CHILD ABUSE

INTRODUCTION

Child abuse should always be suspected, especially if injuries are not consistent with the history of the chief complaint. In order to provide optimal care to these children, it is necessary that the prehospital care provider understand general principles regarding child abuse. The following topics will be discussed:

· Common characteristics of abusers

· Common characteristics of abused children

· Physical and behavioral indicators of abuse

· Sexual abuse

· Assessment skills/techniques

· Appropriate management of the potentially abused child

LESSON OBJECTIVES

At the end of this lesson the participants will be able to:

1. Determine common features present in abusive situations

2. Describe abnormal physical findings that have a high index of suspicion for child abuse

3. Discuss appropriate interventions in cases of suspected child abuse

KEY VOCABULARY

The following terms will be used during this lesson:

Child Abuse -the maltreatment of children by their parents, guardians, or others responsible for their care.

Physical Abuse – injury caused by acts or omissions of the caregiver that cause pain to the child and raise questions as to safety.

Physical Neglect- Chronic absence of the caregiver, without provision of a substitute caretaker and/or failure to provide the child with the physical or emotional necessities of life.

Emotional Abuse- a psychological condition which renders the child chronically/severely anxious, agitated, depressed, withdrawn, psychotic, or in fear for his/her life or safety; or interferes with ability to accomplish age appropriate developmental milestones.

Sexual Abuse – Rape, statutory rape, deviate sexual intercourse, indecent assault, incest, or promoting prostitution by the caregiver. It is also permission from the guardian to have one of the above committed by another.

KEY CONCEPTS

The following section provides information and space for taking notes on the key concepts discussed by the instructor.

General Statistics

At least 1-3% of American children experience child abuse/neglect

each year

Annually, approximately 1.5 million children are abused:

Physical- 200,000
Neglect- 800,000
Sexually- 60,000

Second only to SIDS, 4000 children die each year as a result of abuse

Characteristics of Abusers

In the majority of cases, the abuser is a:

Related caregiver- 90%
Boyfriend of mother- 5%
Unrelated babysitter- 4%
Sibling of child- 1%

Most abusers tend to be lonely, unhappy, angry adults under tremendous stress
Usually isolated, incapable of using a support system
Often, the abuser experienced physical or emotional abuse themselves as children
Mothers are more likely to physically/emotionally abuse than fathers
Fathers are more likely to sexually abuse than mothers
Abusers come from all ethnic, geographical, religious, educational, occupational, and socioeconomic groups

Characteristics of an Abused Child

Demanding, difficult behavior
Decreased level of functioning
Hyperactivity
Intellectual ability equal or above the parent
Usually less than 5 years of age
Boys are physically abused more often than girls

PHYSICAL ABUSE

Contributing Factors

Intermittent, unpredictable abuse is more common than continuous

physical abuse or neglect

Abuse is frequently precipitated by some stressor in the adult caregiver’s life, particularly when the adult expects the child to fill emotional needs created by the stress
Common crises which may lead to an abusive episode:

Financial stress
Loss of employment
Eviction from housing
Marital or relationship stress
Physical illness in a child which leads to intractable crying
Death of a family member
Diagnosis of an unwanted pregnancy

Physical Indicators

Physical findings which trigger a high index of suspicion:

Any obvious or suspected fractures in a child under two years of age
Injuries in various stages of healing, especially burns and bruises
More injuries than usually seen in children of the same age
Injuries scattered on many areas of the body
Bruises or burns in patterns that suggest intentional infliction
Increased intracranial pressure in an infant
Suspected intra-abdominal trauma in a young child
Any injury that does not fit the description of the cause given

Information in the medical history which triggers a high index of suspicion:

A history that does not match the nature or the severity of the injury
Vague parental accounts or accounts that change during the interview
Accusations that the child injured him/herself intentionally
Delay in seeking help
Child dressed inappropriately for the situation

Secondary Assessment Findings

Bruises
Welts
Burns
Subduaral hematomas
Abdominal injuries
Bone injuries

Behavioral Indicators

Child

No expectation of parental comfort
Overly friendly or withdrawn

Adult

o May present angry, fearful, hostile, or quiet

o Unusual parent-child interactions

NEGLECT

Contributing Factors

Inattention to the basic needs of a child
Lack of food, medical care, shelter, education, or clothing
Caregiver’s misuse of drugs and alcohol
Child’s misuse of drugs and alcohol
Child abandonment

Physical Indicators

Underweight
Poor hygiene
Clothing soiled
Bald patches
Gross unattended dental or medical problems

Behavioral Indicators of Child

Dull, inactive
Beg for food
Fall asleep in class
Drug, alcohol addiction
Delinquency

EMOTIONAL ABUSE

Contributing Factors

Caregiver’s failure to provide a nurturing environment

Child may be blamed for events or belittled

Constant lack of concern for child’s welfare

Physical Indicators

Speech disorder
Failure to thrive

Behavioral Indicators of Child

Eating disorder
Phobias
Antisocial behavior

SEXUAL ABUSE

Contributing Factors

Any sexual activity between an adult and child 16 years and younger
Usually associated with physical/emotional abuse or neglect
Often, abuser experienced similar abuse as a child
Females are the most common victims
Over one-half of the victims are under 12 years of age

Types of Sexual Abuse

Vaginal intercourse
Sodomy
Oral-genital contact
Molestation (fondling, masturbation, or exposure)

KEY POINT: Due to the chronic nature of sexual abuse, only 35% will have physical findings.

Physical Indicators

Pregnancy
Venereal disease
Painful urination or defecation
Tenderness or lacerations to the perineal area
Bleeding from the rectum or vagina

Behavioral Indicators of Child

Withdrawn
Infantile behavior
Exhibit sophisticated sexual or seductive behavior
Change underwear often

FIELD MANAGEMENT TECHNIQUES

History Collection

Collect information in a professional, non-judgmental manner
Phrase questions to parents in a non-confrontational manner
Ask the child open-ended questions
Do not press for information the child is not ready to disclose
Do not reveal to the parent information obtained from the child

Physical Assessment

Obtain consent from mentally competent children before physical examination
Look for injuries over entire body; complete genital exam last
Document findings in clear objective statements (i.e. “Palms show one centimeter circular burns” vs. “Cigarette burns to hands”)
Document verbatim statements made by the child or parent

REPORTING REQUIREMENTS

Collaborative Effort

EMS personnel, in most states, are obligated to report suspected incidences of child abuse or neglect
In most states, EMS personnel are considered to be mandated reporters (they are protected from being sued for false allegations)
Physicians and nurses are also mandated reporters
If healthcare professionals ignore the written objective recorded findings from EMS personnel, criminal and civil liability may result
Failure for EMS personnel to report suspected child abuse can result in legal action
It is not necessary for the reporter to “prove” abuse has occurred, only reasonable concern or suspicion is required
Department of Children’s Services is available 24 hours a day by telephone (800) 540-4000

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