Child Abuse/Neglect

Question 1

T/F neglect can be a single act

Answer 1

F - Rarely is neglect a single act
It is an accumulation of harm over time

Question 2

What is neglect?

Answer 2

• Rejection, ignoring, criticizing, isolation, or
  terrorizing of children → erode self-esteem
• 6.5% of children every year are neglected
• Most common form of maltreatment
  In 75% of abuse cases, neglect was confirmed
• Most difficult to detect
  Clinicians must investigate psychosocial history,
  family dynamics, & parental mental health,

Question 3

Physical neglect

Answer 3

• Failure to provide the adequate necessities of food, shelter & clothing

Question 4

Emotional neglect

Answer 4

Failure to provide necessary nurturing,
affection, stimulation
Most common form is verbal abuse or denigration

Question 5

Educational neglect

Answer 5

Failure to provide an educational program; this, may include truancy

Question 6

Medical/Dental neglect

Answer 6

Failure to provide basic medical & dental
care, which results or has the potential to result in harm; this
may include noncompliance with healthcare
recommendations

Question 7

Supervisory neglect

Answer 7

Failure to supervise & ensure safety of a child, given the child’s developmental needs

Question 8

Risk Factors for neglect: Children

Answer 8

Premature birth
Young age
Multiple gestation births
Ex. twin
Chronic disability

Question 9

Risk Factors for Neglect: Parents/caregivers

Answer 9

Substance abuse
Adolescent parents
Poverty
Cognitive impairment
Domestic violence
Mental health issues
Lack of education
Unrealistic expectations

Question 10

Risk Factors for Neglect: family

Answer 10

Isolation
Single-parent families
Unemployment
Family illness
History of involvement with child welfare services

Question 11

Clinical Presentation for physical neglect

Answer 11

Poor hygiene, lack of adequate clothing or diapers, or injuries from exposure (frostbite, heat illness)

Question 12

Clinical Presentation of supervisory neglect

Answer 12

Ingestion, injury from a firearm, dog bite, near drowning, burns or fatality

Question 13

Clinical Presentation of emotional neglect

Answer 13

Lack of a relationship between the child & caregiver
providing a sense of emotional security
Caregiver inability to follow through with
recommendations for psychological care or services

Question 14

Clinical Presentation og educational neglect

Answer 14

• Chronic truancy/poor attendance
• Homeschooling without an educational plan or activities

Question 15

Clinical Presentation: Nutritional neglect

Answer 15

• Undernutrition → starvation, failure to thrive
  Relative absence of subcutaneous fat in the cheeks,
  buttocks, & extremities
  Conditions associated ↓ nutrient & vitamin intake
  Short stature

Overnutrition → obesity with significant medical complications

Question 16

Clinical Presentation: Medical neglect

Answer 16

Seriously ill child & signs of illness were not recognized,
or care not sought
Lack of adherence to tx plans &/or follow-up → serious
exacerbation of chronic health conditions
Lack of primary care visits for vulnerable children

Question 17

Children under ___ months old are incapable of inducing
accidents or accidentally ingesting drugs or poisons on
their own

Answer 17

6

Question 18

Risk Factors for perpetrators

Answer 18

Male
Female
Young maternal age
Single/Unmarried mother
Abused themselves
History of substance abuse

Question 19

What might a history sound like in a patient you are suspecting abuse?

Answer 19

• No history, denial of trauma despite severe injury, or changing history
• Explanation inconsistent with child’s injury/developmental stage
  Short “fall” (<3 feet)
• Severe injury explained as self-inflicted or blamed on other young children or pets
• History discrepancies of various caregivers
  Substantial delay in seeking medical care

Question 20

Physical Exam guidelines for head when abuse is expected?

Answer 20

• hematoma or abnormality of skull
  Abusive head trauma (ie shaken baby syndrome)
• Alopecia (2° hair pulling)
• Eyes
• Mouth (dental trauma)

Question 21

Physical Exam: derm when suspecting abuse

Answer 21

Expose skin, examine, & document precise location &
size of any ligature marks, bites, bruises, burns or scars

Question 22

Physical Exam: MSK when suspecting abuse

Answer 22

• Palpate chest, abdomen, spine & extremities for tenderness
  Evidence of fractures
• Injuries in multiple stages of healing

Question 23

T/F any bruise is a red flag injury in infants <6 months old?

Answer 23

T

Question 24

What is red flag injuries for abuse for abuse under the age of 3?

Answer 24

Frenulum tears - May be from accidental injury (ambulating toddler) or force feeding/bottle jamming
Unexplained oral injuries (teeth, lips, palate)
Missing or fracture teeth with an absent or implausible history
Maxillary or mandibular fractures with an absent or implausible history
Bruising, lichenification, or scarring at the corners of the mouth from being gagged

Question 25

Where are accidental bruises found?

Answer 25

* Front of the body * Boney prominences (extremities) * Forehead

Question 26

Non-accidental bruises are found:

Answer 26

* Torso * Ears, cheeks, neck * Back, buttocks * Patterned * >1 bruise, non-mobile infant * >2 bruises, crawling child

Question 27

Red flag burn injuries in children <3 yo

Answer 27

Burns in the shape of a heated object Immersion burns Burns of the perineum & lower extremities Multiple fractures in different stages of healing

Question 28

Red flag fractures in infants <6 months

Answer 28

Any fracture other than skull or clavicle fractures in the newborn period

Question 29

Red flag fractures in infants 6-12 months

Answer 29

Any fracture other than skull fracture Skull fractures without history or other than simple linear parietal type

Question 30

Red flag fractures in 1 year olds

Answer 30

Any rib fracture Humerus fracture, other than supracondylar Fractures of other long bones Fracture without trauma history or presenting with evidence of healing

Question 31

Red flag intracranial injuries <1 yo

Answer 31

Any subdural hemorrhage/hygroma

Question 32

Red flag fractures in 2-3 year olds

Answer 32

Fracture without trauma history or presenting with evidence of healing

Question 33

Red flag intracranial injuries >1 yo

Answer 33

Unexplained subdural hematoma without history of high-energy trauma (eg, motor vehicle collision, long-distance fall)

Question 34

Red flag visceral injuries <1 yo

Answer 34

Any visceral injury

Question 35

Red flag visceral injuries >1 yo

Answer 35

Traumatic visceral injury unexplained by motor vehicle collision or verified history of accidental high-energy blow to the abdomen*

Question 36

Diagnostic testing appropriate if suspecting abuse:

Answer 36

Skeletal survey Intraabdominal CT Non-contrast CT of head CBC with platelet count , PT, PTT, BMP, liver enzymes, alkaline phosphatase, calcium & phosphate

Question 37

What testing is Gold standard for suspected abdominal trauma?

Answer 37

Intraabdominal CT

Question 38

Sexual assault

Answer 38

Attempted sexual touching of another person without their consent (children cannot give consent) sexual intercourse (rape) oral-genital or anal-genital contact (sodomy) touching the private parts of another person for sexual gratification (fondling)

Question 39

Sexual abuse

Answer 39

- A child engaging in sexual activities (see above) for which he/she cannot give consent, is unprepared for developmentally, cannot comprehend; &/or an activity that violates the law or social taboos of society, whether the victim is clothed or unclothed. - It also includes non-touching abuses Exhibitionism Voyeurism Involving the child in pornography

Question 40

What are “Grooming” behaviors?

Answer 40

- Gaining access to children through caretaking - Targeting children Bribes, gifts, games - Systematic desensitization of victims Touch Talk about sex Persuasion

Question 41

Risk Factors: perpetrators of sexual assault

Answer 41

Male Trusted adult acquaintances US Health & Human Services “Father” → 21% “Other relatives” → 19% Adolescence Peers may constitute the group of perpetrators

Question 41

Risk Factors: victims of sexual assault

Answer 41

All social, cultural, & economic backgrounds *Poor parent-child relationships *Poor relationships between parents *Absence of a protective parent *Presence of a nonbiologically related male in the home

Question 42

What is often the chief complaints given for sexual assault?

Answer 42

Routine care Urinary Tract Infections Enuresis/Encopresis Sleep Disturbance Behavioral Changes Abuse

Question 43

Diagnostic of sexual abuse

Answer 43

STI (N. gonorrhoeae, Syphilis)

Question 44

What happens when sexual abuse is confirmed?

Answer 44

- Interview should be conducted by a trained child protection investigator & forensic examiner - ↓ need to repeat painful & distressing info - Best if interviewed without the parents Patient comfort & exam effectiveness may be facilitated by the parent

Question 45

Interview guidance for gathering a sexual abuse history

Answer 45

Open ended questioning (never leading) "Has someone ever touched you in a way you didn't like or that made you feel uncomfortable?" "Tell me more,” "& then what happened?” Avoid any display of shock or disbelief Information to obtain in a gentle, nonthreatening way

Question 46

Helpful tip for gathering a sexual abuse history

Answer 46

Helpful Tip: Using a doll or drawing may help the child describe what happened

Question 47

Sexual assault nurse examiners (SANEs)

Answer 47

SANEs are certified by examination through the Commission for Forensic Nursing Certification. Requirements before examination include an unrestricted RN license, 2 years of nursing experience, 40 hours of coursework, & competency in supervised sexual assault examination

Question 48

Sexual assault forensic examiner (SAFE)

Answer 48

Physicians, PAs, & nurses The Department of Justice establishes national training standards for SAFEs

Question 49

What does “First do no harm” mean?

Answer 49

The exam should NOT result in additional harm/trauma

Question 50

Sexual Abuse Physical Exam: Oral cavity

Answer 50

Bruising/petechiae of the palate Frenulum tearing Superior, inferior, linguae

Question 51

T/F if a female is G1-2 and being assessed for sexual assault, a Speculum exam is NOT require unless there is active bleeding of an unknown etiology

Answer 51

T

Question 52

Emotional & Psychological sequelae of abuse

Answer 52

Suicide, substance-use d/o, anxiety & depression, violence, & early death ↑ adverse childhood experiences → ↑ risk

Question 53

About 80% of 21-year-olds who were abused as children met criteria for _____

Answer 53

at least one psychological disorder.

Question 54

General indicators of human trafficking

Answer 54

* Shares a scripted or inconsistent history * Is unwilling or hesitant to answer questions about the injury or illness * Is accompanied by a controlling individual who does not let the patient speak for themselves, refuses to let the patient have privacy, or who interprets for them * Demonstrates fearful or nervous behavior or avoids eye contact, resists assistance or demonstrates hostile behavior * Is unable to provide his/her address, not aware of his/her location, the current date, or time * Is not in possession of his/her identification documents * Is not in control of his or her own money * Signs of malnourishment, substance abuse, or poor dental hygiene

Question 55

Sex trafficking indicators

Answer 55

* Patient is under the age of 18 and is involved in the commercial sex industry * Has tattoos or other forms of branding (Ex// tattoos that say "Daddy," "Property of...," "For sale" * Reports a high number of sexual partners * Does not have appropriate clothing for the weather or venue * Uses language common in the commercial sex industry * Multiple STIs * Multiple pregnancies, miscarriages, and/or terminations