SEMINAR

ON
BATTERED CHILD
SYNDROME

SUBMITTED TO, SUBMITTED BY,

Mrs. Bindu K Shankar Aswathy R C
Assist. Professor 1st yr MSc Nursing
Govt. College of Nursing Govt. College of Nursing
Thrissur Thrissur
INTRODUCTION

The battered child syndrome, a clinical condition in young children

who received serious physical abuse, is a frequent cause of permanent
injury or death. The syndrome should be considered in any child
exhibiting evidence of fracture of any bone, subdural hematoma, failure
to thrive, soft tissue swelling or skin bruising in any child who dies
suddenly or where the degree and type of injury is at variance with the
history given regarding the occurrence of trauma. Psychiatric factors
are probably of prime importance in the pathogenesis of the disorder,
but knowledge of these factors is limited. Physicians have a duty and
responsibility to the child to require a full evaluation of the problem
and to guarantee that no expected repetition of trauma will be permitted
to occur.

DEFINITION

Battered child syndrome refers to non-accidental injuries sustained by

a child as a result of physical abuse, usually inflicted by an adult
caregiver.
INCIDENCE
The total abuse rate of children is 25.2 per 1000 children,

 with physical abuse accounting for 5.7 per 1000

 sexual abuse 2.5 per 1000
 emotional abuse3.4 per 1000 and
 neglect accounting for 15.9 per 1000 children.

These categories overlap with sexual and physical abuse or neglect

seldom occur without emotional abuse. These numbers may be
underestimates due to underreporting of the problem or failure of
diagnosis by medical personnel.

In 1996, more than 3 million victims of alleged abuse were reported to

child protective services in the United States; reports were
substantiated in more than one million cases. Parents were abusers in
77 percent of the confirmed cases; other relatives in 11 percent. More
than 1,000 children died from abuse in 1996.

CAUSES

Battered child syndrome (BCS) is found at every level of society,

although the incidence may be higher in lower-income households,
where adult caregivers may suffer greater stress and social difficulties
and have a greater lack of control over stressful situations. Other risk
factors include:
  lack of education
 single parenthood
 alcoholism
 other drug addictions.

The child abuser most often injures a child in the heat of anger or during
moments of stress. Common trigger events that may occur before
assaults include;

 Negativism
 Difficult temperament
 Enuresis
 Soiling
 Spilling
 Mental sub normality
 incessant crying or whining of infants or children
 perceived excessive "fussiness" of an infant or child
 a toddler's failed toilet training.
 and exaggerated perceptions of acts of "disobedience" by a child.

Sometimes cultural traditions may lead to abuse, including beliefs that

a child is property, that parents (especially males) have the right to
control their children any way they wish, and that children need to be
toughened up to face the hardships of life. Child abusers were often
abused as children themselves and do not realize that abuse is not an
appropriate disciplinary technique. Abusers also often have poor
impulse control and do not understand the consequences of their
actions.

PHYSICAL ABUSE
The deliberate infliction of physical injury on a child, usually by the
child’s care giver, is termed as physical abuse. Minor physical injuries
responsible for more reported cases of maltreatment than major
physical injury, but major physical abuse causes more deaths. Despite
the importance of the problem, a universally accepted definition of
what constitutes minor and major physical abuse does not exists.

FACTORS PREDISPOSING TO PHYSICAL ABUSE

The exact cause of child abuse is not known, although three factors

 Parental characteristics
 Characteristics of the child
 Environmental characteristics

Influence the potential for abuse.

1.Parental characteristics

Extensive research has focused on parental characteristics that

distinguish abusive parents from non-abusive parents. Although
physical punishment tends to occur in abusive parent’s childhood, most
of the parents were not physically abused as children. However,
abusive parents who report that they were severely punished as children
are much more likely to injure their own children. If the abusive was
not overt physical violence, abusive parents typically recall their
punishment ad unfair and severe, and they characterize their
relationship with their parents as negative. Abusive parents tend to have
difficulty coping with stress and in controlling anger expression.

 Abusive Families-are often more socially isolated and have

fewer supportive relationships than non-abusive parents.

 Children of teenage mothers- are more at risk of abuse than

those of older mothers with little or no available support system
and the presence of concurrent stresses imposed by the child or
environment, these parents are extremely vulnerable to additional
crises of any nature and literally strike out at the child as a method
of releasing their increasing frustration and anxiety.
 Low self-esteem and less adequate maternal functioning-
Although inadequate knowledge of childrearing is often cited as
a characteristic of abusive parents, research findings do not
consistently support this belief. However, this doesn’t mean that
these parents cannot benefit from learning more constructive way
of rearing their children, especially non-violent discipline
methods.

2.Characteristics of child

 Families of two or more children

In families of two or more children, usually only one child is the victim
of abuse. This child’s temperament, position in the family, additional
physical needs if ill or disabled, activity level and degree of sensitivity
to parental needs all contributes to the potential for physical abuse. For
example, one child may not be abused if he or she fits into the ‘’easy
child pattern’’, whereas another sibling with a difficult temperament
may add to the parent’s stress sufficiently to precipitate on abusive act.

 Disabilities

Occasionally the abused child is illegitimate, unwanted, brain damaged

(especially in situations where the parents cannot accept the
retardation), hyperactive or physically disabled.

 Premature infants

Premature infants may be at risk for maltreatment because of the failure

of parent-child bonding during early infancy. Often a difficult
pregnancy, labour or delivery is a predisposing factor in abusive,
especially when the infant is born prematurely or with congenital
anomalies.

Although one child is usually the victim in an abusive family, removing

that child from the home often places the other siblings at the risk for
abuse. Child maltreatment is not confined to one child because of a
disturbed parent -child relationship but is a result of family in distress.
Therefore, no child is safe if left in the abusive environment unless the
parents can be helped to learn new parenting skills and to meet their
needs and release their frustration through alternatives other than
attacking their children.
3.ENVIRONMENTAL CHARACTERISTICS

* The environment is the significant part of the potential abusive

situation. Typically, the environment is one of chronic stress, including
problems of;

 Divorce
 poverty
 unemployment
 Poor housing
 Frequent relocation
 Alcoholism
 Drug addiction

* Increased exposure between children and parents, such as that

which occurs in crowded living conditions, also increases the
likelihood of abuse.

* The child abuser most often injures a child in the heat of anger or
during moments of stress. Common trigger events that may occur
before assaults include

 Incessant crying
 Whining of infants or children
 Perceived excessive ‘’fussing’’ of an infant or child.
 A toddler’s failed toilet training
 Exaggerated perceptions of acts of disobedience by a child.
* Cultural traditions may lead to abuse, including beliefs that;

 A child is property, that parents (especially males) have the right

to control their children any way they wish.
 Children need to be toughened up to face the hardships of life.
 Child abusers were often abused as children themselves and do
not realize that abuse is not an appropriate disciplinary technique.
Abusers also often have poor impulse control and do not
understand the consequence of their actions.
 Although most reporting of abuse has been from lower socio-
economic populations, child abuse is not a problem of any one
societal group. It spans all educational, social and economic
levels.
 Stress imposed by poverty predispose lower socioeconomic
families to abusive situations and abuse in these groups is more
apt to be reported.
 However, concealed crisis may also be present in upper -class
families. For example, a wealthy family experiencing major life
changes, such as rehousing, the birth of an additional child, or
marital discord, may have sufficient environmental stressors
imposed on them to produce a potentially abusive situation.
 Wealthy families may be so overinvolved with commitments
outside the home that abuse may be inflicted by substitute
caregivers.
Other risk factors include

 Lack of education
 Single parenthood
 Alcoholism
 Drug addictions.

SYMPTOMS

Symptoms may include

 a delayed visit to the emergency room with an injured child

 an implausible explanation of the cause of a child's injury
 bruises that match the shape of a hand, fist or belt
 cigarette burns
 scald marks
 bite marks
 black eyes
 unconsciousness
 lash marks
 bruises or choke marks around the neck
 circle marks around wrists or ankles (indicating twisting)
 separated sutures
 unexplained unconsciousness
 a bulging fontanel in small infants.
Emotional trauma may remain after physical injuries have healed. Early
recognition and treatment of these emotional "bruises" is important to
minimize the long-term effects of physical abuse. Abused children may
exhibit:

 a poor self-image
 sexual acting out
 an inability to love or trust others
 aggressive, disruptive, or illegal behaviour
 anger, rage, anxiety or fear
 self-destructive or self-abusive behaviour
 suicidal thoughts
 passive or withdrawn behaviour
 fear of entering into new relationships or activities
 school problems or failure
 sadness or other symptoms of depression
 flashbacks or nightmares
 drug or alcohol abuse

Sometimes emotional damage of abused children does not appear

until adolescence or even later, when abused children become abusing
parents who may have trouble with physical closeness, intimacy, and
trust. They are also at risk for anxiety, depression, substance abuse,
medical illnesses, and problems at school or work. Without proper
treatment, abused children can be adversely affected throughout their
life.
DIAGNOSIS

Battered child syndrome is most often diagnosed by an emergency

room physician or paediatrician, or by teachers or social workers.
Physical examination will detect injuries such as

 Bruises

 Burns

 Swelling

 Retinal haemorrhages (bleeding in the back of the eye)

 Internal damage such as bleeding or rupture of an organ

 Fractures of long bones ore spiral-type fractures that result from

twisting,

 Fractured ribs or skull

 X rays, and other imaging techniques, such as MRI scan may

confirm or reveal other internal injuries.

The presence of injuries at different stages of healing (i.e., having

occurred at different times) is nearly always indicative of BCS.
Establishing the diagnosis is often hindered by the excessive
cautiousness of caregivers or by actual concealment of the true origin
of the child's injuries, as a result of fear, shame and avoidance or denial
mechanisms.
 CRITICAL STEPS IN INVESTIGATING BATTERED CHILD
SYNDROME

When battered child syndrome is suspected, investigators should

always

 Collect information about the acute injury that led the person or
agency to make the report.
 Conduct interviews with the medical personnel who are attending
the child.
 Review medical records from a doctor, clinic or hospital.
 Interview all persons who had access to or custody of the child
during the time in which the injury or injuries allegedly occurred.
Always interview the caretakers separately-joint interview can
only hurt the investigation.
 Consider any statements the caretakers made to anyone
concerning what happened to the child who required medical
attention.

 Conduct a thorough investigation of the scene where the child

was allegedly hurt

TREATMENT

Medical treatment for battered child syndrome will vary according to

the type of injury incurred. Counselling and the implementation of an
intervention plan for the child's parents or guardians are necessary.
  The child abuser may be incarcerated, and/or the abused child
removed from the home to prevent further harm.

 Decisions regarding placement of the child with an outside

caregiver or returning the child to the home will be determined
by an appropriate government agency working within the court
system, based on the severity of the abuse and the likelihood of
recurrence.

 Both physical and psychological therapy are often recommended

as treatment for the abused child. If the child has siblings, the
authorities should determine where they have also been abused,
for about 20 percent of siblings of abused children are also shown
to exhibit signs of physical abuse.

PREVENTION

Recognizing the potential for child abuse and the seeking or offering of
intervention, counselling, and training in good parenting skills before
battered child syndrome occurs is the best way to prevent abuse.

The use of educational programs to teach caregivers good parenting

skills and to be aware of abusive behaviours so that they seek help for
abusive tendencies is critical to stopping abuse. Support from the
extended family, friends, clergy, or other supportive persons or groups
may also be effective in preventing abuse. Signs that physical abuse
may occur include parental alcohol or substance abuse;
  high stress factors in the family life

 previous abuse of the child or the child's siblings

 history of mental or emotional problems in parents; parents

abused as children

 absence of visible parental love or concern for the child

 neglect of the child's hygiene.

PARENTAL CONCERNS

 Parents who are in danger of abusing their children (for example,

when they find themselves becoming inappropriately or
excessively angry in response to a child’s Behavior) should seek
professional counselling.
 Parents may also call the national child abuse hotline (800-422-
4453 a nationwide 24 hr. telephone hotline), where they will be
counseled through a parenting or caretaking crisis and offered
guidance about how to better handle the situation.
 Parents should also exercise caution in arranging for or hiring
babysitters and other caretakers. If they suspect abuse, they
should immediately report those suspicious to the police or to
their local child protective service agency. They should also teach
their children to report abuse to a trusted adult.
Introduction to Healthy Parenting

Raising happy and healthy children is a tough job. Parenting involves

not just relying on our instincts or doing what our parents did before
us, but knowing what works best for our children, and why.

Role models

Parents are important role models for their children, who learn how to
behave by watching mother and father. Whether it's eating healthy
foods, exercising, treating others kindly, or being honest, children are
paying attention and look to their parents for cues on how to behave.

Don’t Be Too Loving

There is no such thing as "too much" love. Material possessions or lack

of rules and limits is not the same thing as love. "It is simply not
possible to spoil a child with love.

Be Involved in Your Child's Life

Parenting involves a lot of responsibility. Being an involved parent

takes time and is hard work, and it often means rethinking and
rearranging your priorities. It frequently means sacrificing what you
want to do for what your child needs to do. Be there mentally as well
as physically.
Support the child

The age of a child can greatly affect how he or she behaves. Know what
behavioural changes are normal and help support them in their personal
growth and development.

Establish and Set Rules

When a child is younger, it's important to help manage his behaviour,

which teaches him how to manage himself.

Child's Independence

Boundaries for children are important. Setting limits helps the child
develop a sense of self-control. Encouraging independence helps the
child develop a sense of self-direction.

Be Consistent

Set rules and be consistent in applying them. If the rules vary from day
to day in an unpredictable fashion or if you enforce them only
intermittently the child misbehaves.

Avoid Harsh Discipline

Physical discipline is never an option. Children who are spanked, hit,

or slapped are more prone to fighting with other children. They are
more likely to be bullies and more likely to use aggression to solve
disputes with others.
Treat the Child with Respect

Treat children with respect and they will learn to respect others,
including their parents. The best way to get respectful treatment from
the child is to treat him respectfully. Speak to him politely. Respect his
opinion. Pay attention when he is speaking to you. Treat him kindly.
Try to please him when you can. Children treat others the way their
parents treat them.

Rewards of Good Parenting

Good parenting fosters healthy psychological adjustment and it

promotes positive behaviours and attributes such as honesty, empathy,
self-reliance, kindness, cooperation, success in school, intellectual
curiosity, motivation to learn, and the desire to achieve. Steinberg states
good parenting also helps deter children from antisocial behaviours,
drug and alcohol abuse, anxiety, depression, and eating disorders.

CONCLUSION

Internal injuries, cuts, burns, bruises, and broken or fractured bones

are all possible signs of battered child syndrome. Psychological dama
ge to a child is also often the byproduct of child abuse and can result i
n serious behavioral problems such as substance abuse or the physical
abuse of. Abuse of children is alarmingly common. There is an urgent
need for improving the awareness surrounding this issue as it is a major
public health challenge faced by the country. The priority should be on
setting up easily accessible support services for children.
RESEARCH EVIDENCE

1. A study to estimate the one-year and lifelong prevalence of

exposure to violence, physical abuse, emotional abuse, sexual
abuse, and neglect

Objectives: To estimate the one-year and lifelong prevalence of

exposure to violence, physical abuse, emotional abuse, sexual abuse,
and neglect using a validated instrument-the International Society for
the Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse
Screening Tool - Child, Home Version (ICAST-CH).

Results: The one-year prevalence of any abuse was 89.9% (95% CI:
89.1-90.7) suggesting that child maltreatment was widespread.
Physical and emotional abuses were also very common. Although
sexual abuse was least common, a considerable proportion of
adolescents reported it; one-year prevalence of sexual abuse was 16.7%
and lifetime prevalence was 19.9%. Boys reported more abuse than
girls across all the categories of abuse (including sexual abuse). Abuse
was more frequent in the higher age groups and classes at school.
Abuse was also more frequent in nuclear families and families that
reported alcohol use. Children who reported an abusive experience
usually faced more than one category of abuse; abuse in one category
was significantly associated with abuse in other categories.

Conclusions: Abuse of children is alarmingly common. There is an

urgent need for improving the awareness surrounding this issue as it is
a major public health challenge faced by the country. The priority
should be on setting up easily accessible support services for children.

2.A Study to determine if child physical abuse hospitalization rates

vary across urban-rural regions overall and after accounting for
race/ethnicity and poverty demographics.
Study design: This was a retrospective cross-sectional study of black,
Hispanic, and non-Hispanic white children <5 years of age living in all
US counties. US counties were classified as central metro, fringe/small
metro, and rural. Incidence rates were calculated using child physical
abuse hospitalization counts from the 2012 Kids' Inpatient Database
and population statistics from the 2012 American Community Survey.
Counties' race/ethnicity demographics and percent of children living in
poverty were used to adjust rates.
Results: They identified 3082 child physical abuse hospitalizations
occurring among 18.2 million children. Neither crude nor adjusted
overall rates of child physical abuse hospitalizations varied
significantly across the urban-rural spectrum. Rates were
disproportionately higher among black children compared with white
children and their disproportionality increased with population density,
even after poverty adjustment. Rates among Hispanic children were
disproportionately lower compared with white children in nearly all
urban-rural categories.

Conclusions: The results suggest that urban black children have

unique exposures, outside of poverty, increasing their risk for child
physical abuse hospitalization. Identifying and addressing these unique
urban exposures may aid in reducing black-white disproportionalities
in child physical abuse.

REFERENCE
1.OP Ghai, Vinod K Paul. Essential Paediatrics. Seventh edition. CBS
Publishers and Distributors; New Delhi. Page No:753-755.

2.Parul Datta. Textbook for Paediatric Nursing. Third edition. Jaypee

Publishers; New Delhi. Page No:34-35.