Edward M. Santos, MD, DPPS
OBJECTIVES At the end of the lecture, the student should be able to: • Know the definition of child abuse and neglect • Identify the different forms of child abuse • Know the incidence/prevalence of child abuse • Identify physical and behavioral indicators of child abuse • List several short and long term outcomes of child abuse • Identify methods to prevent and address child abuse.

January 5, 2012

Definition (WHO) “all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship, trust , or power…” Definition of a Child • RA No. 7610 • “Special Protection of Children Against Child Abuse, Exploitation and Discrimination Act” • “CHILD” o Person below 18 years of age o Person over 18 years of age unable to care for self or protect self from abuse, neglect, cruelty, or exploitation due to mental or physical disability Forms of Child Abuse • Physical Abuse • Emotional/ Psyhological Abuse • Sexual Abuse • Neglect Incidence History of abuse among adolescents: Physical Abuse = 82.9% Sexual Molestation = 11.9% Forced sex/rape = 1.8%
Source: Baseline Surveys for the National Objectives for Health, Philippines, 2000

Age Group, Sexual Abuse Cases (Child Protection Network, 2008) 0-3 years old – 7.14% 4-6 years old – 16.65% 7-9 years old – 10.98% 10-12 years old – 14.57% 13-15 years old – 31.61% 16-18 years old – 18.48% >18 years old – 0.57% Age Group, Physical Abuse Cases (Child Protection Network, 2008) 0-3 years old – 10.58% 4-6 years old – 13.88% 7-9 years old – 15.13% 10-12 years old – 18.43% 13-15 years old – 25.82% 16-18 years old – 15.36% >18 years old – 0.80% Mandatory Reporting (R.A. 7610) Mandated Reporters: • Physician • Nurse • Head or administrator of health care unit, institution * Reporter is granted immunity from any liability arising from reporting. When to Report? • Report any suspicion of child abuse within 48 hours either orally or in writing • No obligation to prove that abuse happened • Reporter in not the complainant • Reporter need not nform the family concerned that they reported possible child abuse Where to Report? • DSWD Central or LGU Social Worker • Violence Against Women and Children Division (VAWCD), NBI • Women’s and Children’s Desk, PNP • Barangay Council for the Welfare of Children • Commission on Human Rights

DSWD Reports

Contrasting Statistics

Definition (WHO, 2000) Result from an act of commission which produces actual physical harm or hold potential for harm) which is reasonably within the control of a parent or person in a position of responsibility, power or trust. May be single or repeated incident. Indicators

• Physical:
Proportion of Patients per Type of Abuse (Child Protection Network)

unexplained bruises, burns, human bites, broken bones, missing hair, scratches
o Bruises are the most common manifestation of physical abuse o Bruising in a perambulatory infant o Bruising in padded and less exposed areas o Patterned bruising or burns conforming to shape of an object or ligatures around the wrist


Multiple bruises, especially if clearly of different ages

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Categories of Physical Abuse • Spurning o o o o Belittling. lags in physical development. behavioral extremes (aggressive or withdrawn). Glove pattern 1st and 2nd degree burn of the hand The hands were dipped in boiling water. forehead abrasions. serious impairment of the physical. 2. The caretaker explained that the burns were a result of an accidental spillage of hot water from a thermos. and adults. “ A baby cannot exist alone but is essentially part of a relationship. or acts which themselves have an adverse effect on the emotional health and development of a child. indicators of emotional abuse: depression. anxiety. cheek abrasions. poor self esteem. touch and bonding. berating.• Behavioral: wary of physical contact with adults. Her face showed diffuse plethora and petechiae. . ignoring. or isolating a child. Subconjunctival hemorrhages are also evident. lack of empathy • Behavioral Young children need loving and nurturing environments. mental. stealing. cheating. social. . Failure to Develop Attachment • Child will have a lifetime of difficulties with intimacy. 1965 The girl has periorbital bruising. teens. terrorizing. Young children who are physically abused are at high risk to be aggressive children. that causes. Definition (WHO.parental behavior. denigrating or rejecting Ridiculing Singling out Humiliating in public • • • • Terrorizing Isolating Exploiting/ corrupting Denying emotional responsiveness NEGLECT Definition (WHO.includes verbal abuse and humiliation and acts that scare or terrorize the child • Physical indicators of emotional abuse: speech disorders. • Children identified as uncontrolled at age 3 were 2. 2000) 2 of 6 |Page . The caretaker explained that the bruises were a result of the child being awkward and always tripping or falling.2 times as likely to be repeat offenders. or is likely to cause. trust.9 times as likely as adults to be diagnosed with anti-social personality disorder. lying ( a sign that expectations in the home are too high). afraid to go home. Case 2 A 3-year-old girl was brought to CPU (Child Protection Unit) because of multiple injuries. layered clothing Case 1 A 9-year old was actually hung with a rope by her mother’s partner to make it appear that the girl was committing suicide after the child disclosed sexual abuse.” – Winnicott. 2000) Involves intentional acts which lead to a failure to provide a developmentally appropriate/ supportive environment including the availability of a primary attachment figure.5 times as likely to be convicted for a violent offense! PHYCHOLOGICAL ABUSE Her neck showed distinct circumferential ligature abrasion around her neck. Multiple skin lesions Case 3 An 11-month-old boy was brought to the CPU because of burns. • Ability to contribute to society is compromised. or emotional capacities of the child. 4. frightened of parents. failure to thrive. such as rejecting. nose abrasion and bruise on the left side of the lips.

torn. shelter. sleep disturbances. and supervision appropriate to the child’s development.e. sexual promiscuity • More likely to be blamed and not believed Relationship of Child Sexual Abuse to Commercial Sexual Exploitation Cases: • 80-90% of girls involved in commercial sexual exploitation had a previous experience of child sexual abuse such as incest. Father witnessed the alleged perpetrator insert his finger to the girl’s genitalia. regressive behavior (i. These acts include inappropriate exposure to adult sexuality. nutrition. or making a child available to others either directly or indirectly for immoral and illegal acts. or bloody underclothing. Spitz AM. (Includes failure of proper supervision) . ICD 10(International Classification of Diseases) (2007 version) T74. • Behavioral Petechiae at 3 o’clock Impact of Poverty on Early Childhood Development • Increased stress • Poor health • High incidence of child abuse • Poor access to basic services • Learn to be poor • Delay in development SEXUAL ABUSE Definition (WHO. Edwards V. inappropriate clothing for weather conditions. Long Term Impact of Child Sexual Abuse • Emotional o o o o o o o o o o o o o o o Depression Anxiety Somatization Hostility Substance abuse Suicidal ideation Self-destructive tendencies Negative self evaluation Guilt Perceived helplessness Distrust of others Difficulties with intimate relationships Higher tendency to be revictimized Sexual dysfunction Difficulty parenting Fresh laceration at 6 o’clock Anal swelling and laceration at 5 o’clock HYMENAL HEALING Case 2 A 1 ½ yo girl sexually abused girl A drunkard abducted the child from her mother. Williamson DF. poor peer relationships. • Cognitive • Interpersonal Source: Briere and Runtz (1993) J of Interpersonal Violence 8. poor hygiene. lack of appropriate supervision.1 – Physical Abuse T74. unattended physical problem or medical needs. 312-330 Impact of Sexual Abuse on the Teen-Ager • Affect their identity.0 – Neglect or abandonment T74. Child Maltreatment is a Medical Diagnosis. bed wetting). unattended physical problems or medical needs.2 – Sexual Abuse T74. unwilling to change for gym or participate in physical activities. abandonment. Relationship of childhood Case 1 A 15-year-old sexually abused girl: with disclosure of penile – vaginal penetration examined within 24 hours from the time of examination. excessive sleepiness. Nordenberg D. stained. Mark JS. drug abuse. venereal disease. emotional development. abrupt change in personality.Maltreatment syndromes T74. frequent sleepiness. inappropriate clothing for weather conditions. education. such as through pornography. Koss MP.3 – Psychological Abuse T74. Absence of injury on the 3rd day of incidence __________________________________________________________ • Physical indicators of sexual abuse: difficulty in walking or sitting. • Felitti VJ. 2000) Involves acts in which an adult uses a child for sexual gratification. shelter or safe living conditions..Failure to provide for the development of the child in one or more of the following spheres: health. indicators of neglect: begging or stealing food. withdrawn. protection from harm. Anda RF.9 – Maltreatment Syndromes Unspecified ADVERSE CHILDHOOD EXPERIENCES Study • It is the largest study ever done to examine the health and social effects of childhood experiences throughout the lifespan (17. hygiene. and medical care. • Behavioral indicators of sexual abuse: age-inappropriate sexual knowledge/sexual touch.failure of parents or caretakers to provide needed. intimate relationships • Coping strategy: running away. • Physical indicators of neglect: constant hunger. promiscuous behavior/seductive behavior.421 participants). drop in school performance/decline in school interest. attempting suicide. lack of appropriate supervision. bruises or bleeding in rectal/genital area. pain or itching in genital area. With genital and anal penetration 3 of 6 |Page . age appropriate care including food. clothing.8 – Other Maltreatment Syndromes Mixed Forms T74. direct sexual contact. abandonment.

Indigestion • Depression Consequences of Child Maltreatment Health Risk Behaviours Alcohol abuse Behavioral problems Injected/ illicit drug use Sexual risk behaviour Smoking Mental. • 5 times more likely to commit suicide. Other Social Problems Anxiety Depression Eating Disorders Obesity PTSD School failure Unwanted pregnancy Disease and Inquiry Conditions Cancer Chronic Bronchitis/ Emphysema Diabetes Ischemic Heart Disease Hepatitis Skeletal Fractures STD/ HIV Stroke Suicide PREVENTION Where prevention comes in? • The The higher the number of ACE’s the greater the risk for the following health risk behaviors: • Drinking alcohol • Smoking tobacco • Sexual promiscuity • Using illicit drugs • Overeating/ eating disorders • Delinquent behavior The higher the ACE score. social malfunction and mental illness • ACE’s are the main determinant of the health and social wellbeing of the nation. Lancet 2009 Results of the Metro Manila ACE Study Those who were sexually abused are: 4 of 6 |Page . mentally ill. et al. the risk for one or more of the following increase: • Ischemic Heart Disease • Chronic Obstructive Pulmonary Disease • Lung Cancer • Depression • Liver Disease • Suicide Attempts • Sexually Transmitted Disease • Alcoholism • Risk for DV • Unintended Pregnancies • Fetal Death • Autoimmune Disease Adverse Childhood Experiences and Health-Risk Behaviors Among Adults in a Developing Country Setting (For publication in Child Abuse and Neglect.abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. • Primary prevention requires the development of a beneficial and acceptable intrusion into the closed realm of personal and family experiences. 1998. Wathen. Ramiro. The International Journal) Laurie S. American Journal of Preventive Medicine. PhD University of the Philippines. Manila UP Manila Child Protection Unit Centers for Disease and Prevention Atlanta World Health Organization magnitude of the ACE problem is so great that primary prevention is ultimately the only realistic solution. PhD Bernadette J. Madrid. institutionalized.. MD David R. • 12 times more likely to engage in early sex. or suicidal 7) Domestic violence 8) One or both biological parents absent 9) Emotional or physical neglect Findings • ACE’s still have profound effect 50 years later • Transformed from psychosocial experience into organic disease. • 9 times more likely to have early pregnancy. Constipation. What can we do? • Stop treating symptoms and treat the cause. Reproductive. Strong graded response between number of ACE’s and poor health • Bronchitis/ Emphysema • Asthma • Ischemic Heart Disease • Hypertension • Tuberculosis • Skin problems • UTI • Liver problems • GI problems – Ulcers. Identify cases early and allow treatment of basic causes rather than vainly treating the symptom! Framework for prevention of child maltreatment and associated impairment . • We need to do a better job of routinely screening at the earliest point for ACE’s.MacMillan. Brown. 14:245-258 • Now with more than 50 scientific articles published What is an “ACE”? • An ‘ACE” is contact with any of the following conditions prior to age 18: 1) Recurrent physical abuse 2) Recurrent emotional abuse 3) Contact sexual abuse 4) An alcohol and/ or drug abuser in the household 5) An incarcerated household member 6) Someone in the home who is chronically depressed.

Enhance protective factors Develop positive parenting skills Improve coping skills Provide accessible mental health services * already available in the Barangay health centers * what NGO’s do in communities 4 Best Predictors of Child Maltreatment • Family revenue below poverty line • Mother sole financial provider • Mother’s first pregnancy occurs before the age of 21 • Four or more children in the family Source: Palacio. e. potential perpetrators) After (Secondary and Tertiary Prevention) • Respond to violence when it occurs • Provide services to survivors • Prosecute perpetrators • Encourage awareness of services. and REFER to the responsible agencies What are the consequences? o (Jenny. • The longer the abuse continues and the closer the child is to the abuser. Source: MacMillan. Lancet 2009 Programs that Prevent Child Maltreatment • School-based educational programs improve knowledge and protective behaviors.. the physician must raise concerns with the parents/caretakers. but it can happen in families of any class. depending on their age. development or whether force has been used • STDs. no data • CPU (PGH) – average of 9 cases of Shaken Baby Syndrome per year • World Studies of Abuse in the Family Environment (WorldSAFE) : 20% of Filipino mothers “shook the child” as a form of discipline Primary Prevention of Child Abuse • Prevent the problem before it starts: 1.CASE VIGNETTES Case 1: BOBBY What is bobby’s diagnosis? Shaken Baby Syndrome • Abusive head injury is a problem of very young children • In the US: 0. complications or repeat child abuse can have serious effects.9% physical abuse o 13. emotional symptoms or behavioral changes.2-0. 1999) o 27% of children whose initial head trauma is missed are reabused before being recognized o 40% suffer complications o 7% die What happened to Bobby? o He survived but with severe neurological damage. Reduce risk factors Reduce poverty Reduce alcohol abuse Reduce parental conflict * resolved on the national level How common is child maltreatment? • In the US: over 1% (data from child protection agencies) • In the Philippines – no systematic data collection • DSWD reports: 6. JAMA. child protection units • Emergency medicine for victims • Legal intervention with abuses • Foster placement for abused child In Summary. while ruling out alternate explanations • If abuse remains a possibility. the more likely that the child will have psychosomatic symptoms • 90% have normal PE findings • Spontaneously made child disclosures are true 5 of 6 |Page ..7% sexual abuse o 5. it is important to carefully clarify the circumstances and evidence. Wathen. not the family characteristics • If you miss child abuse. Case 2: MARIA Was Maria sexually abused? • Sexually abused children may present with various physical signs. • Families who look outwardly good/phenotype can commit child abuse • The injuries should direct you to consider child abuse.4% neglect Why was abuse not suspected initially? o The MD believed the parents’ story o Didn’t know that bruising at that age is unusual o Had a hard time believing this family would hurt the child • Abuse is more common when the parents are young. and in poor families • When families don’t look as mentioned above. abuse is more likely to be missed • Abuse happens more in at risk families.3% of infants per year • In the Philippines. 1993 – not in the Philippines Primary Prevention Programs that have been found to work: • Home-visiting programs: Nurse-Family Partnership • The Triple P: Positive Parenting Program • Hospital-based educational programs to prevent abusive head trauma and enhanced pediatric care for families at risk of physical abuse and neglect Source: MacMillan.g. Before (Primary Prevention) • Change conditions/ policies that encourage violence • Support Conditions/ policies that discourage violence • Encourage positive behaviors • Discourage negative behaviors (e. et al.if the physician diagnosed it at the first consult.701 cases in 2008 ( the number is greater than this stat because of many unreported cases) • DOH Prevalence Study in 2000 o 85. race or composition • The possibility of child abuse must be considered in the differential diagnosis of all children who have suffered an injury • In considering abuse. Teaching Points • Child abuse is a common occurrence 2.9% of adolescents experienced some form of abuse in their lifetime o 82.g. Lancet 2009 children’s Secondary Prevention • Early identification and treatment to stop or slow the progression of the problem o Identify families with poor parenting practices or uses harsh discipline o Intervene with aggressive parents o Identify potential cases in early stages and provide services Tertiary Prevention • Treatment or rehabilitation after violence happens. Wathen. PTSD. et al. et al. when there is only one parent.Quintin and Ethier. like 6080% of children who suffered abusive head trauma o May have been prevented.

affection and social bonds. infection. Teaching Pounts • The effects of abuse can be mitigated through protection and treatment • Know the resources in your community for protecting children. though they are not purposely harmed is a very common and potentially very dangerous form of maltreatment • Most sexually abused boys and girls have normal physical exams • The majority of sexual abuse disclosures are true Case 3: JOSE • Adverse childhood experiences • Sexual abuse • Domestic violence • Effects are often very broad and long lasting • Immediate: injury. abuse and abandonment -> “runaways”. early sexual activity.• Many abused children deny abuse when first asked (child fears the perpetrator) • Violence. and how to use them • Certain fracture patterns suggest child abuse • Brittle bone diseases alter the specificity of these findings • “novel theories of causation” are scientific sounding excuses to obscure child abuse CONCLUSION • Providing the best outcome for possibly abused children is a complicated process that includes the following: • Identifying abuse • Stopping abuse and further abuse • Treating the medical and emotional child consequences of abuse in the • Finding a safe home for the child • Supporting the family to help them take adequate care of the child 6 of 6 |Page . school failure and conduct disorders. in many ways. and other crimes • Depression. What about Maria’s children? • Neglect –persistent failure to meet a child’s essential needs • Defined as failure to protect from danger. and failure to provide proper education • Neglect – associated with poverty Teaching Points • Child abuse has mid range effects on child and adolescent behavior including risk taking behaviors and mental illness • Abused children can become maltreating adults forming a multi generational pattern • Neglect. failure to meet the child’s emotional need for love. could substantially reduce the long term negative outcomes Teaching Points • Child abuse has lifelong consequences for its victims. treating abusing families. “street children” -> juvenile delinquency. PTSD. death • Chronic pain disorders. malnutrition. failure to provide food. chronic insomnia and other chronic psychosomatic disorders of adults often have their roots in childhood experience and abuse • Early identification. affecting them in surprising ways even as adults • Witnessing domestic violence is. in which children’s needs are not met. little is known about this disease . but tends to be less reported CASE 4: SUSAN • Rib fractures during infancy are due to abusee in 80% of nth time • • Multiple fractures happening several times -> child abuse! • Unusual bone fragility – main alternative explanation Temporary brittle bone disease – Most doctors do not believe in the existence of this disease. drug abuse. as damaging as being abused as a child • Sexual abuse occurs in boys as well as girls. or prevention.

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