MPAS573 2020 Child Abuse & Neglect

CHILD ABUSE
& NEGLECT
M PA S 5 7 3 , P E D I AT R I C S
GWU 2020
M A R I C H A D W I C K , PA - C 1
OBJECTIVES
• PED-17.1 The student will investigate the incidence and compare each of the following based on common presentation in the pediatric
population:
– Child neglect
– Child abuse
– Sexual abuse
• PED-17.2 The student will define the state and federal laws governing the reporting of child abuse/neglect by health care providers and
other professionals
• PED-17.3 The student will assess parents and children most at risk for child abuse/neglect in terms of the following:
– Cultural factors
– Family stresses/social situational stresses
– Child-produced stresses
– Parent-produced stresses
– Triggering situations
– Maltreatment
• PED-17.4 The student will devise the diagnostic evaluation for a suspected child abuse case
• PED-17.5 The student will examine the most common reasons for NOT reporting any type of abuse by the:
– Victim
– Parent/family member
2
REPORTING SUSPECTED
ABUSE/NEGLECT
• In the United States, each state is responsible for providing its own definitions of child abuse and neglect within
its civil and criminal codes, consistent with federal law. The Child Abuse Prevention and Treatment Act (CAPTA)
amended in December 20th, 2010, by the CAPTA Reauthorization Act of 2010 (Public Law 111-320), defines
child abuse as any recent act or failure to act :
– Resulting in death, serious physical or emotional harm, sexual abuse, or exploitation; or imminent risk of serious harm
– Involving a child (a person under the age of 18, unless the child protection law of the state in which the child resides
specifies a younger age for cases not involving sexual abuse)
– By a parent or caretaker (including any employee of a residential facility or any staff person providing out-of-home care)
who is responsible for the child's welfare.
• The four major types of child abuse are:
– Physical abuse
– Sexual abuse
– Emotional abuse
– Child neglect [ UpToDate: Physical abuse in children: Epidemiology and clinical manifestations]
3
CHILD ABUSE: EPIDEMIOLOGY
• Child abuse is common

• Annual rates in the U.S.:
– 700,000 to 1.25 million are abused or neglected annually, and almost 3 million are at risk for harm
– 18% physical abuse
– Prevalence of physical abuse at any time during childhood is 5-35 %, with only 5% of episodes reported to
child protective services
– Disproportionate number of deaths from inflicted injuries in children under 1 year of age
– Abuse is more frequent in African American, Pacific Islanders, and Native American children (U.S.) than in
white children, less frequent in Asian, and about the same as Hispanic. Causes seem to be multifactorial,
although risk factors for abuse and neglect (ie. Poverty) most likely account for the differences
4
CHILD ABUSE: FEATURES
• Perpetrators: usually parents
– Biological parents – 81%
– Nonbiological parents and partners – 12 %
– Other adult – 7%
• Abusive head trauma: most likely the fathers, then mothers’ boyfriends, female babysitters, and mothers..
• Risk factors (family) for abuse:
– Young or single parent
– Multiple siblings
– Lower levels of education
– Unstable family situation or poverty
– Hx of abuse or neglect themselves
– Domestic violence
– Stress factors
– Substance abuse, alcohol abuse
5
CHILD ABUSE: CHILD FACTORS
• Some children are more likely to be abused:

– Age < 4 years (32% of cases)
– Prior abuse history
– Medical conditions-
• Speech and language disorders, learning disabilities, conduct disorders, non-conduct psych
• Failure to thrive
• Congenital anomalies, intellectual disability, other handicaps, chronic illness
• Attention deficit hyperactivity disorder
• Prematurity and low-birth weight
• Adopted or step-child
6
CHILD ABUSE: MANIFESTATIONS
(COMMON)
• Bruises:
– Most common type of injury
– Location can help determine if accidental or intentional –
• Unintentional bruising tends to occur on bony prominences – forehead, extremities, front of the body
• Intentional bruising often centrally located on the buttocks, back, trunk, genitalia, inner thighs, cheeks, earlobes, or neck
• Bruising in nonmobile babies is unusual if unintentional
• Clustered pattern of multiple injuries consistent with inflicted injury
– Bruising patterns:
• Pattern corresponds to an implement or biomechanical model (handprint)
• Linear or ligature patterns
• Stages of healing – heal over 1-3 weeks. Best determined through serial photographs
7
RED FLAGS
• Parental explanations of observed trauma in a child should raise concerns for child abuse if:
– There is no explanation given or a vague explanation for significant injuries
– Important details of the story change dramatically
– Explanation is inconsistent with the pattern of injury, age of child, or severity
– Explanation is inconsistent with the child’s physical capabilities
– Different witnesses give markedly different explanations for the injury
• Usually young children sustain injuries in a forward direction (of motion) if unintentional, thus distal
arms, legs, knees, elbows, and forehead
• Bruises on abdomen, buttocks, thighs, genitalia, ear lobes, and cheeks are uncommon if unintentional
8
TEN-4
Bruising clinical decisions rule for bruises
concerning for abuse. LR+ = positive likelihood
ratio.
TEN stands for torso, ears and neck, areas more

predictive of abuse patterns in children under age
4 years
“4” is for 4 months. A child this age or younger is
not cruising, and should not have any bruising.
Source: Child Abuse and Neglect, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e
Citation: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,
8e; 2016 Available at: http://accessmedicine.mhmedical.com/content.aspx?sectionid=109435341&bookid=1658&Resultclick=2 Accessed:
March 01, 2018
Copyright © 2018 McGraw-Hill Education. All rights reserved
10
Loop Marks. Loop and linear marks signify use of a cord or other similar object.
(Photo contributor: Alan B. Storrow, MD.)
Source: CHILD ABUSE, The Atlas of Emergency Medicine, 4e
Citation: Knoop KJ, Stack LB, Storrow AB, Thurman R. The Atlas of Emergency Medicine, 4e; 2016 Available at:
http://accessmedicine.mhmedical.com/content.aspx?sectionid=125436623&bookid=1763&Resultclick=2 Accessed: March 01, 2018
Ligature Bruise. This bruises around the neck of this child represent ligature marks.
(Photo contributor: Cincinnati Children’s Hospital Medical Center.)

Purpura and erosions on the soft, padded areas of the buttock and thighs,
representing very obvious abuse. (Used with permission from Paul Bellino, MD.)
Source: Chapter 106. Skin Signs of Physical Abuse, Fitzpatrick's Dermatology in General Medicine, 8e
Citation: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Fitzpatrick's Dermatology in General Medicine, 8e; 2012 Available
at: http://accessmedicine.mhmedical.com/content.aspx?sectionid=41138818&bookid=392&jumpsectionID=41150988&Resultclick=2
Accessed: March 01, 2018
Cigarette Burn—Inflicted. Cigarette burns are circular injuries with a diameter of about 8 mm. Children who
accidentally run into a lit cigarette often have burns to the face or distal extremities. Accidental burns may be
less distinct or deep compared with inflicted burns. (Photo contributor: Kathi L. Makoroff, MD.)

Pinna Bruise. Any bruising to the ear is concerning for abuse and should trigger a thorough
evaluation for other abusive injuries. (Photo contributor: Daniel M. Lindberg, MD.)
16
METHOD OF INJURY/IMPLEMENT PATTERN OBSERVED
Grip/grab Relatively round marks that correspond with fingertips and/or thumb
Closed-fist punch Series of round bruises that correspond with the knuckles of the hand
Slap Parallel, linear bruises (usually petechial) separated by areas of central sparing
Loop marks or parallel lines of petechiae (the width of the belt/cord) with central sparing; may see
Belt/electrical cord triangular marks from the end of the belt, small circular lesions caused by the holes in the tongue of the
belt, and/or a buckle pattern
Rope Areas of bruising interspersed with areas of abrasion
Other objects/household implements Injury in shape of object/implement (e.g., rods, switches, and wires cause linear bruising)
Human bite Two arches forming a circular or oval shape, may cause bruising and/or abrasion
Strangulation Petechiae of the head and/or neck, including mucous membranes; may see subconjunctival hemorrhages
Marks around the wrists, ankles, or neck; sometimes accompanied by petechiae or edema distal to the
Binding/ligature ligature mark
Marks adjacent to the mouth if the child has been gagged
Excessive hincar (punishment by
kneeling on salt or other rough Abrasions/burns, especially to knees
substance)
Traumatic alopecia; may see petechiae on underlying scalp, or swelling or tenderness of the scalp (from
Hair pulling
subgaleal hematoma)
Abusive cases have been described, but can also be a cultural phenomenon (e.g., Maori body
Tattooing or intentional scarring
ornamentation) 17
18
(COMMON)
• Bite marks:
– May be associated with physical or sexual abuse
– Circular or elliptical bruises or abrasions, possibly with a clear center or with erythema, edema and
petechiae
– Human bite marks are usually superficial
– Adult bites – canines at least 2.5-3 cm apart, with adult tooth pattern
– More evident 2-3 days later
19
Adult Bite Marks. This adult bite mark demonstrates evidence of suction (hickey) within the bite
mark itself. The size of the facing arches indicates an adult bite. (Photo contributor: Kathi L.
Makoroff, MD.)
(COMMON)
• Fractures:
– Second most common type of injury seen in physical abuse
– No particular pattern that is pathognomonic for abuse
– Orofacial injuries:
• Occur in ½ cases of physical abuse. Face most commonly.
• Includes fractures of maxilla, mandible, or other facial bones
• Basilar skull fractures: “raccoon eyes”, Battle sign, &/or blood behind the TM
• Other (nonfracture) injuries – burns, intraoral injuries, bruising & Lichenification or scarring at the corners
of the mouth, oropharyngeal GC or syphilis, black eyes, ear trauma, nasal trauma, traumatic alopecia and/or
subgaleal hematoma
21
(COMMON)
• Fractures, continued:
– Fractures highly suggestive of intentional injury include;
• Metaphyseal corner fractures
• Rib fractures
• Fractures of the sternum, scapula, or spinous processes
• Multiple fractures in various stages of healing
• Bilateral acute long-bone fractures
• Vertebral body fractures and subluxations in the absence of a history of high force trauma
• Digital fractures in children younger than 36 months of age or without a corresponding history
• Epiphyseal separations
• Complex skull fractures in children younger than 18 months of age, particularly without a corresponding history
• Less suggestive are isolated long bone fxs in ambulatory children, linear skull fxs, clavicle fxs, and
subperiosteal new bone formation
22
Acute left clavicle and healing rib fractures in an infant.
Source: Child Abuse and Neglect, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e
Citation: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,
8e; 2016 Available at: http://accessmedicine.mhmedical.com/content.aspx?sectionid=109435341&bookid=1658&Resultclick=2 Accessed:
March 01, 2018
29
(COMMON)
• Burns: 6-20% of child abuse. Pattern of injury suggesting abuse –
– Brands/contact burn
– Cigarette burns
– Immersion burns
– Microwave burns
– Stun gun burns
• Forced ingestion: intentional poisoning, including water intoxication, and salt poisoning
• Starvation: uncommon, but often lethal form of child abuse, mostly in young infants
30
31
32
33
Inflicted Scald Burn. Partial thickness burn on the lower extremity with sharp demarcation is suspicious for intentional injury. (Photo contributor: Kathi
Makoroff, MD.)

35
CHILD ABUSE: SEXUAL
• Definition: when a child engages in sexual activity for which he/she cannot give consent, is
developmentally unprepared, cannot comprehend, and/or the action violates laws or taboos of
the society
• Includes:
– Fondling, and all forms of oral-genital, genital, or anal contact with the child (whether clothed or not)
– Nontouching – exhibitionism, voyeurism, child pornography
– Sexual assault
• Must differentiate sexual abuse and “sexual play”. Abuse occurs when there is asymmetry in age
or development with coercion. Play involves children of the same age (< 4 years difference) or
developmental level who view or touch each others genitals (normal) because of mutual
curiosity.
36
CHILD ABUSE: SEXUAL
• Epidemiology: 1% of children experience sexual abuse each year (> 60,000) in the U.S., about 9% of
children who are abused each year. Worldwide, estimates of 25% girls and 9% of boys are sexually
abused in childhood. Reported sexual abuse cases grossly underestimate the actual prevalence.
• Evaluation requires great sensitivity. Remember HEADSS:
– H—home
– E—education
– A—activities
– D—depression and drugs
– S—sex and sexual abuse
– S—suicide
• Allows the evaluator to ask difficult questions last
37
CHILD ABUSE: SEXUAL
• Up to 50% of sexual abuse involves penetration of the vagina, anus, or oral cavity, or oral-genital
contact. With penetrative abuse, there is associated poorer medical and mental health outcomes.
• In most cases, the adult perpetrator is known and trusted by the victim, then deceived or forced by
the perpetrator’s position of authority to allow the abuse
• Children often wait months to years to disclose the abuse
• Clinical features:
– Behavior changes such as depression, increased sexual behaviors, somatic complaints (headaches,
abdominal pain, constipation, etc.). May be asymptomatic.
– Child may present to a medical provider because he/she has disclosed the abuse, a caregiver suspects
abuse, or the child is present for a routine visit and sexual abuse is suspected based on clinical findings
38
CHILD ABUSE: SEXUAL
• Physical findings:
– Acute or healed anal/genital injuries
• Abrasions or bruising of the hymen, perihymenal structures, or anus
• Acute or healed tear of the posterior hymen extending to or nearly to the base of the hymen or
posterior vestibule
• Anal bruising or lacerations
– Vaginal discharge in a prepubertal child
– HPV lesions or HSV genital lesions (or oral)
– Petechiae or bruising on the soft palate with a history of forced oral penetration
• Studies estimate that < 5% of child sexual abuse victims show evidence of penetrative
trauma (lesions heal quickly, or no tissue damage occurred)
• A “normal” exam does not mean “nothing happened”
39
From: Part 2. Specialty Areas
The Atlas of Emergency Medicine, 3e, 2010
Legend:
Labial Traction Examination Technique. Position the child in a supine position with her knees out and soles together. Hymenal
inspection in prepubertal girls is best accomplished when lateral (1) and posterior (2) traction to the labia is applied as shown here.
(Adapted from Giandino AP, et al. A Practical Guide to the Evaluation of Sexual Abuse in the Prepubertal Child. Sage Publications;
1992.)
Date of download: 2/23/2016 Copyright © 2016 McGraw-Hill Education. All rights reserved.
From: Part 2. Specialty Areas
The Atlas of Emergency Medicine, 3e, 2010
Legend:
Acute Bruise of the Hymen. The hymen has bruising from 3 o'clock to 5 o'clock after recent sexual assault. (Photo contributor:
Cincinnati Children's Hospital Medical Center.)
From: Chapter 9. Child Sexual Abuse
The Color Atlas of Family Medicine, 2e, 2013
Legend:
A 10-year-old girl with an acute tear of the posterior vestibule after recent sexual assault by a stranger. The posterior vestibule is the
most common location for acute penetrative trauma in females. (Courtesy of Nancy D. Kellogg, MD.)
Legend:
Acute hymenal hematoma in a prepubertal girl from penile penetration/contact. One reason why the considerable majority of
examinations are normal may be that contact is more common than complete penetration and injuries resulting from penile contact
are uncommon or are minor injuries that heal quickly and completely within days. (Courtesy of Nancy D. Kellogg, MD.)
From: Part 5. Neurocutaneous and Psychocutaneous Aspects of Skin Disease
Fitzpatrick's Dermatology in General Medicine, 8e, 2012
Legend:
Sexual abuse. Perianal wound in a 3-year-old girl after anal penetration. (Used with permission from Dr. Francesca Navratil, Zurich,
Switzerland.)
Legend:
Acute rectal laceration in a young boy who was sexually abused by a relative. More than 95% of anal examinations in children with a
history of anal penetration are normal or nonspecific. (Courtesy of Nancy D. Kellogg, MD.)
Legend:
Hymenal cleft visible when the girl in Figure 9-1 is more carefully examined using a saline moistened cotton-tip applicator to gently
separate and demonstrate the edges of the hymen. This injury was caused by sexual abuse and may have been missed without the
more careful examination. (Courtesy of Nancy D. Kellogg, MD.)
CHILD NEGLECT: TYPES
• Physical neglect: Failure to provide adequate food, clothing, shelter, hygiene, protection;
inadequate supervision with risk of harm to the child.
• Emotional neglect: Failure to provide love, affection, security, and emotional support; failure
to provide psychological care when needed; spouse abuse in presence of the child.
• Educational neglect: Failure to enroll the child in school or ensure school attendance or
home schooling; failure to address specific educational needs.
• Medical neglect: Refusal to seek or delay in seeking medical care resulting in damage or risk
of damage to the child's health.
• Child neglect includes both actual and potential harm to the child. It is a nondeliberate act.
Accounts for over 50% of cases reported to DSS.
47
48
CHILD NEGLECT: RISK FACTORS
• Disorganized family system:
– Parental substance abuse
– Unemployment
– Physical disability
– Cognitive impairment
• Difficult child temperament
• Years of maternal education (inverse correlation)
• Poverty
• Violence
• Lack of social support systems
• Homelessness
49
CHILD NEGLECT: MANIFESTATIONS
• Includes:
– Nonorganic failure to thrive
– Developmental delay
– Starvation or dehydration
– Poor child hygiene – body, clothes, diapers
– Severe and untreated dental caries
– School truancy
– Injuries from lack of supervision, such as burns, ingestions, near-drowning, etc.
– Physical abuse
– Emotional or behavioral problems
– Delinquent and criminal behavior
50
51
52
CHILD ABUSE TYPES
• Emotional abuse: the most common form of child abuse because it does occur independently
and is a component of all other forms of child abuse.
– May be mild – without malicious intent, with no immediate danger of emotional harm;
– Moderate – with malicious intent or imminent probability of emotional harm, but not both
– Severe – harm inflicted with malicious intent.
• Physical abuse: injury inflicted upon a child by a parent or caretaker.
• Sexual abuse: engaging of dependent, developmentally immature children in sexual activities
that they do not fully comprehend and to which they cannot give consent, or activities that
violate the laws and taboos of a society
• Medical abuse: formerly Munchausen syndrome by proxy. Drugs or toxins are given to the
child to simulate illness. Most perpetrators are mothers, often with a medical background. This is
a rare diagnosis.
53
CHILD ABUSE: EMOTIONAL
• Hardest to define, but according to the National Center of Child Abuse and Neglect is child abuse that
results in impaired psychological growth and development. It is a repeated pattern of harmful
interactions between the parent)s) or caregiver(s) and the child that results in the child feeling
unloved, unwanted, or somehow flawed and imperfect.
• Multiple categories, and may also result from child neglect, unreliable parenting, and witnessed intimate
partner violence
• Risk factors, children:
– Whose parents are involved in domestic violence or a contentious divorce
– Who are unwanted or unplanned
– Whose parents are unskilled or inexperienced in parenting
– Whose parents engage in substance abuse
– Whose parents have mental health issues
– Who are socially isolated
– Who are intellectually or emotionally handicapped
54
CHILD ABUSE: EMOTIONAL,
CATEGORIES
• Rejecting - lack of affection, nurture, praise; refusal to acknowledge a child’s worth or needs
• Isolating – denial of normal relationships & social experiences. Child may be locked up.
• Terrorizing – verbal assault/threats, making child feel unsafe, use of weapons to terrorize
• Ignoring – psychologically unavailable for child, emotional starvation, no protection from danger
• Corrupting – encouraging destructive, antisocial, deviant, or sexually exploitative behavior
• Verbal assault or spurning – name-calling, sarcasm that affects self-esteem, humiliating the child
in public
• Overpressuring – unrealistic expectations of child’s behavior and accomplishments, and criticism
of age-appropriate behavior as inadequate
55
CHILD ABUSE: EMOTIONAL,
PRESENTATION
• Emotional disturbance:
– Anxiety
– Depression
– Agitation
– Fearfulness
• Social withdrawal
• Running away from home
• Developmental delay
• Drug or alcohol abuse
• Eating disorders
• Later consequences may include low self-esteem, marital and parenting difficulties, and psychiatric disorders and
substance abuse or eating disorders
56
WHEN TO SUSPECT ABUSE -
EXAMPLES
• The story does not make sense or does not ring true, or it changes over time, or different people give different
stories.
• Poisoning:
– The child is nonambulatory (eg, a child younger than 6 months of age), yet presents with poisoning from a drug or toxin.
– The child is older than 4–5 years of age. Accidental ingestions are rare in older children, and ingestion may be a signal of
abuse or neglect.
– The drug ingested was a tranquilizer (eg, haloperidol or chlorpromazine), a drug of abuse (eg, cocaine or heroin), a
sedative (eg, diazepam), or ethanol, or the parents are intoxicated.
– Long delay between time of ingestion and the time the child is taken for medical evaluation.
• There are signs of physical or sexual abuse or neglect: multiple or unusual bruises; a broken bone or burns; a
very dirty, unkempt child; or a child with a flat affect or indifferent or inappropriate behavior.
• A history of repeated episodes of possible or documented poisonings or a history of prior abuse.
57
SUSPECTED ABUSE: OBTAINING THE
HISTORY
• Injury – ask open-ended questions about how the injury occurred, followed by more specific ones
– Ask the child questions first (if able to speak) with parents present. If suspicion of child abuse suspected,
then request to interview the child alone. Most parents consent. If not, “red flag”. Contact social services.
– Avoid yes-no questions, as children answer these inaccurately
– Use open ended questions that do not introduce concepts of abusive acts, or an abuser
– Example: following a child's statement that "he hurt me":
• "You said 'he' hurt you, who is 'he'"?
• "What did he do?"
• "Where did he do it?"
• "When did this happen?"
58
HISTORY SUSPICIOUS FOR ABUSE
• The history provided by the parent or caretaker is inconsistent with the injuries of the child
• The history is vague or lacking in detail.
• The history changes in repeated versions given by the same caretaker, or conflicting histories
are given by different family members
• Injury that is blamed on young siblings; this account may be a cover story or may be true and
related to sibling rivalry, inadequate supervision, or violence in the home. No history is offered.
• History that is inconsistent with the developmental stage of the child
• Implausible history
• History of prior episodes of bruising or orofacial injury in an infant who is not cruising .
59
PHYSICAL EXAMINATION- SUSPECTED
ABUSE
• Try to interview a child without parents present (unless being interviewed elsewhere), but
parents may be present for the PE
• PE should include a full physical examination including genitalia
• Abusive head trauma (AHT) causes the majority of morbidity and mortality, and may be caused
by direct impact, asphyxia, and shaking
– Nonspecific signs include lethargy, vomiting (without diarrhea), changing neurologic status or
seizures, and coma.
– Retinal hemorrhages – marker for AHT
– Cranial fractures – get CT head for acute injury, MRI 5-7d later
60
EVALUATION OF A CHILD FOR
SUSPECTED ABUSE
• Skeletal survey (see next slide)
• Unenhanced head CT – preferred imaging study for suspected head trauma
• Laboratory – based on PE :
– Bleeding disorder?
– Serum amylase, lipase, AST, ALT if suspected blunt abdominal trauma (elevated if injury)
– Serum electrolytes, osmolality may be abnormal with abusive head trauma, or water intoxication
61
Absolute indication for skeletal survey:
• Suspected physical abuse in a child under
24 mos. of age
Relative indications for skeletal survey:

• Child 24-60 mos old with concern for abuse
• Concern for abuse in children with limited
mobility or communication skills, or altered
LOC (any age)
• Children 24 mos or younger, who are
asymptomatic, but share a home with an
abused child
62
Intracranial bleeding:
A- older blood
B- new blood
63
64
Retinal Hemorrhages. Multiple retinal hemorrhages (too numerous to count) are present in this image. A pediatric or general ophthalmologist can obtain a
more complete view of the retina with dilated direct ophthalmoscopy and should be consulted to evaluate for retinal hemorrhages. (Photo contributor: Rees
W. Sheppard, MD.)

66
REPORTING SUSPECTED
ABUSE/NEGLECT
• All 50 states require physicians to report child neglect to child protective services
• Most states (48) also specifically require other professional groups to report, including:
– Medical and mental health professionals
– Educators
– Child care providers
– Social service providers
– Law enforcement personnel
• Those states not specifying the groups mandated to report cases state that “all persons”
• Many states require clergy to report suspected cases
• See the following online publication from the federal government:

– https://www.childwelfare.gov/pubpdfs/manda.pdf
67
REPORTING SUSPECTED
ABUSE/NEGLECT
• In most states, reports of neglect are made orally by telephone or in person, then followed by
a written report within 36 h -5 d. Included on the written report:
– Name, age, sex, and address of the child
– Nature and extent of the child’s injuries or condition
– Name and address of the parent or other person responsible for the child
• In most states, Child Protective Services (CPS) conducts initial evaluations , generates reports,
and offers rehabilitative services to families.
68
69
70
REASONS FOR LACK OF REPORTING OF
CHILD ABUSE
• Victim:
– Fear and coercion
– Embarrassment
– “Deserve it” (low self-esteem, has been told was worthless or bad, punishment)
• Parent/family member:
– Guilty party (perpetrator)
– Denial
– Anger
– Embarrassment
– Inadequacy – possibly due to parental drug or alcohol use
71
REASONS FOR LACK OF REPORTING
OF CHILD ABUSE
• Health care provider:
– Despite mandatory reporting laws, some PCPs do not report suspected abuse
• Reasons given include alternative management strategies designed to monitor for or limit further abuse,
and some feel that they can intervene better than CPS
• Inadequate training to recognize clinical manifestations of abuse
• Cultural attitudes
• Perception that CPS intervention is ineffective
• Lack of support from professional societies
• Child Welfare Information Gateway (www.childwelfare.gov/) - resource
72
ASSOCIATED READINGS
• Accessmedicine.com
– Current Diagnosis & Treatment: Pediatrics. 24th ed. Chapter 8. Child abuse & neglect
– Current Diagnosis & Treatment: Psychiatry. 2nd ed. Chapter 42. Child maltreatment
– Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. Chapter 150. Child abuse and neglect
• UpToDate.com
– Physical abuse in children: Epidemiology and clinical manifestations
– Physical abuse in children: Diagnostic evaluation and management
73
QUESTIONS?
74

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CHILD ABUSE

• Child abuse is common

• Some children are more likely to be abused:

TEN stands for torso, ears and neck, areas more

Source: CHILD ABUSE, The Atlas of Emergency Medicine, 4e

Source: CHILD ABUSE, The Atlas of Emergency Medicine, 4e

Source: CHILD ABUSE, The Atlas of Emergency Medicine, 4e

Relative indications for skeletal survey:

Source: CHILD ABUSE, The Atlas of Emergency Medicine, 4e

• See the following online publication from the federal government:

• Child Welfare Information Gateway (www.childwelfare.gov/) - resource

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