Dr. Sarah Zia presented on child abuse, defining it as any act or condition that deprives children of their rights and optimal development. She discussed the various types of abuse including physical, sexual, emotional abuse and neglect. She also covered risk factors, signs and symptoms, long term health impacts, and the importance of thorough medical evaluation for suspected victims of abuse. Proper documentation and reporting to authorities is crucial to protect children and ensure their needs are met.

1. Presenter
Dr Sarah Zia
CHILD
ABUSE

2. IS THIS ABUSE?
• A girl is slapped for screaming at her mother; the slap
stings, but leaves no lasting mark or pain.
• A boy is punished in a way that requires stitches.
• A father burns his daughter’s palms with a lighted
cigarette when he finds her smoking.
• A mother is careless and spills scalding coffee on her
daughter, who is seriously burned.
• A boy’s arm is broken after wrestling with his father for
sport.
• A girl is spanked so hard she is badly bruised, but the
father says he did not mean to hurt her.
• A boy is grounded for a week for a minor offense.
• A father takes away his son’s driver’s license for getting a
parking ticket.
• A young mother was asked to get help and get off drugs
but her baby was born addicted to drugs

3. DEFINITION
• Any act of commission or omission by
individuals, institutions or society as a whole
and any conditions resulting from such acts or
inaction, which deprive children of equal
rights and liberties, and/or interfere with their
optimal development, constitute by
definition, abusive or neglectful acts or
conditions.

4. CHILD RIGHTS
• Main features of child rights are:
1. Right of survival and development
2. Right to have a name and nationality
3. Right of freedom of expression
4. Right of freedom of thought
5. Right of health and medical care
6. Right of education
7. Right of having a good standard of living
8. Right of leisure, recreation and cultural activities
9. Right of administration of juvenile justice

5. History of child abuse
• 1860 - Ambroise Tardieu
– French physician
– Medical, psychiatric, social and demographic features of child abuse as a
syndrome
• 1946 – Dr. Caffey (pediatric radiologist)
– Subdural haematoma and long bone fractures inconsistent with accidental
injury
• 1953 – Silverman
multiple fractures resulted from intentional trauma and not organic disease, as
commonly thought.
• 1962 – Dr. C. Henry Kempe
– “The battered child syndrome” in JAMA
– 447 abuse cases reported in 1962
• (2.9 million cases reported in 1992)

6. Shaken Baby Syndrome
• Shaking is a prevalent form of abuse seen in very young children.
• The majority of shaken children are less than 9 months old.
• Most perpetrators of such abuse are male, though this may be more a
reflection of the fact that men, being on average stronger than
women, tend to apply greater force, rather than that they are more prone
than women to shake children.
• Intracranial hemorrhages, retinal haemorrhages and small ‘‘chip’’
fractures at the major joints of the child’s extremities can result from very
rapid shaking of an infant.
• They can also follow from a combination of shaking and the head hitting a
surface.
• There is evidence that about one-third of severely shaken infants die and
that the majority of the survivors suffer long-term consequences such as
mental retardation, cerebral palsy or blindness.

7. Battered Baby Syndrome
• One of the syndromes of child abuse is the
‘‘battered child’’.
• This term is generally applied to children
showing repeated and devastating injury to the
skin, skeletal system or nervous system.
• It includes children with multiple fractures of
different ages, head trauma and severe visceral
trauma, with evidence of repeated infliction.
• Fortunately, though the cases are tragic, this
pattern is rare.

8. Münchausen syndrome by proxy
• Münchausen syndrome by proxy (MSbP or MBP)
is a controversial label for a behavior pattern in
which a caregiver deliberately
exaggerates, fabricates, and/or induces
physical, psychological, behavioral, and/or mental
health problems in those who are in their care.
• With deception at its core, this behavior is an
elusive, potentially lethal, and frequently
misunderstood form of child abuse or medical
neglect that has been difficult to define, detect
and confirm.

9. PLAY ACTIVITIES THAT ARE HAZARDOUS:
• Tossing a small child into the air
• Jogging while carrying an infant on the back or
shoulders
• “Riding a horse” – bouncing on the knee
• Swinging the child around by his/her ankles
• Spinning a child around
WARNING: If this happens take child to Emergency Room
immediately. The child can be treated.

10. Epidemiology
Child abuse is a world-wide phenomenon and can
affect children of all ages
It is difficult to gain a true estimate of child abuse
due to the hidden nature of the problem.
 In industrial countries it is estimated that:
• 4% to 16% of children are physically abused,
• around 10% are neglected or emotionally abused,
• 15% of boys and 35% to 40% of girls are exposed to sexual
abuse.
• Around 80% of child abuse is perpetrated by care takers or
parents

11.  Children less than 12 years of age are the most abused at
36.4%, followed by children between 15 and 18 years of
age at 36%, and then children between 12 and 14 years old
 Orphans children are more vulnerable to abuse than others
at 70%, followed by children of separated parents at
58%, and then children of divorced parents are subject to
physical abuse at 42
 This study has also indicated that child abuse happens
more in poor families and those under poverty threshold

12. Etiology
• Multi-factorial
– Child Characteristics
– Parental Characteristics
– Family/Environmental Factors
– Triggering Situations

13. Child characteristics
• Premature birth
• Colic
• Physical disabilities
• Developmental disabilities
• Chronic illness
• Emotional/behavioral difficulties
• Unwanted child

14. Parental characteristics
• Low self-esteem / depression
• Abused as a child
• Poor impulse control
• Substance abuse
• Teenage parent
• Unrealistic expectations of child behavior
• Negative view of themselves & their children

15. Triggering situations
• Crying baby
• Child’s misbehavior
• Discipline gone awry
• Argument, family conflict
• Toilet training

16. Social/Situational Stresses
• Working parents
• Isolation
• Family/domestic violence
• Non-biologically related male in the home
• Poverty
• Unemployment/financial problems
• Single parent
• Animal abuse

17. TYPES OF CHILD ABUSE
• Physical abuse
• Emotional abuse
• Sexual abuse
• Neglect

18. PHYSICAL ABUSE:
Non-accidental injury of a child that leaves
marks, scars, bruises, or broken bones.
Behavior indicators:
Aggressive or
withdrawn
Afraid to go home
Lying
Layered clothing

19. Health consequences of Physical abuse:
• Abdominal/thoracic injuries
• Brain injuries
• Bruises and welts
• Burns and scalds
• Central nervous system injuries
• Disability
• Fractures
• Lacerations and abrasions
• Ocular damage

20. SEXUAL ABUSE:
Fondling, sexual intercourse, assault, rape, incest, child
prostitution, exposure and pornography
Behavior indicators:
• Inappropriate sexual knowledge
• Abrupt change in personality
• Withdrawn
• Poor peer relationships
• Sleep disturbances
• Regressive behavior

21. Health consequences of Sexual abuse:
• Reproductive health problems
• Sexual dysfunction
• Sexually transmitted diseases, including
HIV/AIDS
• Unwanted pregnancy
• Infertility

22. EMOTIONAL ABUSE:
Rejecting, terrorizing, berating, ignoring, and
isolating, that is likely to cause serious impairment of the
physical, social, mental, or emotional capacities of the
child.
Behavior indicators:
• Failure to thrive
• Speech disorders
• Lags in physical development
• Habit disorders, conduct disorders
• Sleep disorders or inhibition of play
• Aggressive or passive

23. NEGLECT:
Failure of parents or caretakers to provide needed, age appropriate
care. Including food, clothing, shelter, protection from harm,
supervision appropriate to the child’s development, hygiene, and
medical care.
Behavior indicators:
• Hunger
• Poor hygiene
• Excessive sleepiness
• Lack of appropriate supervision
• Unattended physical problems or
medical needs
• Abandonment
• Inappropriate clothing for weather
conditions

24. Psychological and behavioural health consequences:
• Alcohol and drug abuse
• Depression and anxiety
• Developmental delays
• Eating and sleep disorders
• Feelings of shame and guilt
• Hyperactivity
• Poor relationships
• Poor school performance
• Poor self-esteem
• Post-traumatic stress disorder
• Psychosomatic disorders
• Suicidal behaviour and self-harm

25. Other longer-term health consequences
• Cancer
• Chronic lung disease
• Fibromyalgia
• Irritable bowel syndrome
• Ischaemic heart disease
• Liver disease

26. Medical Evaluation of
Victim of Suspected Abuse
• History
• Physical Examination
• Laboratory and Radiologic Studies
• Differential Diagnosis
• Documentation

27. HISTORY
Taking history from a parent / caretaker
• Children should not be present!!
• Interview adults who are present separately

28. Taking a history from the caretaker/parent
• Who?
• What?
• When?
• Where?
• Why?
• How?

29. Suspicious History
• History inconsistent w/physical examination
• Magical injury
• Sibling blamed
• History changes with time or varies between
caregivers
• Delay in seeking care
• Self-inflicted injury incompatible w/development
• Poor Parent Child Interaction
• History of abuse in parents childhood
• Stress or crisis in the family or parents
• Unrealistic expectations of parents for the child

30. Suspicious Behavioral Complaint
– Depressed, angry, withdrawn, other changes
– School performance
– Aggressive behavior, temper tantrums
– Behavior with family, pets/animals
– Detailed information about adult sexual
behavior
– Explicit demonstration of sexual play
– Excessive sexual curiosity
– Bedwetting
– New risk taking behaviors

31. Physical Examination
• Therapeutic and diagnostic
• Complete head to toe evaluation
• Growth parameters
• Child behaviour
• Must look at all skin surfaces
– Remove ALL clothing (lack of clean clothing and poor
personal hygiene indicate neglect)
– Description of all skin findings (abrasions, alopecia, bites,
bruises, burns, dental trauma, fractures, lacerations,
ligature marks, or scars)
– Ears, Neck, Mouth.
– Genitalia and anal region.

32. Physical Exam
“Red Flags”
• Most common indication of physical abuse
• Occurs in >50% of abused children
• Bruises are uncommon in infants
< 6 months.
– “Those who don’t cruise rarely bruise.”
• Two characteristics separate abusive from accidental
bruises:
LOCATION
PATTERN

33. Location
ACCIDENTAL ABUSIVE
Shins Anterior thigh
Lower arms Upper arms
Under chin Neck
Forehead Face
Hips Buttocks
Elbows Trunk
Ankles Ears
Bony prominences Genitalia

34. Laboratory and Radiologic
Studies
• Labs
– Trauma labs
– Bruising hematology workup
– If fractures; Ca, Phos, Alk Phos
– Consider levels; Vitamin D, PTH and Copper
• Radiology Studies
– Skeletal survey
• All children < 2 years of age
• 2-5 years: selective survey
– Bone scan
– CTs / MRIs
• Ophthalmology
• Medical photography
• Examine siblings, other children in household
– Twins receive IDENTICAL workup

35. The Skeletal Survey
Skull: frontal and lateral views
Spine: frontal, lateral thoracolumbar spine
(including sternum)
Chest: frontal
Extremities:
Upper - frontal to include shoulders and
hands
Lower - frontal to include lower lumbar
spine, pelvis, feet

36. Differential Diagnosis
• Must rule out medical diagnosis other than
abuse

37. Differential Diagnosis of Bruises
• Erythema multiforme – palms/soles initially, extension
upwards, can become purpuric
• ITP, other coagulopathies
• Henoch-Schönlein purpura – normal platelets – IgA mediated
vasculitis – often involves buttocks and lower extremities
• Cultural practices
– Cao gio (coining)
– quat shat (spooning)
– cupping

38. Differential Diagnosis of Burns
First Degree
 Cellulitis, erysipelas
 Sunburn
 Contact dermatitis
 Diaper rash
 Drug reaction

39. Differential Diagnosis of Burns
Second Degree
 Bullous impetigo
 Staphylococcal scalded skin syndrome (SSSS)
 Toxic epidermal necrolysis
 Epidermolysis bullosa
 Phytophotodermatitis
 Psoriasis

40. Differential Diagnosis of Fractures
• Minor falls
– Do not cause fractures in most instances
– Studies show very low incidence of fractures from short
falls
• Obstetrical/birth trauma
– usually produces only humeral and clavicular fractures
– no rib fractures
• Prematurity
– Osteopenia can lead to fractures

41. Differential Diagnosis
Accidental Fractures
Toddler’s Fracture
Accidental oblique fracture of tibia in children
9 months to 3 years of age
Often are unwitnessed injuries of trivial
nature
Limp, refusal to bear weight
Localized tenderness may be present, no
swelling
X-rays often negative

42. DDX: Skeletal Fractures
• Neoplasm:
• Congenital:
– Leukemia
– Osteogenesis imperfecta
– Langerhans cell histiocytosis
– Menke’s syndrome
– Bony metastases
• Nutritional / Metabolic:
• Normal variant:
– Copper deficiency
– Physiologic periosteal new bone
– Rickets
– Scurvy
– Renal osteodystrophy • Neuromuscular disease:
– Cerebral palsy
• Infectious: – Congenital insensitivity to pain
– Congenital syphilis
– Osteomyelitis

43. Management
• Child abuse is often an ongoing process. If the diagnosis of
child abuse is being considered, the parents and/or carers
must be informed of all relevant investigations and referrals
being made.

44. • Reporting to authorities (Documentation)
Doctors are required to share information with
other agencies, and with social work and law
enforcement bodies, to ensure that the child's needs
are met and he or she is protected from harm.
Doctors are required to provide written reports
for use in multi-disciplinary meetings, police
investigations, and civil or criminal courts, and may be
required to appear as witnesses (of fact or as experts)
in court.
Accurate reporting also involves photographs of
visible injuries and forensic swabs (e.g., of bites).

45. • Counselling
Counselling should be considered following full
investigation and immediate management of injuries.
Cognitive behavioural therapy is increasingly
used, but must be individualised. Family therapy is
also indicated in certain situations to support other
members of the family.

46. • Management of injuries/specialist consultation
Individual injuries should be managed as
appropriate, irrespective of whether they are caused
by abuse or accident.
However, where abuse is considered, the
physician should ensure that an appropriate search
for additional or hidden injuries is also carried out.

47. HOW TO REACT IF A CHILD TELLS YOU
ABOUT ABUSE:
• Listen, do not interfere, assume or interrogate.
• Reassure the child that he/she has done the right thing by
telling you and that you are glad they told you.
• Make sure they understand it was not their fault.
• Remain calm and accepting, don’t over react.
• Do not promise not to tell.
• Be honest and tell the child what to expect.
• Reassure them you will do what needs to be done to make
sure it doesn’t happen again.
• Determine the child’s needs for safety.

48. Conclusions
• Child abuse is very common
• Often missed by clinicians
• Must have high index of suspicion
• Mandated reporters must report suspicion of abuse
• Complete careful histories and examinations
• Document, document, document!
• Avoid the misdiagnosis of abuse

49. THANK YOU