Child Abuse and Neglect
last authored: April 2012, David LaPierre
last reviewed:
Introduction
Child abuse can be physical, sexual, or psychological injury leading to harm.
Sexual abuse is tragically common, occurring in 1:4 females and 1:10 males. Peaks in incidence are 2-6 and 12-16 years. Most perpetrators are male and known by the victim.
Risk Factors
Risk factors for abuse include:
Environment
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Cargivers
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Children
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Suspecting Abuse
It is important to have a index of suspicion with injuries.
Never interpret a bruise in isolation; assess in the content of medical and social histories.
- asking about the injury
- patterns of injury
- signs of neglect
- sexual abuse
Asking about the Injury
Particular concern should be present if:
- the explanation does not match the injury
- the story contains half-truths with shady details
- inconsistent history
- there is a delay in seeking treatment
- unrealistic explanations of child's behaviour by caregivers
- there has been a recent family crisis
- there are multiple injuries of varied ages
- atypical pattern of injury
If concerned, ask also about:
- who also lives in the house?
- are there other children in the house?
- developmental milestones, medical history, medications, allergies, ROS
- planned pregnancy? problems with pregnancy or birth?
Patterns of Injury
There are particular patterns of injury that occur with particular forms of abuse:
- shaken baby syndrome: intracranial hemorrhage, retinal hemorrhage, posterior rib fracture
- brusing in babies that "bruise before they cruise"
- being whipped with a looped cord: changing patterns
- immersion into hot water: a linear pattern of burn on the legs or buttocks
- cigarette burns
- belt buckle,
- slap marks: parallel linear, peticeal marks
Regarding location, more suspicious injuries include:
- face
- abdomen
- buttocks and backs of legs
- inside of thigh
- posterior rib fractures
Less concerning injuries are over the front of the body, on bony prominences
- shins
- knees
- elbows
- chin
- forehead
There are some findings that may appear concerning, but have a more benign explanation:
coining: rubbing a coin along the back for respiratory infection
cupping: placing a warm cup glass on the back, leading to round marks; traditional practice for respiratory infection
Mongolian spots: grayish birthmarks; non-blanchable; does not change over time
Signs of Neglect
When evaluating the child, look for:
- failure to thrive
- developmental delay
- poor hygiene, dirty clothing
- poor parental attachment
- no stranger anxiety
Sexual Abuse
Diagnosis usually follows disclosure by child. Signs can include:
psychosocial:
- anxiety, depression
- nightmares
- withdrawal, lack of trust
- low self-esteem
- school failure
- sexual aggression, preoccupation, or play
physical:
- recurrent UTIs
- pregnancy
- STIs
- vaginitis
- vaginal bleeding, pain, genital injury
- enuresis
Duty to Report
With reasonable suspicion of abuse or neglect, physicans must personally disclose all information to the appropriate authorities. This duty is more important than confidentiality.
Management
Document and photograph all injuries.
Workup may include:
- Blood tests for coagulopathy
- STI work-up
- skeletal survey or bone scan
- CT/MRI
- ophthalmology exam
If Abuse is identified or strongly suspected, admit the child for safety and investigations. Consult a child psychiatrist and pediatric orthopedic surgeon as required. The Children's Aid Society (or equivalent) must become involved.
The child may be returned once the situation is deemed safe. Family therapy, with frequent follow-up, is required.
Resources and References
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