Child Maltreatment/Abuse

Wong’s Essentials pg. 401 – 404, 480 - 490.ATI Unit 3 pg. 606 - 610

Dondi Kilpatrick, MSN, RN

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Child Maltreatment Objectives

• Define types of child maltreatment• Recognize S/S of child maltreatment• Describe contributors to child maltreatment• Discuss effects of child maltreatment• List cultural practices mimicking maltreatment

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Child Maltreatment

Definition: Intentionalphysical abuse or neglectemotional abuse or neglect orsexual abuse of children

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Wong’s Essentials of Pediatric Nursing 8th ed p480

Mental/Emotional Effects of Child Maltreatment bindler 245

• sleep disturbances• anxiety • hyperactivity

conduct disorder• learning/memory

problems• alcoholism• depression

• drug abuse• eating disorders• post traumatic stress

disorder• obesity• sexual promiscuity• suicide

4Videbeck 4th ed, Bindler

Physical Effects of Maltreatment

– Fractures, bruises, lacerations, etc– Severe head trauma

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Bindler p 244

Predisposing Factors for Child Maltreatment

• Exact cause unknown

• 3 Contributing Factors

• Child• Parent/Caregiver• Environment

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Wong’s Essentials of Pediatric Nursing 8th ed p 481

Characteristics of the childChildren unintentionally contribute –

THEY ARE NEVER TO BLAME• Behavior disorder• Ordinal position/position in family• Temperament• Less than 3 years old• Prematurity(NICU, have many needs)• Illegitimate, unwanted, brain damaged, hyperactive, or

physically disabled child

• Usually one child is the victim of abuse• Removal often places other siblings at risk

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Wong’s Essentials of Pediatric Nursing 8th ed p 481 - 482

Parental Characteristics• History of abuse /neglect themselves• Difficulty controlling aggressive behavior• Drug addiction/alcohol abuse• Social isolation/ inadequate support systems• Marital stress• Teenage mother-social network, many

adjustments • Low self esteem• Inadequate knowledge of child rearing

/inappropriate expectations for child’s developmental level

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Hockenberry p698

Environmental Contributors• Chronic stress• Poverty• Unemployment• Poor housing• Frequent relocation

• Crowded living conditions

• Re housing• Marital discord• Addition of a child

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Child abuse spans all educational, social, and economic levels

Avoid Stereotyping

Hockenberry p699

Types of Child Maltreatment

• Neglect• Emotional abuse/neglect• Physical abuse• Sexual abuse

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Neglect

• Failure to provide for a child’s basic needs– Physical– Emotional– Educational

• Most Common type of maltreatment

ENPC 2004

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Physical Neglect:

~Deprivation Of Necessities~ more details– Food– Clothing– Shelter– Supervision– Medical Care– Education

Neglect Signs and Symptoms

• Unclean or inappropriate clothing• Poor personal hygiene• Failure to thrive (FTT)• Frequent injuries• Evidence of poor health care

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Emotional Maltreatment

Emotional Neglect:~FAILURE

to meet the needs of affection, attention, and emotional nurturance

Emotional Abuse:~DELIBERATE

attempt to destroy or significantly impair a child’s self-esteem or

competence

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Failure to Thrive (FTT)

• R/O neglect• FTT may be a result of:

– Physical problems ex) HIV– Psychosocial issues– Poverty– Health beliefs– Family stress– Feeding issues

http://emedicine.medscape.com/article/915575-media

Physical Maltreatment

“DELIBERATE” infliction of physical injury

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Injury from Abuse

• Can occur from:• Punching• Beating• Shaking• Kicking• Biting• Throwing• Burning• Throwing

• May result in:• Bruises• Bites• Burns• Lacerations• Pinch Marks• Swelling• Tenderness

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Suspicious Injuries Suggestive of Abuse

• Bruises– Varying stages of healing– Location– Number– Patterned bruises

– Are they walking or not? Does the bruise match the child’s activity level

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http://emedicine.medscape.com/article/915664-media

Suspicious Burns

• Non-Accidental Patterns– Forced immersion burns

• No Splash pattern

Pattern from object

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Inflicted burns may have a pattern or be circumferential

Suspicious Lacerations

• Frenulum of upper lip– Frenulum- small fold of tissue that prevents

an organ in the body from moving too far.• Ex: Forced fed = mouth injuries

• Rectal area• Vaginal area

Suspicious Skeletal Fractures• May be single/multiple, new/old or a

combination • Metaphyseal fractures

– The metaphysis is the wider portion of a long bone adjacent to the epiphyseal plate. It is this part of the bone that grows during childhood

• Rib, scapular, or sternal fractures• Transverse, oblique, or spiral • Bilateral or symmetrical• Greenstick is normal fx

Metaphyseal fracture: bucket- handle fracture

http://www.medscape.com/features/slideshow/child-abuse?src=mp&spon=24&uac=135492FK

Rib fractures

http://www.medscape.com/features/slideshow/child-abuse?src=mp&spon=24&uac=135492FK

Child Abuse: Radiologic-Pathologic Correlation1 Gael J. Lonergan, Lt Col, USAF MC, Andrew M. Baker, MD, Mitchel K. Morey, MD and Steven C. Boos, Lt Col, USAF MC 2003

Spiral fracture

Anteroposterior Compression

Fractures due to the squeezing pressure – NOT from CPR

http://radiographics.rsnajnls.org/cgi/content/figsonly/23/4/811

Suspicious Abdominal Injuries

• Injury inconsistent with history• Delay in seeking care

• 2nd most common cause of death in child abuse

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Suspicious Head Injuries

• Head injury with bruising of upper extremities or ribs

• Serious head injury with retinal hemorrhages– Shaken baby suspicion

• History of injury inconsistent with injury– Skull fracture after tripping over dog– Keep in mind: does the injury match the child’s age

• # 1 cause of death in child abuse

Shaken Impact Syndrome / Shaken Baby Syndrome

• Signs/symptoms – poor feeding/eating– altered LOC– seizures– bruising of upper extremities or ribs– serious head injury with retinal

hemorrhages, can become blind

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Retinal hemorrhages

http://emedicine.medscape.com/article/1176849-media

Common “Triggers” for Shaking

• Crying• Toilet training• Feeding issues• Interrupting

• What can you do to reduce abuse related to these triggers?– EDUCATE

Serious Physical Abuse and SIDS Program 2005

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Preventing Injuries Nursing Alert

• Stress to parents the dangers of shaking infants

• Advise against shaking as a method of burping or waking infant

• Advise against tossing infant in the air• Advise against shaking infant when feeling

angry or tense

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http://www.dontshake.org/sbs.php?topNavID=3&subNavID=24

Munchausen’s Syndrome By Proxy

Illness that one person fabricates or induces in

another to gain __ATTENTION__ from medical staff

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Wong’ s Essentials of Pediatric Nursing 8th ed p 481

Munchausen’s Syndrome by Proxy:

• Caretaker may:– Present fictitious medical history– Chronically poison child – Suffocate child to cause apnea/seizure– Allege child has been sexually abused by

someone else to gain recognition as child’s protector

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Munchausen Syndrome By Proxy: Warning Signs

• Unexplained, prolonged, recurrent or extremely rare illness

• Discrepancies between clinical findings and history• Illness unresponsive to treatment• Signs/ symptoms only occurring in parent’s presence• Parents knowledgeable about illness, procedures, and

treatments

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Munchausen warning signs con’t

• Parents very interested in interacting with health team members

• Parents very attentive toward child (refuse to leave hospital)

• Family members with similar symptoms

Hockenberry p698

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Munchausen by Proxy

• Cause unknown• 10% of cases fatal• May lead to :

– Chronic invalidism-many children may think that they have a chronic illness

– Continued psychiatric trauma

– REMEMBER: it’s the caretaker who has MBP not the child

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Sexual AbuseThe Use, Persuasion, Or Coercion

Of Any Child To Engage In Sexually Explicit Conduct

(Or Any Simulation Of Such Conduct) For Producing Any Visual Depiction

Of Such Conduct, Or Rape, Molestation, Prostitution, Or Incest

With Children(The Child Abuse And Prevention Act [Public Law 100-235]) 39

Sexual Abuse • Typical abuser – male who victim knows• Offenders come from all levels of society

• Coercion Methods: – Children are offered gifts or privileges– Adult tells child it is “O.K.”– Children enticed by adults who meet their needs

for warmth and human contact– “Secret” relationship– Offender plays on child’s fears– Coercion-to force someone to do something that

they do not want to do

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Signs and Symptoms• Physical

– Injury to/discharge from genitalia– Chronic dysuria “diff urinating”, enuresis “urinary incontinence”,

constipation, or encopresis “involuntary bowel movement”

– Sexually transmitted diseases– Difficulty walking or sitting– Pregnancy

• Emotional/psychological– Sexual comments, behaviors or play– Regressive behavior i.e bed wetting– Resistance of child to remove clothes for exam

Health issues and/or practices mimicking maltreatment/abuse

• Cultural practices• Mongolian spots- blue or purple-colored splotches on the baby's lower

back and buttocks; common in darker-skinned babies.• SIDS- unexplained, sudden death of an infant up to 1 year of age.• Osteogenesis imperfecta- a genetic disorder that is also characterized

by easily fractured bones “brittle bone disease”• Congenital anomalies of genitalia- an abnormality present at birth.• Diaper rash, erythema multiform- erythema multiform- red rash

caused by hypersensitivity to a drug or disease or other allergen • Idiopathic thrombocytopenia purpura (ITP)- having a low platelet

count (thrombocytopenia) of no known cause (idiopathic). • Leukemia- A cancer of developing blood cells in the bone marrow.• Accidental straddle injuries

Cultural Practices

Cuppinghttp://www.ethnomed.org/ethnomed/

Cultural Practices

Coininghttp://www.ethnomed.org/ethnomed/

Mongolian Spots

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http://www.fwcc.org/mongolianspot.htm

Sudden Infant Death Syndrome (SIDS)

• Sudden Death of an Infant < one year old• Death unexplained post autopsy,

examination of the scene of death, and a review of the case

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Wong’s Essentials of Pediatric Nursing 8th ed p 401

National Institute Of Child Health And Human DevelopmentNational Institute Of Child Health And Human Development

SIDS

• Etiology unknown• 3rd leading cause of death in children under

1 yr of age• Peak Age- 2-4 months of age• Occurs during sleep

– Suspicion of co2 buildup– Usually peaks in the winter

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Babies At Risk For SIDS• Maternal smoking• Poor prenatal care• Low maternal age• Prematurity or low

birth weight• Intrauterine drug

exposure• Multiple births-twins• Males

• 2 or more SIDS victims in family

• Winter months• Overheating the infant• Soft pillows, bedding

in crib• Prone position for

sleeping• Co-sleeping

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Nursing Care of the Maltreated Child

• Recognize

• Protect-remove from situation

• Treat physical injuries

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• Encourage child to verbalize feelings about incident

• Refer to appropriate agencies

• Prevent further abuse

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Reporting - What is your role?

• Nurses are mandatory reporters• Child abuse is against the law, and so is

failure to report• A person making the report is immune from

civil or criminal liability provided the report is made in good faith

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How do you report abuse?

• Texas Abuse Hotline is 1-800-252-5400or

• https://www.txabusehotline.org

• Tell exactly what happened and when

• Report all injuries you observed

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