Child at Risk of Abuse Flashcards
1
Q
What is the definition of child abuse?
A
“Physical or psychological damage caused to the child by the abusive behaviour of others, or the failure of others to protect a child from such damage”
2
Q
What are reportable concerns?
A
- Parents or carers have not made proper arrangements and are unable or unwilling for their child to receive an education;
- A series of acts or omissions when viewed together may establish a pattern of risk of significant harm (cumulative impact).
3
Q
Are you protected when reporting concerns for child welfare?
A
- Workers either reporting or furnishing information will:
- not be held to constitute a breach of professional etiquette or ethics or a departure from acceptable standards of professional conduct
- not be liable for defamation
- not constitute a ground for civil proceedings for malicious prosecution
4
Q
How do you make a report in NSW for child welfare concerns?
A
- Mandatory Reporter Guide (MRG)
- https://reporter.childstory.nsw.gov.au/s/mrg
- Outcomes
- Make a Report ROSH Telephone or Ereport the Helpline (CS) 133 111
- Contact Child Wellbeing Unit 1300480420 BH
- Document and continue working with child/family
- Record details in client record or case notes
- Feedback to Reporters
5
Q
How do you write an effective report of a child welfare concern?
A
- Identify and name the abuse or risk of significant harm factor
- Identify and list statements or indicators that led you to this conclusion/suspicion
- How acute/longstanding, degree to which it may impact on the child’s development
- Identify and detail any and all issues you think require further assessment and/or treatment
- Complete the Mandatory Reporter’s Guide and act on the advice given
- Don’t use jargon and explain medical terms simply
- Indicate what outcome you would like
6
Q
Should you tell a parent about a report for child welfare concerns?
A
- Assess safety –child, family & worker
- Honesty and respect
- Professional power v’s patient loss of control
- Be prepared for negative angry reaction
- Find common goal - ie child’s welfare
- Consult and get professional support
7
Q
List examples of physical harm/non-accidental trauma
A
- Bruising
- Burns
- Head injuries
- Intra-abdominal injuries
- Ingestions
- Fractures
- Non organic failure to thrive
- Drowning
- Munchausen by proxy- factitious or induced illness.
8
Q
Describe inflicted head injuries
A
- Statistics
- Most common cause of child abuse deaths
- High morbidity with severe neurological outcomes.
- Intra-cerebral trauma & retinal haemorrhages
- No external pathology
- 50% of cases have fractures found on skeletal survey
- Multiple rib and metaphyseal fractures are characteristic.
- Nuclear Bone Scans useful
- Skeletal survey repeated after two weeks may demonstrate healing rib fractures.
9
Q
What are some red flags for child abuse?
A
- Delay in presentation
- History
- does not explain injury (child fell from low height)
- changes with time
- inconsistent with developmental ability
- unexplained or unwitnessed fall (neglect)
- Suspicious - tripped or slipped carrying child; sibling did it
- Resuscitation efforts caused injuries
- Child choked, shaken to dislodge object;
- Child turned blue, shaken to revive
10
Q
Define emotional harm
A
- The actions of a caregiver leading to the failure of the emotional and psychological development of a child, including self esteem, the ability to trust, love and form mutual relationships, and ability to resolve problems without violence to self or others
- Rejection
- Unavailable to meet the child’s needs
- Isolation
- Terrorise - verbal assault, climate of fear, making the world appear capricious and threatening
- Corruption involvement in thieving, substance abuse, aggression, sexualisation
11
Q
Define neglect
A
- Failure to adequately care and provide for the child, thereby placing the child at increased risk of injury or ill-health
- inadequate feeding-quality and quantity
- cleanliness and hygiene
- inadequate clothing
- lack of accommodation
- failure to provide medical care
- lack of supervision
- Education
- Impacts brain development and attachment
12
Q
Describe sexual harm
A
- Sexual assault includes any sexual act or sexual threat imposed on a child or young person
- Exploits their dependency and immaturity
- Coercion inherent
- coercion may be physical or psychological
- differentiates child sexual abuse from consensual peer sexual activity
- Abuse of power (exploiting the dependency and immaturity of the child)
- Crime
- Range of behaviours
- fondling, kissing of non-genital areas- normalisation of sexual touching
- touching of genital areas, including fondling and oral sex
- penetration- digital, penile, objects
- Involvement of child in pornography
13
Q
Describe some risk factors/red flags for child abuse
A
- Economic – poverty, housing, overcrowding
- Social – racism, social isolation
- Community – dangerous or disadvantaged communities
- Parental - substance abuse, mental health issues, lack interest in child’s needs, intellectual functioning, strong belief in corporal punishment, trans generational trauma & impact on parenting, critical demeaning attitude to child - humiliate or frighten child, isolate child from social, emotional nurturance
- Child – low birth weight, special needs, behavioural problems
- Family – poor relationship, no. of children, single or early
- parenthood chaotic home
- Ecological - violence, gambling loss & trauma
- Abuse or Neglect - previous experience
14
Q
Describe the effects of trauma exposure
A
- Attachment. Traumatised children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to, empathizing and trusting others.
- Biology. Traumatised children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems.
- Mood regulation. Children exposed to trauma can have high emotional arousal & difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.
- Dissociation. Some traumatised children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.
- Behavioral control. Traumatised children can show poor impulse control, self-destructive behavior, and aggression towards others.
- Cognition. Traumatised children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.
- Self-concept. Traumatised children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.
15
Q
What are some health problems related to child abuse
A
- Immunisations – 51% not up to date
- Vision – 20% failed screen
- Dental – 30% caries
- Hearing - 25% (16/64) failed hearing test
- Development: 68% of under 5s failed screen
- Speech: 50% of under 5s speech delay
- Growth: Failure to thrive 1, Small stature 7, Overweight 2, Infections 10, Respiratory URTI, ear, Skin impetigo, infected eczema, warts
16
Q
What are some screening questions for domestic violence?
A
- Women disclose if asked
- Identification is first step to remediation
- In the last year have you been slapped or hurt in other ways be your partner?
- Are you frightened of your partner?
- Are you safe to go home when you leave here?
- Would you like some assistance with this issue?
17
Q
What to do when abuse is disclosed?
A
- Remain calm
- Listen to the story and be nonjudgmental
- Let them know they are believed and not bad and were right to tell
- You know other children / people this has happened to
- Explain to the child in child’s language what you are going to do to arrange help
- Don’t promise
- Adults sometimes do wrong things
- Report
18
Q
Describe consensual peer sex
A
- Adolescent age 13,14 or 15 years
- Sexual partner within 2 chronological years
- Both partners consent – understand and freely agree to participate
- Neither individual has any condition that impairs their cognitive capacity (e.g. intellectual delay, under influence of drugs/alcohol, mental health episode)
19
Q
Describe child sexual abuse accommodation syndrome
A
- The process by which the perpetrator gains access to the child - opportunity
- establishes a nonsexual relationship - grooming
- initiates the abuse
- gradual sexualisation of the relationship
- assures cooperation and secrecy
- may use threats, intimidation
- more often discovers and exploits a particular child’s vulnerability
- inducements – material, emotional
- guilt, responsibility
20
Q
What are risk factors for vulvovaginitis?
A
- Most common cause = nonspecific
- Increased in
- Eczema
- Atopy
- Tight nylon clothing
- Obese
- Masturbation
- Poor hygiene
- If discharge – increased likelihood of other Dx
- Local irritation – diaper
- Factors
- Inadequate hygiene
- Lack of
- Protective hair
- Labial fat
- Estrogenisation
- Easily traumatised by clothing, friction
21
Q
What are differentials for vulvovaginitis?
A
- Pinworm
- Chickenpox
- Seborrhea
- Eczema
- Group A beta hemolytic strep
- Candida – very rare in prepubertal girls
- STI
- Foreign Body eg toilet paper – case example – 2 year Hx discharge – several drs said normal -FB found
22
Q
What is lichen sclerosus?
A
- Uncommon
- White parchment like patches on skin – vulva and anus
- Unknown cause
- Associated with low estrogen state
- Autoimmune?
- Infection?
- Possible symptoms
- marked itching
- painful urination, defecation c oitus
- bleeding
- Whitish thickening of foreskin
- Treated with potent steroids
- Increased risk of skin cancer
23
Q
What are some STI causes of vulvovaginitis?
A
- Neisseria gonorrhea
- Gardnerella vaginalis
- Trichomonas
- Chlamydia trachomatis
- Herpes simplex
- Condyloma accuminata
- All extremely unusual in prepubertal child
24
Q
Differentials for PV bleeding in a child?
A
- Trauma
- Accidental
- Self inflicted
- FB
- Vascular malformation
- Urethral prolapse
- Hematuria
- Rectal bleeding
- Vulvovaginitis
- Skin condition
- Lichen sclerosus
- Eczema
- Dermatitis
- Menstruation
- Precocious puberty
- Follicular cyst
- Neoplasia
25
Q
What are masked presentations for child abuse to be aware of?
A
- Behavioural presentations - (long list)
- Sleeping, eating, school, social etc
- Genital symptoms
- Abdominal pain
- Constipation or rectal bleeding
- Straddle injury
- Pregnancy (no history of pregnancy given)
- Chronic or recurrent urinary tract infections
- not usually CSA, but can be
- STIs
- Sperm in urine sample
- DDx CSA
- Consider referral and/or consultation with specialist unit e.g. CPU
26
Q
How common is sibling sexual abuse?
A
- Most common type of intrafamilial abuse, though least reported – 5x child/parent incest
- High incidence of attempted or actual penetration
- De Jong (1989): 89% attempted or actual Vg penetration
- Adler, Shultz (1995): 83% includes oral, anal, Vg penetration
27
Q
What are the chances of finding forensic evidence after 24 hours?
A
- Urgent – Assault within 72 hours
- Up to one week??
- Possible saliva, semen?
- Urine drug screen?
- Discharge, bleeding, pain?
- No bath
- Little chance of obtaining forensic evidence in prepubertal child after 24 hours
- Investigators can still collect clothing and review scene
28
Q
Describe consent by a minor
A
- Freely given, informed, based on competence to consent
- Gillick principle for <16 years - maturity to fully understand what they are consenting to
- Aust common law – Marion’s case (1992)
- ‘parentalpowertoconsenttomedicaltreatmenton behalf of a child diminishes gradually as the child’s capacities & maturity grow’ – ‘sufficient understanding & intelligence’
- Can consent to Rx but no capacity to refuse Rx
29
Q
What are some signs of direct violence?
A
- Contusions/scratches/lacerations on the face, inside of lips.
- Redness and swelling of eyelids and suffusion of conjunctivae after crying.
- Bruising of knuckles, the ulnar border of forearms or the shins suggest fights.
- Broken fingernails from scratching assailant.
- Scratches/dirt particles on trunk and lower limbs suggest dragging.
- Forceful abduction of legs may leave bruises.
30
Q
What are some examples of injuries during child sexual abuse?
A
- Biting – swab for DNA, photo
- Fellatio
- Petechial hemorrhages e.g. from clothing pulled tight
- Hematoma of scalp from pulling hair
- Assault – beating, kicking, punching
- Strangulation, asphyxia
- Restraint, ligature
- Injuries in self defense – e.g. forearms, hands
31
Q
What are signs of manual strangulation?
A
Fingertip bruising and fingernail marks on the neck of the victim. There may be scratches from the victim’s attempts to pull the assailants hands away.
32
Q
What are signs of asphyxia?
A
Gagging by hand or object and compression of the neck cause petechial haemorrhages on the face and conjunctivae and oedema.
33
Q
- Define
- Abrasion
- Bruise
- Laceration
- Incision
A
- BLUNT FORCE TRAUMA:
- Abrasion: pressure + movement; a superficiaI scraping injury of the body surface with or without bleeding
- Bruise: Haemorrhage into surrounding tissues causing discoloration; usually skin
- Laceration: tear or split in the tissues
- SHARPFORCE:
- Incision: a cutting type injury that severs tissues in a clean and generally regular fashion
34
Q
How do you perform a genital examination for suspected child abuse?
A
- Labial traction
- Not a speculum examination
- Colposcope
- Forensic kit (Cotton swabs)
- Sexually transmitted infections
- Pregnancy
- Consider EUA
- Surgical repair of genital injuries
35
Q
What are some possible reasons for normal anogenital examination with allegiation of penetration?
A
- Type Of Abuse
- Use Of Lubricant
- Physical findings vary with the type of abuse, objects or body parts used, amount of force used, use of lubricants and number of episodes of abuse.
- One would not expect any specific injuries following many types of sexual abuse eg, oro-genital contact or genital touching
- Lubrication with saliva, vaseline or lotions reduce the likelihood of specific injury to the hymen or anus during penetration
- Offender Behaviour
- Most perpetrators cause as little discomfort as possible to child physically.
- to increase the likelihood of engaging the child again.
- to decrease the likelihood of medical attention or child telling caretaker.
- Little research on effects of grooming on genital relaxation, early menarche.
- A key difference between the dynamics of sexual and physical abuse.
- Most perpetrators cause as little discomfort as possible to child physically.
- Child’s Cognition About / Penetration
- Child’s language
- Intracrural; intrabuttock;
- Both perpetrator and child may perceive penetration through the labia up to the hymen (ie introital intercourse), but not through into the vagina, as being penetration of the vagina.
- Prepubertal children will have no frame of reference or concept of penetration of the vagina through the hymeneal opening until it actually occurs.
- Hymen deeply set
- Elasticity, Distensibility
- Common misconception that damage will always occur with the first episode of penetration of the hymen. Can be penetration of the hymen by a finger or a finger- sized object such as a pencil without causing any specific injuries to the hymen, even if the child reports pain in this situation. Even in prepubertal girls, the hymen has a degree of elasticity and can tolerate digital penetration without any specific injuries occurring.
- Examples – FB, vaginal injury
- Rapid Healing; Delayed Presentation
- Rapid healing; with little or no scar formation. Hymen and vagina lined with mucosal tissue, like inside mouth ie buccal mucosa
- Pubertal changes may mask healing
- Healed lacerations may be a fraction of original size
- Disclosure a long time after the event
36
Q
What are some relevant findings when examining the hymen?
A
- Acute lacerations
- Bruising
- Scar
- Hymenal transection
- Missing segment hymenal tissue
- In posterior (inferior) half
- STI-not perinatal transmission
- Sperm
- Pregnancy
48
Q
Describe risk of HIV transmission with different sexual actions
A
58
Q
Where are the differences between accidental and abusive bruising?
A
61
Q
Describe tramline bruising
A
