teaching Points Steps in Helping Abused Children

• Identify abuse
• Stop abuse, prevent further abuse
• Treat the medical AND emotional
  consequences
• Support the family - help make it safe
• OR
• Find a safe alternative home

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Teaching Points

• Many abused children suffer from life long
  problems

However
Many abused children become successful adults
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To Request an Electronic Copy. . .

• Send email to
• training_at_ispcan.org

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Teaching Points

• How is protection provided for in your social /
  legal system?
• What can you do to improve that?
• What treatment is available for abused children
  and their families?
• How can access be improved?

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Teaching Points

• Up to 1/3 of inflicted head trauma cases are
  missed at 1st presentation
• 27 re-abused
• 40 complications
• 7 die

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Teaching Points

• Sexual abuse presents many ways
• Injuries
• Sexually transmitted infections
• Disclosure
• Emotional and behavioral changes
• Post traumatic stress disorder (PTSD)

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Teaching Points

• gt 90 of physical exams are normal
• Fondling
• Oral and anal sex
• Healing of injuries
• Anatomic variation

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Teaching Points

• Many later consequences of abuse
• PTSD, depression, suicide
• Conduct disorder, school troubles, drug use
• Early sexual activity, pregnancy, STIs, HIV

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Discussion

• What are the consequences of neglect for Marias
  children so far?
• What social, environmental, and family factors
  contributed to this situation?

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Discussion

• What are Maria's legal rights to stay with her
  children?
• What are Paulo's rights and responsibilities to
  help, support and visit his children?

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Teaching Points

• Rights and responsibilities of the family?
• Maria
• Paulo
• Extended family
• Ability of the social system to substitute for or
  support the family?