Child Abuse

Presented By;
Nirav Valand
 Definitions
Child abuse any recent act or failure to act on the part of a parent
or caretaker, which results in death, serious physical or emotional
harm, sexual abuse or exploitation.
Neglect refers to omissions in care, resulting in actual or potential
harm.
Omissions include inadequate healthcare, education, supervision,
protection from hazards in the environment, and unmet physical
needs (e.g., clothing, food) and emotional support.
 Global incidence
Based on international studies, the World Health Organization
(WHO) has estimated that approximately 20% of women and
5-10% of men report being sexually abused as children, while 25-
50% of all children report being physically abused
 Risk factors
Risk factors exists at 4 levels;
Individual level, a childs disability or a parents depression or
substance abuse predispose a child to maltreatment.
Familial level, intimate partner (or domestic) violence presents risks
for children.
Influential community factors include stressors such as dangerous
neighborhoods or a lack of recreational facilities.
 Risk factors
Broad societal factors, such as poverty and its associated
burdens, also contribute to maltreatment.
WHO estimates the rate of homicide of children is
approximately 2-fold higher in low-income compared to high-
income countries (2.58 vs. 1.21 per 100,000 population).
 Physical abuse
Physical abuse of children by parents affects children of all ages.
It is estimated that 1% to 2% of children are physically abused
during childhood and that approximately 1500 children are fatally
injured each year.
In Uganda, this is widespread both at homes and schools; and is
used in the context of disciplining the children.
These punishments involve use of sticks, shoes, brooms, belts etc.
 Although mothers are most frequently reported as the perpetrators of
physical abuse, serious injuries, such as head or abdominal trauma,
are more likely to be inflicted by fathers or maternal boyfriends.
 Diagnosis
Is easy if the child is battered, has obvious external injuries, or is
capable of providing a history of the abuse.
History provided by the parent is often inaccurate because the
parent is unwilling to provide the correct history or is a non
offending parent who is unaware of the abuse.
The child may be too young or ill to provide a history of the assault.
An older child may be too scared to do so or may have a strong sense of
loyalty to the perpetrator.
 Clinical manifestations.
Bruises are a universal finding e.g. slap marks; and are distributed
over the bony prominences
Approximately 10% of children hospitalized with burns are victims
of abuse. Symmetric burns are especially suggestive of abuse as are
burns of the buttocks and perineum
 Fractures
Inflicted fractures occur more commonly in infants and young
children.
Diaphyseal fractures are most common in abuse.
Fractures that should raise suspicion for abuse include fractures that
are unexplained; occur in young, non-ambulatory children; or involve
multiple bones.
Certain fractures have a high specificity for abuse, such as rib,
metaphyseal, scapular, vertebral, or other unusual fractures
 Abdominal injury.
A serious form of injury.
Blunt trauma to the abdomen is the primary mechanism of injury,
and infants and toddlers are the most common victims.
Injuries to solid organs, such as the liver or pancreas,
predominate and hollow viscus injury occurs more commonly
with infliicted trauma than accidental.
 Head trauma.
leading cause of mortality and morbidity from physical abuse.
Most victims are young; infants predominate.
Shaking and blunt impact trauma cause injuries.
The culprits are most commonly fathers and boyfriends, and the
trauma typically is precipitated by the perpetrators intolerance to
a crying, fussy infant.
Victims present with neurologic symptoms ranging from lethargy
and irritability to seizures, apnea, and coma
 DDx
Bruises
Accidental injuries
Hematological disorders Vitamin K deficiencies, leukemia, DIC.
Cultural practices.
Burns
Accidental burns
Infection e.g. impetigo
Dermatological e.g. Severe diaper dermatitis
 Fractures
Accidental injury
Birth trauma
Rickets
Infection e.g. congenital syphilis.
Head trauma
Accidental head injury
Intracranial vascular abnormalities
 Sexual abuse
Sexual abuse is defined as the 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.
It includes all forms of incest, sexual assault or rape, and
pedophilia.
Usually a chronic event.
 Sexual abuse
Most perpetrators are adults or adolescents who are known to the
child and who have real or perceived power over the child.
Most sexual abuse involves manipulation and coercion and does not
involve physical violence.
Perpetrators are more often male than female and include parents,
relatives, teachers, family friends, members of the clergy, and other
individuals who have access to children.
 Approximately 80% of victims are girls, although the sexual abuse
of boys is under recognized and underreported.
Hypersexual behaviors should raise the possibility of abuse.
Sexual abuse occasionally is recognized by the discovery of an
unexplained vaginal, penile, or anal injury or by the discovery of a
sexually transmitted infection.
 Presentation.
Children who have been victims of sexual abuse may present in a
number of ways, including:
Sexually transmitted infections: Gonorrhea; Chlamydia;
Trichomonas vaginalis.
Pregnancy.
Vaginal bleeding in prepubertal girls
Disclosure by the child.
2 wetting and/or fecal soiling.
 Presentation.
Genital or peri-anal injury with an absent or unsuitable explanation.
Behavioral changes:
Self-harm;
Withdrawal;
Aggression;
Sexualized behavior;
Unexplained deteriorating school performance.
 Signs
Few signs are diagnostic and there may be no findings in 5090%.
Acute signs
Girls: acutelytears in hymen; vaginal bleeding; bruising around
genital area; and hand grip marks.
Boys: bruising to genital area; urethral injury; torn frenulum of penis.
Anal signs: anal fissure; gaping anus; swelling of anal margin. Note:
these signs may disappear rapidly.
 Chronic signs
These signs are more difficult to interpret.
In girls the following that may be suggestive of previous, repeated
penetrative trauma:
scar in posterior fourchette;
old tear or scar of the hymen;
complete absence of tissue at posterior hymen
In both sexes: anal fissure and scars when other causes have been
excluded.
 Emotional abuse & Neglect
Emotional or psychological abuse has been defined as the rejection,
ignoring, criticizing, isolation, or terrorizing of children, all of
which have the effect of eroding their self-esteem.
Children who witness domestic violence should be considered
emotionally abused.
 Emotional abuse & Neglect
The most common feature of emotional neglect is the absence of
normal parent-child attachment and a subsequent inability to
recognize and respond to an infants or childs needs.
A common manifestation of emotional neglect in infancy is
nutritional (nonorganic) failure to thrive.
 Symptoms of emotional abuse
Loss of self-esteem or self-confidence.
Sleep disturbances.
Somatic symptoms (e.g., headaches and stomach aches).
Hypervigilance.
Avoidant or phobic behaviors (e.g., school refusal or running away)
may be presenting complaints.
 Being excessively clingy.
Attention-seeking behavior.
Overly anxious.
Overly serious.
Being anxious to please.
 Parental behaviours are a clue to the diagnosis. Any of these must
be persistent and severe, and have a major impact on the child in
order to reach the threshold for emotional abuse:
Persistently negative view of the child.
Inconsistent and unpredictable responses.
Expectations that are very inappropriate.
Induction of a child into bizarre parental beliefs
Medical Care Neglect
Medical care neglect is failure to provide the needed treatment to
infants or children with life-threatening illness or other serious or
chronic medical conditions.
Medical Child Abuse
Previously referred to as Munchausen syndrome
Medical child abuse is the preferred term for a relatively unusual
clinical scenario in which a caregiver seeks inappropriate and
unnecessary medical care for a child.
Oftentimes, the caregiver either simulates or creates the symptoms or
signs of illness in a child.