Child Abuse Jinan Usta MD Professor Clinical Medicine Scale of the problem • WHO: 53,000 child deaths in 2002 were homicides • 20% and 65% of school aged children reported having been verbally or physically bullied in school in the previous 30 days • Only 2.4% of the world’s children are legally protected from corporal punishment in all settings Child abuse: Definition • All forms of physical and/or emotional illtreatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power. . World Health Organization. "Child abuse and neglect by parents and other caregivers" Child abuse: Types • • • • • Emotional Neglect Physical Family Sexual . Child abuse: Causes/risk factors • Parents have negative attitudes towards children • Associate their own negative feelings with child’s difficult behavior • Poor parenting • Parental mental health problems • Being abused as a child • Drug and alcohol misuse. . Health problems • The psychological and medical sequelae of abuse can appear immediately or later, sometimes very late Child abuse- injuries • Skin: bruising, cuts, wounds, redness or bulla • Brain: micro hemorrhages, bleeds • Eyes: retinal hemorrhages, conjunctival hemorrhages, orbital swelling • Abdomen: acute abdomen, hematuria • Skeleton: fractures multiple or in various stages of healing • Sudden death Indirect health consequences of abuse • Increase injurious health behaviors • Reduce preventive health behaviors • Problems managing co morbid state Physical health consequences of abuse • • • • • • • • • Abdominal and thoracic injuries Brain injuries Bruises and welts Burns and scalds Central nervous system injuries Fractures Lacerations and abrasions Damage to eyes Disability Psychological consequences of abuse • Alcohol and drug abuse • Cognitive impairment • Criminal, violent and other risk-taking behaviors • Depression and anxiety • Developmental delays- regressive behaviors • Eating and sleep disorders Psychological consequences of abuse • • • • • • • • Hyperactivity Poor relationships Poor school performance Poor self esteem Antisocial behaviors Post traumatic stress disorder Psychosomatic disorders Suicidal behaviors and self harm Sexual and reproductive health consequences of abuse • • • • • Reproductive health problems Sexual dysfunction STIs/HIV Unwanted pregnancy Infertility Lifetime Health Impact • • • • • • • • Pulmonary disease Alcoholism- Substance abuse- Smoking Obesity Depression and suicide GI diseases: Irritable bowel disease- hepatitis Heart disease Diabetes Cancer Mental health problems • Difficulty to concentrate, poor school performance • Eating disorders • Withdrawal, low self esteem • Anxiety, fear, sleeplessness, nightmares • Obsessive compulsive- perfectionist • Depression, guilt, suicide • Borderline, excessive daydreaming, Dissociative symptoms • Drug addiction, substance abuse Behavioral problems • Aggressiveness: violence is acceptable way to assert one’ s view, or to discharge stress • Hyperactivity and regressive behaviors • Avoidance, mistrust Cognitive problems • The world is a dangerous place, chronic perception of helplessness and powerlessness, low self esteem • Impaired sense of self: difficulty protecting self or setting boundaries Relationship problems • Violence is an inherent part of a loving relationship • Intimacy dysfunction: difficulty in self disclosure or expressing warmth in intimate relationships, high need for closeness Financial consequences of abuse • Direct: treatments, visits to hospitals, ER… • Indirect: loss of productivity, disability, decreased quality of life, premature death, cost to social welfare, educational system, employment sector… Role of the health care provider • Victims of abuse are frequent visitors to the health care system • Importance of detection by screening, providing guidance and counseling and assistance • The approach is very delicate and sensitive- can endanger the child Kids who don’t cruise rarely bruise When to suspect abuse • There is either no explanation or a vague explanation given for a significant injury • There is an explicit denial of trauma in a child with obvious injury • An important detail of the explanation changes in a substantive way When to suspect abuse • An explanation is provided that is inconsistent with the pattern, age, or severity of the injury or injuries • An explanation is given that is inconsistent with the child’s physical and/or developmental capabilities • There is an unexplained or unexpected notable delay in seeking medical care • Different witnesses provide markedly different explanations for the injury or injuries When to suspect abuse: Signs in childhood • Feel unhappy, frightened or distressed • Behave aggressively and antisocially, or act too mature for his age • Experience difficulties with academic achievements and school attendance • Find it difficult to make friends • Show signs of physical neglect and malnourishment • Experience incontinence and mysterious pains When to suspect sexual abuse • Unusual sexual behavior or knowledge • Eating and/or sleeping pattern changes • Change in school performance and relationship with peers • Inappropriate touching of others • Age regression or infantile behavior • Promiscuity, prostitution, substance abuse • Aggressive behaviors, destroying possessions, self destructive activities • Withdrawn, socially isolated or clinging How can violence against ?children be prevented How can violence against ?children be prevented • Addressing the underlying causes and risk factors specific to each type… – Child maltreatment by parents and caregivers can be prevented by: • Reducing unintended pregnancies • Reducing harmful levels of alcohol and illicit drug use during pregnancy and by new parents How can violence against ?children be prevented • Improving access to high quality pre- and post-natal services • Providing home visit services by professional nurses and social workers to families where children are at high-risk of maltreatment • Providing training for parents on child development, non-violent discipline and problem-solving skills Preventing child abuse • Provide ways to discipline the child- THERE ARE SO MANY WAYS TO DISCIPLINE A CHILD – COROPORAL PUNISHMENT EVEN FOR THE SAKE OF DISCIPLINE IS CHILD ABUSE Scenario 1 • A mother starts to shout at a toddler in the reception area. She calls her a ‘stupid cow’, and starts hitting her hard slaps • How to respond? ?How to respond • Try to diffuse the situationâž” take mother and child aside, away from the reception area and discuss the incident with her as supportively as possible, ensuring you are chaperoned • Make it clear, using supportive and non accusatory language that you are concerned regarding the incident • Mention that you are there to support the mother but also to support her small child ?How to respond • Ask simple questions to clarify what has happened, with the mother and also, if safe and appropriate, with the child • You are not expected to investigate the incident • What you do next will depend on the response/s from the mother and/or child Scenario 2 • You see a 6-year-old boy at school. He is brought by the nurse because he vomited in the classroom. You notice that he has several broken teeth, and bruises on different areas of his body. He is very thin, his hands feel cold, he is grubby, unkempt and uncommunicative • You remember seeing his brother few months ago with several broken teeth ?How to respond • Discuss your concerns with the parent/caregiver of the child and/or the child- Don’t confront • Document clearly, and in a timely manner any discussions you have with the parent/caregiver/ child, separating facts from speculation and using the child and parent/caregivers language as much as possible • If it is safe and appropriate, try to gain consent from the parent/caregiver to make a referral to a social worker ?How to respond • Document the response of the parent/caregiver to your offer of support • Check the child’s and sibling’s records for any previous concerns regarding the child’s health, including any missed appointments or delayed attendance for treatment • Child care social services can also be contacted for further advice and guidance Recommendations • Encourage all primary health care professionals to screen for abuse • Train health care professionals in skills needed to support the abused child and his family • Incorporate screening for child abuse in schools • Teaching of child’s rights within the school curricula • Conduct series of workshops teaching discipline for parents and teachers Reference: AAFP, WHO
