Child Abuse and Violence

Definition
• Child physical abuse describes a non-accidental injury
of a child by parent or caretaker, which leads to or
creates a high risk of harm.
• Sexual abuse describes any action with a child that is
done for the sexual gratification of an adult or
significantly older child constitutes sexual abuse.
• Emotional abuse describes infliction of emotional
harm through the use of words or actions.
• Neglect of a child describes lack of minimal or basic
care, physical and emotional support, educational and
medical needs and supervision of a child by parents or
supervisor.
 Classification
Physical abuse Sexual abuse
•shaking •intercourse, which is oral,
•dropping anal, or vaginal penetration
• striking • molestation, which is genital
contact without intercourse
• biting
•exposure, showing sexual
• burning
material to a child, and
•most common cause of
forcing a child to participate
serious head injury in infants
in a sex act with another
•In toddlers abdominal injury child or to participate in the
is most common making of sexual material
•Corporal punishment (may •(sexual play between
be culturally defined) children >4yr isn’t included)
Emotional abuse
•berating a child by yelling or
screaming, spurning by
belittling the child's abilities
and achievements,
•intimidating and terrorizing
with threats
•exploiting or corrupting by
encouraging deviant or
criminal behavior
•Withhelding or omitting
words or actions (ignoring or
rejecting the child, or
isolating him from
interaction with other
children or adults)
Neglect
•Physical neglect includes
failure to provide adequate
food, clothing, shelter,
supervision, and protection
from potential harm.
•Emotional neglect is failure
to provide affection or love
or other kinds of emotional
support.
•Educational neglect is failure
to enroll a child in school,
ensure attendance at school,
or provide home schooling.
•Medical neglect is failure to
ensure that a child receives
appropriate preventive care,
such as vaccines or needed
treatment for injuries or
physical or mental disorders
 Maltreatment of children
• One of the most important goals for a medical
doctor is the recognition and evaluation of the
possible abusive or violent familial raising of the
child.
• Don‘t miss families where not just neglect but as
well cruelty towards a child is present.
• The earlier we notice this situation the more
chances we will have to inhibit the development
of dangerous system which makes the child
suffer.
 Etiology and pathogenesis

• Multifactorial complex
• Individual case – individual severity of single
components
• Factors may affect the child or parents or
family
Etiology and pathogenesis
 Factors leading to abuse and violence
Familial
• Low income
• Unemployment of father
• Multiple children
• Isolation from society
• Disagreements and marital
conflicts
• Several caregivers or a caregiver
with several sex partners
Infantile
• Low birth weight and immaturity
(30%)
• Malformations and deformities
• Developmental disturbances (70%)
• Undesireability
• Biologically unrelated children
(Stepchildren)
• Affective instability
• Hyperactivity
• Attention Deficit Disorder
• Nonpredictive or abnormal,
irritable, demanding behavior
• Incapability to inoculate moral
principles
 Factors leading to abuse and violence
Parental
• Psychiatric illnesses (alcoholismus, psychosis, personality problems)
• Certain personal characteristics (weak or absent control of impulses,
sensitivity, tendency for isolation, high fear level, depressive-aggressive)
• Drug or alcohol abuse, or limited intellectual capacity
• Persons who have a character defect or weakness which allows realization
of aggressive impulses towards a helpless child
• Persons with permanent hostility and tendency for misusage of their social
position
• Persons strongly dependent on others
• Persons obsessed by implementation of strict discipline
• Persons overcoming familial conflicts
• Persons who are not able to fullfill their parental part
• Persons with history of own abuse, lack of love, warmth, inadequate self-
esteem and emotional immaturity
• Low positive and high negative interaction rate
• Relatively low education
 Suspicious pecularities about parental
behavior
• Discrepance between objective findings and parental report
• Non-cooperative to hostile parental behavior
• Withholding and postponing of medical care
• Inadequate reaction to childish injury
• No visits for hospitalized children
• Negligence and abuse in own history
• Infantile marriage or partnership
• Strong familial tendency for isolation, lack of neighbourhood
contacts
• Nonrealistic expectations towards the child
• Often change of doctor or hospital
• Alcohol consum
 Possible signs of abuse or violence
• Non explanable bodily findings
• Signs of previous injury sequellas
• Burns, intoxications, hematomas, fractures
• Signs of psychical or physical disregard, for that there
is no adequate explanation
• „Barriers“ against any signs of conflict for elder
children
• Lack of protection instinct for younger children
• Highly fearful child
 Symptoms and signs of physical abuse
• Skin lesions:
- handprints or oval fingertip marks from slapping or grabbing and shaking
- long, bandlike ecchymoses from belt whipping or narrow arcuate bruises
from extension cord whipping
- multiple small round burns from cigarettes
- symmetric scald burns of upper or lower extremities or buttocks from
intentional immersion
- bite marks
- thickened skin or scarring at the corners of the mouth from being gagged

• Patchy alopecia can result from hair pulling

• Fractures (rib, vertebral, long bone, digit, metaphyseal)
• CNS injuries (confusion, coma, stupor, retinal hemorrhage in 65-95% of
shaken babies)
• Traumatic injury to chest or abdominal organs

• Child is fearful and irritable and sleep poorly, appear depressed or

anxious. Violent suicidal behavior may occur.
 Symptoms and signs of sexual abuse
• rarely exhibit behavioral or physical signs of sexual
abuse
• In some cases, abrupt or extreme changes in behavior
may occur
• Aggressiveness or withdrawal may develop, as may
phobias or sleep disturbances
• Age inadequate sexual behavior
• difficulty in walking or sitting
• bruises or tears around the genitals, rectum, or mouth
• vaginal discharge or pruritus
• STD
• If a disclosure after a few days to 2 wk, the genitals
may be normal or may reveal healed, subtle hymen
changes.
 Symptoms and signs of emotional abuse
• blunt emotional expressiveness and decrease
interest in the environment
• failure to thrive
• Delayed development of social and language skills
• Child is insecure, anxious, distrustful, superficial in
interpersonal relationships, passive, and overly
concerned with pleasing adults, has low self-esteem,
fearful and withdrawn
• Difficulties to establish relationships
• Affected children may start to commit crimes or
abuse alcohol or drugs
 Symptoms and signs of neglect

• Malnutrition
• Fatigue
• Lack of hygiene or appropriate clothing
• Failure to thrive
• Stunted growth and death from starvation or
exposure may occur
Violence and abuse may lead to
Inadequate Instable psycho-
Abnormal
physical emotional
reactions
development development

Problems with
Depressed
social Physical injuries
personality
adoptation

Intellectual Behavioral
disturbances pecularities
“Muenchausen-by-Proxy-Syndrome
Psychological problems of, lack
of attention and love for
primary caretaker (PC) (usually
mother: ca. 98% of cases)

PC makes the child (typ.

preschool age) ill by e. g.: giving
dangerous medicines ( Insulin,
Recovery of the child, lack of
Diuretics, Cortisone, etc),
attention and sympathy for PC
poisoning with quicksilver,
injuring, taking care badly,
infecting repeatedly , etc)

Expensive diagnostic and

PC gains attention and
therapeutic measurements,
sympathy from doctors, nurses.
repeated visits of out-patient
Feels her/himself more
departments and frequent
powerful, as misleads personal
hospitalizations
 Diagnosis
• Establishment is difficult
• Need for high index of suspicion
• Often missed
• Anamnesis collection should be performed in relaxed
atmosphere and include open-ended questions and
yes-or-no questions
• Observation of interaction of victim and perpetrator
may help
• Accurate documentation of history and physical
examination are essential
• Take photographs of injuries

Physical abuse dg. based on:
• History and physical examinations
• Discrepancies in reports victim vs
perpetrator
• Inappropriate response of parents
to the severity of injury
• Delayed report of injury
• Atypical injuries and injuries
incompatibel with stated history
• Concern should be raised by:
bruises on the back, buttocks, back
of the legs, classic metaphyseal
lesions, rib fractures (post. And 1st
rib), depressed or multiple scull
fractures from apparently minor
trauma, scapular, sternal, spinous
processes fractures
• Repeated injuries
Diagnosis
Sexual abuse dg. based on:
• STD in child < 12 yr
• Behavioral changes (e.g:
irritability, fearfullness,
insomnia)
• Hair samples and swabs of
body fluids
• Vag. Examinations by specially
equipped colposcope
Emotional abuse and neglect dg.
based on:
• General appearence and
behavior
• Statement from teachers or
social workers
• Missed appointments and not
up-to-date vacations
• Medical neglect of life-
threatening diseases like
airways dysfunction syndrome
or DM
 Treatment

• Treatment first addresses urgent medical needs (including possible

STDs) and the child's immediate safety
• Families should be approached
• Immediate safety: Physicians and other professionals in contact
with children (eg, nurses, teachers, day care workers, police) are
required by law in all states to report incidents of suspected abuse
or neglect.
• Depending on country physicians are encouraged but not mandated
to report suspected abuse (Child Protective Services or appropriate
institution)
• Sequence of informing parent/caretaker/governmental institution is
unrestricted
• Depending on situation protective measurements for child should
be considered (protective hospitalization, placement with relatives
or temporary housing, temporary foster care
Spectrum of prophylactic and
therapeutical tactics
Psychotherapy
with the child

Psychotherapy with
parents

Familial psychotherapy

Collective psychotherapy with further

families
 Help and advice by

Representatives
Physicians Social workers of child protective
agencies

Teachers Relatives
 Definition
• Child sexual abuse is a form of child abuse in
which an adult or older adolescent abuses a child
for sexual stimulation. Forms of CSA include
asking or pressuring even violently a child to
engage in sexual activities against child’s
will(regardless of the outcome), indecent
exposure of the genitals to a child, displaying
pornography to a child, actual sexual contact
against a child, physical contact with the child's
genitals, viewing of the child's genitalia without
physical contact, or using a child to produce child
pornography
 The US statistics of sexual abuse
• 1 in 4 girls is sexually abused before the age of 18.
(2008)
• 1 in 6 boys is sexually abused before the age of 18.
(2008)
• 1 in 5 children are solicited sexually while on the
internet. (2001)
• Nearly 70% of all reported sexual assaults (including
assaults on adults) occur to children ages 17 and
under. (2000)
• An estimated 39 million survivors of childhood sexual
abuse exist in America (1999)
Etiology and Pathogenesis (interaction-
orientated approach)

Unrealistic
expectations from
Stronger intra- children, which
familial reciprocal may include
dependency. satisfaction of
Isolation from sexual desires.
social
environment.

Incest-families
have difficulties
to see the line
between family
members.
Sexual abuse
in family as
disturbance
of family-
system
 Incidence
• Ca. > 50% intra-familial cases
• Ca. >1/3 of cases in circle of acquaintances
• Ca. 12% of cases by total strangers
 Clinics
• Incest
• CSA of underaged usually without violence but
with psychological impact
• Both sexes: anal and vaginal intercourse
• Oro-genital contact for male victims
• Genital manipulations for female victims