Abuse - MH Flashcards
(24 cards)
Definition of Physical Abuse
Physical abuse is generally defined as “any non-accidental physical injury to the child” and can include striking, kicking, burning, or biting the child, or any action that results in a physical impairment of the child
Legal definition varies by state
Risk Factors
- 2% had a Disability
- Mental Retardation
- Emotional Disturbance
- Behavioral Problems
- Another Medical Problem – chronic
Domestic violence Exposure
- 25.1% of victims
- 8.2% of non-victims
Types of Maltreatment
78.5%: Neglect
17.6%: Physical abuse
9.1%: Sexual abuse
8%: Emotional maltreatment
Who Were the Victims?
Birth to 2 years: 27.1%
Younger than 9 years: 63%
Race
- White: 44%
- African American: 22%
- Hispanic: 22%
- Other, unclassified: 12%
Perpetrators
81% were parents
-4/5 child fatalities were caused by one or more parents
85% were 20-49 years
54% were women
Taking a History
- Medical providers are not investigators
- However, medical providers are often recording the first history
- Take time to get a detailed history
- Talk a little and listen a lot
- Document description of injury in detail
- Identify “players”
- Use quotes when possible
- Be sure that anything in quotes is actually a quote
- Don’t skimp on the documentation
- Skimpy documentation more, not less, likely to require testimony to clarify
- Consider taking histories from each caregiver individually
- Control information exchange
- Information offered by health care providers may be woven into a false history
- DO NOT OFFER POTENTIAL EXPLANATIONS
- Did you squeeze him?
- Did you shake him?
- Avoid confrontation or accusation
- Ask for details
- What happened next?
Past Medical History
- Should be a general review and focused on area of concern with documentation of pertinent negatives
- Bone disease: history of fractures, prematurity, diet and vitamin D exposure, drugs
- Bleeding: circumcision or surgeries, frequent bruises, diet, drugs
Family History
- Include known diagnosis as well as symptoms suggestive of occult diagnosis (document absence of symptoms)
- For example, hearing loss and poor dentition may suggest OI
- Coagulation disorders may be familial and may be suggested by easy bruising or prolonged menses
Social History
- Include history of domestic violence and CPS involvement
- Use caution in relying too heavily on social history
- Abuse occurs in all socioeconomic classes
- Missed more frequently in higher SES
- Medicine does not train us to identify “good” or “bad” people
History Red Flags
- Developmentally inappropriate histories
- No history—particularly in very young infants
- Histories inconsistent with injuries
- Short falls resulting in serious injuries
- Serious injuries inflicted by small children
- Delay in seeking medical care
- Changing history
Commonly provided histories for serious injury/death that should raise the concern for child maltreatment
- Child fell from low height
- Child fell onto furniture, floor, or object
- Child unexpectedly found dead
- Child choked; shaken to dislodge object
- Child turned blue; shaken to revive
- Child experienced sudden seizure activity
- Resuscitation efforts caused injuries
- Caused by traumatic event a day or more prior
- Adult tripped or slipped while carrying child
- Child’s sibling injured the child
- Child left alone for short time
- Child fell down stairs
Falls
- The leading cause of nonfatal injuries for all children
- Rarely cause fatal injury in children
- a morality rate of 0.48 cases per 1 million children for short falls in children under 5 yrs
- Very common history in abused children
- Falls are common
- Falls most often result in no injury
- Serious injury or death from short falls is reported but is exceedingly rare
Physical Exam Considerations
- Head: External marks, bruises under hair
- Intraoral: Frenum tears, dental trauma, -tongue lesions
- Neck: Bruises, strangulation marks
- Ears: Bruises of pinna, hemotympanum
- Eyes: Bruises around eyes, retina
- Chest: Grab marks, tender areas, bruises
- Abdomen: Distention, tenderness, bruises
- Ano-genital: Bruises, tissue damage of female genitalia, anal trauma, scrotal hematoma, penile lesions
Bruises
-Common manifestation of physical abuse
Keys to diagnosis
-Child’s development
-Location
-Pattern
-Accidental bruises – bony prominences: shins, elbows, lower arms, forehead, underneath chin, ankles, hips
-abuse bruises: upper anterior thighs, trunk (torso, chest, back), upper arms, face and ears, hands and feet, buttocks and anus, genitalia
Age/Development
- Bruising is rare in infants/pre-cruisers and becomes increasingly more common as children age and develop
- If bruising is seen in a non-ambulatory child, consideration should be given to abuse or some other underlying condition
Pattern Injuries
Patterned injury (of any type) should significantly heighten the concern for an abusive etiology over an accidental one
- Slap marks
- Loop or elliptical marks
- Linear marks
- Vertical bruising on the buttocks
- Objects
Skeletal Injuries
- All cases with fractures require a comprehensive history and physical examination, including details of the event and developmental history
- Accidental vs abusive etiology is rarely made based on the type of fracture
- Location, however, can provide important information in making this determination
High specificity for abuse
- Metaphyseal lesions
- Posterior rib fractures
- Scapular fractures (rare)
- Spinous process fractures (rare)
- Sternal fractures (rare)
Moderate specificity for abuse
- Multiple fractures, especially bilateral
- Fractures of differing ages
- Epiphyseal separations
- Vertebral body fractures
- Digital fractures
- Complex skull fractures
Low specificity for abuse
- Clavicular fractures
- Long bone shaft fractures
- Linear skull fractures
Head Injury
- The large size of children’s heads relative to their bodies causes the head to be a frequent site of injury, accidental and inflicted
- Certain injuries (subgaleal hemorrhage or epidural hematoma) are more commonly associated with accidental injury
- Both accident and abuse can cause intracranial injury, complicating the diagnosis
Factors more commonly associated with abusive head injury
- Young age (<1 year)
- Lack of history of a significant traumatic event
- Changing history from the caregiver
- Presence of head injury symptoms/seizures at presentation
- Poor outcomes
- Report that home resuscitation caused the injury
Subgaleal Heamtoma
- May occur from traumatic hair-pulling
- Detailed birth history is necessary for young infants, as newborns may have the same findings as the result of an instrumented delivery
Scalp Bruising
- Simple bruising is expected in ambulatory children over the bony prominences, including the forehead
- More extensive bruising of the scalp, especially in the setting of additional injury, should heighten concerns of abuse
Epidural Hemorrhage
- Epidural hematomas in children are often from accidental mechanisms
- However, as with all childhood injuries, differentiation of accidental from abusive etiologies requires careful analysis of the history provided and the injuries sustained
Subdural Hematoma
- Although these bleeds may result from accidental mechanisms, in infants and young children abusive mechanisms more commonly account for subdurals than epidurals
- Subdurals are the most common cranial radiographic abnormality in child abuse
Head Injury
- Evaluation requires comprehensive history and physical examination, consideration of injury biomechanics, epidemiology of childhood injury, a thorough search for occult injury, and a careful investigation into the cause of injury for each child
- The medical literature supports the conclusion that severe head injuries, unless related to a motor vehicle accident or a fall from a significant height, are likely to be the result of abuse
Visceral Injury
-Blunt abdominal trauma is a relatively rare form of child abuse, but is the second most common cause of death from child abuse
Factors associated with abuse
- Increased severity of injury
- Multiple injuries
- Delay in seeking care
