For Health Professionals

Developed by the ISPCAN Medical Curriculum
Development Taskforce
• Members: Dr. Steve Boos (Chair), Dr. Evelyn Eisenstein (Co-Chair),
Dr. Moh Sham Kasim, Dr. Randa Youssef, Dr. Patricia Lai Sheung
Ip, Dr. Tufail Muhammad, Dr. Margaret Lynch and Dr. Randall
Alexander
• Dr. Howard Dubowitz, Facilitator and Editor
• ISPCAN Staff Support

Vignette 1
• Infant Male: USA
– Economically stressed family
– Fussy baby
– Bottom bruises
– “Otitis media”
– Subdural hematoma
– Extensive retinal hemorrhages

Vignette 1
Fussy infant
Source: AAP

Discussion
• What is child abuse?
• How common are child maltreatment, child physical abuse, abusive head trauma?
• Were Bobby’s injuries due to child abuse?
• What is Bobby’s diagnosis?
• Why didn’t the doctor suspect child abuse at Bobby’s two week well-baby-check?

All forms of physical &/or emotional ill treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to a child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.
(World Health Organization 1999)

50
43
40
40
31
30
20
10
11
0
Physical
Abuse
NCANDS
Sexual
Abuse
NIS-4 Harm
Neglect
NIS-4 Endanger
Total
Self report

150
125
100
75
50
25
0
250
225
200
175
6.6
250
2.3
150
Physical Abuse Sexual Abuse
NCANDS NIS-4 Harm NIS-4 Endanger Canada WHO Estimates

Rates of Harsh Physical Punishment
60
50
40
30
20
10
0
Hit on buttocks with object
Hit elsewhere with object
Chile
Egypt
India
Phillipines
US
Kicked Burned
Source: WHO WorldSAFE study
Runyan DK. Pediatrics. 2010;126:e701-11

Rates of Psychological Punishment
60
50
40
30
20
10
0
Called names Cursed at
Chile Egypt
Threatened abandonment
Locked out of house
India Phillipines US
Source: WHO WorldSAFE study

3000
2000
2600
• Shaking of children < 2 years
• Keenan: ICU admissions & deaths
1000
17
• Theodore: parental report
0
Keenan Theodore
Keenan, et al. JAMA. 2003;290:621-6
Theodore, et al. Pediatrics. 2005;115:e331-7

60
54
50
50
40 rate per
30
1,000
20
10
10
0.2
0
Child
Abuse
Asthma Autism* Cancer
* Denotes prevalence. All others are incidence rates

• #1 - Trauma
• #2 - Trauma
• #3 - Trauma

• Non-inflicted trauma
• Bleeding disorder
• Ruptured aneurysm
• Ehlers-Danlos
• Glutaric aciduria type I

• Normal newborn
• Bleeding disorder
• High blood pressure
• Metabolic disorder
• Aneurysm
• CPR
• Infection
• Above rarely cause extensive hemorrhage!

• Non-inflicted trauma : should be history of severe trauma (eg, MVC, direct blow)
• Birth injury : history of difficult delivery
• Metabolic bone disease: OI, rickets, etc.
• Extreme prematurity

• HIGH SPECIFICITY
FOR ABUSE
– Especially if posterior or lateral
• Usually occult
• Acute rib fractures often missed, esp. if anterior or lateral
• Easier to see on X-ray when healing, after 1-
2 wks.

Rib Fractures - Mechanism of Injury
• Compression of the chest causes leverage of posterior ribs over spine.
• Compression places tension along inner aspects of the rib head and neck regions, causing fracture.
•Kleinman, PK. Diagnostic Imaging of Child Abuse, 2 nd ed. St Louis, MO: Mosby, Inc. 1998. p116.

• Abusive head trauma – any inflicted injury to the head of a child
• Encompasses “shaken-baby syndrome” and “shaking-impact syndrome”
• Contact and/or non-contact injury

• Occurs most commonly in infants
• Shaking injury reported in children up to 5 years of age
• At least 2/3 of serious head injuries in infants

• Subdural hemorrhage
• Retinal hemorrhage
• Brain injury
• Fractures – especially rib and metaphyseal

• Crying
• Toilet training
• Perceived misbehavior
• None

LESS SEVERE
• Lethargy
• Irritability
• Poor appetite
• Vomiting
MORE SEVERE
• Seizures
• Unconsciousness
• Breathing difficulty
• Death

Contributors to Child Maltreatment
Society
Community
Family
Parents
Child
Professionals
Belsky, Psychological Bulletin.
1993;114:413

• Age - younger children
• Gender -
girls: higher risk for infanticide, sexual abuse, educational and nutritional neglect.
boys: higher risk for physical abuse
• Special Characteristics – twins, children with handicaps, prematurity, unwanted pregnancy

• Young age
• Single parent
• Unwanted pregnancy
• Poor parenting skills
• Substance abuse
• Physical or mental illness

• Overcrowded living circumstances
• Poverty
• Social isolation
• Major stress
• Domestic violence

• No/poorly enforced child protection laws
• Limited value of children
• Social acceptance of violence (family, community or society – including war)
• Cultural norms
• Social inequities - poverty

Professional Factors
Failing to:
• Acknowledge that child maltreatment exists
• Identify and address child maltreatment
• Offer necessary services to children and families
• Help prevent maltreatment
– By promoting health, development and safety
– By addressing major risk factors

Discussion
• Why didn’t the doctor suspect child abuse when Bobby returned with symptoms?
• Assuming abuse, what do you think are the consequences of Bobby’s child abuse?
• Why do you think abuse might have happened in this family?

Teaching Points
• Physicians look to the history for the answer; disregarding the history is hard.
• Thinking of abuse is uncomfortable, particularly in families who are
“nice,” sympathetic
• Inflicted trauma is often occult

Non-specific findings
+
Absent or misleading history
_______________________
Missed diagnosis

• More common in families who are:
–White
–Have married parents
–Higher income

• Mental retardation
• Severe brain damage
• Learning disabilities
• Seizures
• Hearing and speech impairment
• Visual impairment
• Behavioral disorders
• Death

Vignette 2
• Maria - teenage mother, Brazil
– Found unconscious, possible suicide attempt
– 3 month old and 4 year old children – dirty, hungry, developmental concerns
– Elena - 4 year old girl is masturbating frequently – physical exam is normal
– Maria was sexually abused as a child

Discussion
• Was Elena sexually abused?
• How does Elena’s physical examination influence your impression?
• What were the consequences of child abuse for Maria?

Discussion
• Have Elena and her brother been neglected?
• What is the relationship between
Maria’s experiences and the neglect and sexual abuse of her children?

• Involvement of a child in sexual activity that he/she:
– does not fully comprehend,
– is unable to give informed consent to,
– is not developmentally prepared,
– violates laws and taboos of society
• Children can be sexually exploited by an adult or other child who by virtue of age or development is in a position of responsibility, power or trust
(From ISPCAN & WHO in, “Preventing Child Maltreatment”, 2006)

• Often a ‘hidden’ assault
• All forms of sexual activity are included , not just intercourse and other physical types
• Includes child prostitution and exposure to pornography

• No typical profile
• Many appear normal, successful and have no criminal record
• Most are male
• Most are familiar to the child many in position of trust, authority
• 20 - 40% adolescents
• Many (not all) were abused themselves

• About 85% female (cases known to system)
• Peak ages:
– Girls and boys – early school age 5-7 years
– Girls – 14-15 years
• Vulnerable, needy

• Physical signs: injury or infection
• Child’s disclosure – to another child, parent, therapist, or trusted adult
• Child sexually abuses another child
• Child uses sexually explicit language, behavior beyond normal development

• “It’s normal to be normal”
• More than 95% of referred children have normal exams
• Why???
– Abusive acts may leave no injury (e.g. fondling)
– Causing injury increases risk of disclosure
– Injuries often heal without scars before disclosure and medical evaluation

• Genital injury –
– Acute - tears, bruises, bite marks
– Sub-acute, chronic – healed hymenal tears, scars
• Sexually transmitted infections
• Pregnancy
• Forensic evidence – sperm, semen, etc.

Possible causes:
• Sexual abuse
• Poor understanding of societal norms
– E.g. child with developmental disabilities
• Sexual curiosity/exploration
• Exposure to explicit sexual activities
– Witnessed activity in home, on TV, movies
– Viewing pornography
– May be inadvertent, neglectful, or abusive

Common Behaviors - 2-9 years
(unlikely to be related to abuse)
Friedrich WN. Normative sexual behavior in chidren. Pediatrics. 1998; 101:e9
Boys
1) Touches sex parts at home
2) Touches breasts
3) Stands too close
4) Tries to look at other people when they are nude
5) Touches sex parts in public
6) Masturbates with hand
Girls
1) Touches sex parts at home
2) Touches breasts
3) Tries to look at other people when they are nude
4) Stands too close
5) Masturbates with hand
6) Touches sex parts in public

Common Behaviors - 10-12 years
(unlikely to be related to abuse)
Friedrich WN. Normative sexual behavior in chidren. Pediatrics. 1998; 101:e9
Boys
1) Very interested in opposite sex
2) Wants to watch TV nudity
3) Tries to look at pictures of nude people
4) Knows more about sex
5) Talks about sex acts
6) Touches sex parts at home
Girls
1) Very interested in opposite sex
2) Knows more about sex
3) Stands too close
4) Wants to watch TV nudity
5) Touches sex parts at home
6) Talks about sex acts

Uncommon Behaviors @ 2-12 years
(more likely to be related to abuse)
1) Puts mouth on sex parts
2) Asks to engage in sex acts
3) Masturbates with object
4) Inserts objects in vagina/anus
5) Imitates intercourse
6) Makes sexual sounds
7) Tries to french kiss
8) Undresses other people
9) Asks to watch explicit TV
10) Imitates sexual behavior with dolls

• Excessive focus on sexuality, knowledge beyond normal development
• Inappropriate behavior despite redirection
• Sexual behavior/exploration/coercion with much older/younger children
• Inflicts injury to own or other’s genitals
• Disturbing toileting behavior
• Drawings with genitals predominating
• Sexual contact with animals

What were the consequences of sexual abuse for Maria?

• Short term
– Acute injuries
– STD’s
• Long term:
– GI problems (irritable bowel)
– Chronic pain (headache, abdominal, back, or pelvic pain)
– Obesity, failure to thrive
– Somatization

• Behavioral problems – withdrawal, acting out, delinquency
• Depression
• PTSD & other anxiety disorders
• Substance abuse
• Eating disorders – anorexia, bulemia
• School failure
• Low self esteem, interpersonal difficulties

Child-Centered Definition of
Neglect
• Neglect occurs when a child’s basic needs are not met , resulting in potential or actual harm.
• Basic needs include adequate:
– Food - Clothing
– Supervision
– Health care
- Protection
- Education
– Love & nurturance - Home

Teaching Points
• All forms of maltreatment increase with social risk factors, especially poverty
• Sexual abuse is the least related
• Neglect is the most related
• All forms of abuse happens in every ethnic, social and economic group

Additional Teaching Points
• False allegations are rare
• False denials are common
• Sexually abused children often grow up to be unsympathetic witnesses
• Runaways
• Street children
• “Delinquents”

Teaching Points
• Neglect: failure to meet a child’s basic needs (rights)
• Emotional
• Nutritional
• Housing
• Safety
• Health
• Education

Teaching Points
• Neglect may seem benign
• It’s not
• It has serious potential effects:
• Physical: eg, poor growth, ingestions, death
• Cognitive: eg, developmental delay, learning problems
• Mental health: eg, emotional and behavioral problems
• Social: Juvenile delinquency and criminal behavior

Vignette 3
• Middle-aged man: China
– Physical and psychosomatic ailments
– Tobacco and alcohol abuse
– Beaten as a child
– Witnessed domestic violence
– Broke off relationship with “mentor”
– Socially isolated

Discussion
• What “adverse childhood experiences” can you identify or do you suspect?
• What do you think happened between Lao Zhang and his mentor?
• Could it have been sexual abuse?

Discussion
• What possible behavioral consequences may be related to Lao Zhang’s childhood experiences?
• What medical consequences have occurred, or might occur, in a patient like Lao Zhang?

Impact of Maltreatment on Children
• Every child is affected – extent varies
• Several factors determine the impact:
– Nature of maltreatment
– Child’s personality
– Protective factors
• Consequences can be:
– Physical
– Psychological
– Behavioral
– Societal

Physical Consequences
• Injuries i.e fractures, burns, injury to internal organs, lacerations, head injury
• Impaired brain development
• Short and long-term disability
• Death

Odds of Ischemic Heart Disease
By Number of Adverse
Childhood Experiences
3.5
3
2.5
2
1.5
1
0.5
0
1
2
3
4
5-6
7-8
Control Med
Risk
Control
Psychosocial
Risk
Control Both

Psychological Consequences
• Common
• May include:
– Immediate issues of isolation, fear and lack of trust
– lifelong problems of depression, low selfesteem, relationship difficulties
– Impaired cognitive development

12.2
14
12
Adjusted
Odds
10
8
6
4
2
0
1
1.8
3
6.6
0 1 2 3 4 or more
Number of Adverse Childhood Experiences

Teaching Points
• Many older people suffered abuse that they may not see as abuse, or, may not discuss
• This is particularly true of sexual abuse in boys
• Witnessing domestic violence can seriously affect children

Teaching Points
• “Adverse childhood experiences” may have long term health effects
– Health problems (eg, heart disease)
– Mental health problems (eg, depression, suicidality)
• Vulnerability due to stress, social isolation?

Vignette 4
• Six-year old girl
• At seven-months of age:
– Symptomatic femur fracture
– Old and new rib fractures
– “classic metaphyseal lesions”
• Protected
• Family treated
• Reunified

Discussion Questions
• What do you think caused Palwasha’s many fractures?
• What might have happen to Palwasha when she was removed?
• What services might be helpful to Palwasha and her family?

What are possible causes of Palwasha’s many fractures?

Differential Diagnosis of
Long-bone Fractures
• Child abuse
• Non-inflcited (accidental injury)
• Medical disorders that increase risk for fractures
– Osteogenesis imperfecta
– Rickets

• Low specificity for abuse
• EXCEPT IN INFANTS (pre-ambulatory children)
• Spiral or oblique fracture: non-specific
– Indicates torsional (twisting) force

• Common non-inflicted patterns:
–Running & falling, especially with twisting motion
–Twisting against a planted foot with a fall
• Femur fractures very suspicious for abuse in infants not yet walking

• Shaft fractures
– Consider age of child & hx of injury
• Supracondylar fx
– Due to fall on elbow
– Mostly not inflicted
– Abuse more likely in infants

Long Bone Fractures
– Tibia
• Toddler’s fracture
• Oblique, non-displaced fracture of distal tibia
• History of minor or no trauma
• In infants & toddlers who have just begun to cruise or walk
• NON-INFLICTED

• Corner or bucket-handle depending on view
• Mechanism: twisting or pulling of extremity or acceleration/deceleration forces during shaking
• HIGHLY SPECIFIC FOR
ABUSE

Rib
Scapula
HIGH
CML
MODERATE LOW
Multiple fx, esp. bilateral Subperiosteal new bone
Fx of different ages Clavicle
Epiphyseal separation Long bone shaft
Spinous process
Vertebral body
Sternum fx Fingers/toes
Linear skull
Complex skull fx
Kleinman, PK. Diagnostic Imaging of Child Abuse, 2 nd
9.
ed. St Louis, MO: Mosby, Inc. 1998. P

What might have happened to Palwasha when she was removed?

Discussion
• What system exists in your community to protect abused children?
• How do you activate that system?
• What services exist in your community to treat abused children, their nonabusive family members, and those who abuse children?

Teaching Points: Steps in
Helping Abused Children
• Identify abuse
• Stop abuse, prevent further abuse
• Treat the medical AND emotional consequences
• Support the family - help make it safe
OR
• Find a safe alternative home

Teaching Points
Many abused children suffer from life long problems
However…
Many abused children become successful adults

Send email to: training@ispcan.org

Teaching Points
• How is protection provided for in your social / legal system?
• What can you do to improve that?
• What treatment is available for abused children and their families?
• How can access be improved?

Teaching Points
Up to 1/3 of inflicted head trauma cases are missed at 1 st presentation
– 27% re-abused
– 40% complications
– 7% die

Teaching Points
• Sexual abuse presents many ways:
– Injuries
– Sexually transmitted infections
– Disclosure
– Emotional and behavioral changes
– Post traumatic stress disorder (PTSD)

Teaching Points
• > 90% of physical exams are normal
• Fondling
• Oral and anal sex
• Healing of injuries
• Anatomic variation

Teaching Points
• Many later consequences of abuse:
• PTSD, depression, suicide
• Conduct disorder, school troubles, drug use
• Early sexual activity, pregnancy, STIs, HIV

Discussion
• What are the consequences of neglect for
Maria’s children so far?
• What social, environmental, and family factors contributed to this situation?

• What are Maria's legal rights to stay with her children?
• What are Paulo's rights and responsibilities to help, support and visit his children?

Teaching Points
• Rights and responsibilities of the family?
• Maria
• Paulo
• Extended family
• Ability of the social system to substitute for or support the family?