Child Abuse

 

More than 3.6 million child maltreatment cases were investigated in 2005.  Of these cases approximately 900,000 cases were determined to be substantiated.  Exact definitions of what constitutes child maltreatment vary from state to state.  In general, child maltreatment consists of neglect, physical abuse, sexual abuse, and emotional abuse; physical abuse is second only to neglect in the number of child maltreatment cases.  

 

Risk Factors

á   Age- the incidence of maltreatment is inversely proportional to victim age; children aged birth to 3 years have the highest rates of maltreatment

á   Low infant birth weight

á   Congenital drug addiction

á   Having 2 or more siblings

á   Maternal depression

á   Having an unwed mother

á   Presence of unrelated adults at home

á   History of domestic violence between guardians

á   Low Socioeconomic status

á   Significant life stressors

 

Prevention

á   Screen for risk factors

á   Provide anticipatory guidance on normal behavior of children

á   Suggest appropriate disciplinary methods

á   Suggest methods to reduce parental stress

 

 

Signs of Maltreatment

á   Explanation of injury inconsistent with the age or development of the child

á   Explanation of injury inconsistent with severity or pattern of injury

á   No explanation of childÕs injury

á   Frequent changes regarding the mechanism of injury

á   Explanations regarding the mechanism of injury vary among witnesses

 

History

When child maltreatment is suspected, all care givers (parents, babysitters, etc.) should be interviewed separately and the child should be interviewed in the absence of parents if possible. 

Thorough documentation is essential; whenever possible try to document the direct quotes of witnesses.  Avoid commenting on the feasibility of the mechanism of injury proposed by care givers when initially interviewing them.  Avoid putting words into the mouths of care givers.  Do not worry about getting every detail of the story.  Remember your first responsibility is to the health and safety of your patient.  Leave formal interrogation to the police, CPS, and Department of Child and Family Services workers.

 

á   Document the childÕs behavior and activity before, during, and after the injury

á   Document proposed mechanism of injury

á   Document the time between injury and presentation to physician

á   Document if there were any witness

á   Document if any other siblings or children remain at risk; this must be reported to CPS immediately

 

Physical Exam

For suspected child maltreatment cases have a high level of suspicion for severe head injuries or possible internal bleeding.  You must do a complete skin exam looking for any soft tissue bruises, lacerations, or scares.  Perform a complete neurological exam with glascow coma scale. 

 

á   Document the general appearance of the child

á   Document and plot the height, weight, and head circumference

á   Document the size, location, and approximate age of any bruises or lacerations

á   Document any obvious fractures.

á   Use a body diagram or photographs to document findings

 

Workup

The following list contains suggestions for further workup/ evaluation of suspected victims of child maltreatment.  When determining which tests are necessary, one must consider the individual circumstances of a particular case.  

á   Lab Test

      CBC

      BMP

      LFT

      Pancreatic Enzymes

      Prealbumin

á   Retinal Exam

á   Radiological Imaging

      Skeletal Survey

      Head CT

      Abd CT

 

Treatment

á   Secure the immediate safety of the child

á   Secure the immediate safety of any children that remain in the care of the suspected abuser

á   Treat any injuries the child has sustained

á   Report suspicions to the CPS and the police

á   Work with CPS to establish a safety plan that includes into whoÕs care the child should be discharged

á   Work with CPS to establish close medical and psychological follow up for the victim and family

 

References and Additional Information:

Kellogg, et al. Evaluation of Suspected Child Physical Abuse Pediatrics Vol 119 No 6

http://pediatrics.aappublications.org.proxy.uchicago.edu/cgi/content/abstract/119/6/1232

 

Gaudiosi, et al. Child Maltreatment 2005 US Department of Health and Human Services http://www.acf.hhs.gov/programs/cb/pubs/cm05/index.htm

 

Jenny, et al. Evaluating Infants and Children with Multiple Fractures Pediatrics Vol 118 No 3

http://pediatrics.aappublications.org.proxy.uchicago.edu/cgi/content/full/118/3/1299