Child Abuse
An acts of parents/guardians (and other
adults)
– Abuse
– Maltreatment
Universal Definition
• Abused child: < 18 years old, has
had serious physical injury inflicted
by non-accidental means (includes
sexual offences)
• Maltreated child:< 18, whose
physical, mental, or emotional
condition is in danger
NYS Definition of an abused child:
• An adult inflicts or allows to be inflicted
upon the child a serious injury , or
substantial risk of physical injury
• Commits or allows to be committed against
the child a sexual offense defined in the
penal law
NYS definition of a maltreated child
• Failure of a parent or legal guardian to
exercise minimum degree of care
• Examples:
– Alcohol/drug use
– Inadequate food, clothing, shelter, education,
medical care although financially able to do so
– Improper supervision
– Excessive corporal punishment
Mandated Reporters
• Physicians
• Nurses
• Dentists
• School officials
How to report:
• Call NY State Child Abuse &
Maltreatment Register (800-3423720)
When to Report
• When a mandated reporter has
“reasonable cause” to suspect
that a child whom the reporter
sees in his/her professional or
official capacity is abused or
maltreated
OR
• if the person legally responsible
for the child states from personal
knowledge that the child is being
abused or maltreated
What is reasonable cause?
Obligations of mandated
reporters
• Photographs and x-rays
• Take appropriate measures to
protect a child’s life and health;
when appropriate, taking
protective custody of a child
without the consent of the legal
guardian (MD’s, hospital
administrators, police officers)
Immunity
• Any person who in good faith
makes a report has immunity
from any liability civil and
criminal that might be a result of
such actions.
• Mandated reporters have
confidentiality
Penalties for Failure to Report
Legally:
• Any person required by law to report a
case of suspected child abuse or
maltreatment, who willfully fails to do so,
may be guilty of a class A misdemeanor.
• May also be civilly liable for damages
caused by the failure to report.
Professionally:
• NYS Education Department can charge a
professional with unprofessional conduct
leading to potential license revocation
after an investigation
3 services when a report is made
• Investigation: to determine if
evidence credible.
– contacts child, siblings, parents,
mandated reporter
• Determination: made within 60
days, indicated or unfounded
• Assessment/Service Planning:
realistic plan for child/family is
made, CPS may become
involved
Behavioral & Environmental
Characteristics of Abusers
• Parent abused or neglected as a
child
• Lack of friendships or emotional
support (lack of self-esteem)
• Marital problems
• Physical or mental health
problems
• Life crises (unemployment)
Behavioral & Environmental
Characteristics of Abusers
• Alcohol/substance abuse
• Adolescent parents
• Absence of nurturing child-rearing
skills (violence for discipline)
• Delay or failure in seeking health
care for child’s injury, illness, routine
check-ups, immunizations
• Unreasonable expectations for child
Types of Abuse
Physical
Neglect
Emotional
Sexual
Physical Abuse
• Deliberate infliction of physical injury on a
child usually by caregiver
– Minor
– Major
Indicators
of Physical Abuse
• Injuries that are unexplained or are
inconsistent with the
parents/caretakers explanation
• Bruises, welts, bite marks on face,
torso, back, buttocks, thighs
• Injuries to both eyes or cheeks
• Clustered, forming regular patterns
reflecting shape of article used
Physical Indicators of
Abuse
• Grab marks on arms or shoulders
• Lacerations or abrasions to mouth,
lips, gums, eyes, external genitalia
• Burns: especially on soles, palms,
back or buttocks, immersion burns
(doughnut-shaped), patterned, rope
burns
• Fractures
• Head injuries
Child Behavioral Indicators
• Wary of contact with parents or other
adults
• Apprehensive when other children
cry
• Behavioral extremes: (aggressive,
withdrawn)
• Reports injury by parents
• Inappropriate clothes for the season
Neglect
• Physical neglect:
• Emotional neglect:
• Emotional Abuse:
Neglect
Physical indicators:
• Failure to thrive
• Positive toxicology
• Lags in physical development
• Consistent hunger, poor hygiene
• Consistent lack of supervision
• Unattended physical problems or
medical needs
• Chronic truancy
Neglect
Behavioral indicators:
• Begging, stealing food
• Extended stays at school
• Constant fatigue, falling asleep
in class
• Alcohol or drug abuse
Failure to Thrive (FTT)
most common form of neglect
• Organic: result of physical cause
(congenital heart defect)
• Nonorganic: result of
psychosocial factors (knowledge
deficit of parent, altered
maternal/child attachment,
abuse)
Other Factors
• Poverty
• Health beliefs
• Inadequate nutritional
knowledge
• Family stress
• Insufficient breast milk
FTT Clinical manifestations
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Growth failure
Developmental retardation
Poor hygiene
Withdrawn behavior, apathy
Feeding or eating disorders
No fear of strangers
Avoidance of eye contact, minimal
smiling
• Wide-eyed gaze and continual scan
of environment
FTT
Diagnosis:
• weight & height < 5th
percentile
Treatment:
• reverse the malnutrition
Prognosis:
• depends on cause
Sexual Abuse
• No universal definition
• In general: use, persuasion or coercion of a child
to engage in sexually explicit contact
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Incest
Molestation
Exhibition
Pornography
Prostitution
Sexual Abuse
Physical indicators:
• difficulty in walking or sitting
• torn, stained or bloody underclothes
• pain or itching in genital area
• bruises or bleeding in external
genital, vaginal or anal areas
• bruises to hard or soft palate
• STD’s (preteens), repeated UTI’s
• pregnancy (early adolescence)
Sexual Abuse
Behavioral indicators:
• Unwilling to change for gym
• Withdrawal, fantasy or infantile behavior
• Bizarre, sophisticated or unusual sexual
behavior or knowledge
• Poor peer relationships
• Reports sexual assault by caretaker
• Prostitution
• Forcing sex acts on other children
• Extreme fear of being touched
• Low self-esteem, general fearfulness
Munchausen Syndrome by Proxy
• Parent fabricates symptoms of illness in the child
(usually under age 6 years)
• May be done to gain entry into medical system for
own needs, thrives on medical attention
• Suspected when unexplained, recurrent, rare
conditions occur, illness does not respond to
treatment, symptoms are inconsistent
Munchausen Syndrome by Proxy
• CNS symptoms most commonly reported
– Apnea, fever, seizure, N/V/D, blood in urine or stool
• Overdose on medications in order to cause side
effects
• Child is fearful, anxious, uncooperative while
parent appears knowledgeable, cooperative,
calm, suggests treatment or diagnostic tests
Munchausen Syndrome by Proxy
• Abuser is usually the mother, is young,
married, middle class, and often has a
health care background
• Often was a victim of abuse
• Usually confirmed by covert video
surveillance, collection of evidence
Hospitalization of the Abused Child
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Nursing Interventions:
Verify that the case has been reported
Promote a trusting relationship with child
Integrate child into normal daily routine
Observe all interactions between child and
parents
Remove child/parents from unit if
necessary
Participate in multidisciplinary meetings
re: child progress/status
Allow parents to verbalize, listen nonjudgmentally, and avoid threatening
questions
Interviewing the Child
• Indirect hints: “My brother wouldn’t let me
sleep last night”.
• Response: “Can you tell me more”?
• Disguised Disclosure: “What would
happen if a girl told someone her mother
beats her”?
• Response: “What do you know about this
girl”?
• Disclosure with strings attached: “If I tell
you I have a problem can you promise not
to tell anyone else”?
• Response: Let the child know you want to
help, but it may be necessary to get
special people involved.
Interviewing the Child
Do:
• Conduct the interview in private
• Sit next to the child
• Tell the child that the interview is
confidential
• Conduct the interview in language
the child understands
• Ask the child to clarify words/terms
which are not understood
• Tell the child if any further action will
be required
Interviewing the Child
Don’t:
• Allow the child to feel “in trouble” or
“at fault”
• Suggest answers to the child
• Probe or press for answers the child
is unwilling to give
• Display horror, shock or disapproval
of parents, child or the situation
• Force the child to remove clothing
The nurse overhears a group of student nurses in
the break room discussing the role of the nurse
in suspected child abuse. The nurse concludes
that the student who most accurately
understands the role is the one who makes
which of the following statements?
1.
Nurses should only report abuse if they are
certain
2. Nurses should tell the child’s doctor if child
abuse is suspected
3. Only the physician can report child abuse
4. Nurses are required to report any case of
suspected child abuse to child protective
services
Case Study
A 5-year-old female who is a victim of sexual
abuse committed by her uncle is being
admitted to your hospital unit for treatment
of a urinary tract infection and labia
lacerations.
As you admit the child to the unit, what will be
your initial approach with her?
What measures can you take to promote a
sense of security for the child?
The child tells you that she is “bad” because
she told on her uncle.
How would you respond?
• The parents are arguing loudly in the
child’s hospital room.
• What actions would you take?