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Course: Pediatric Nursing

Topic: Child Maltreatment - Part I

The Nurses International Community

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Module Goals

Learners will be able to:

Define maltreatment in children.
Identify risk factors for various maltreatment in children.
Discuss strategies for taking history in a abused child.
Discuss history and physical findings suggestive of different abuse.
Identify common forms of abuse.
Identify medical conditions that mimic abuse.

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Child Maltreatment

Purposeful maltreatment of a child with the aim of causing harm or injury.
Includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another individual in a custodial role (such as a religious leader, a coach, a teacher) that results in harm, the potential for harm, or threat of harm to a child.
Most common in children under the age of 5 years.
The younger the child the greater is the risk of severe injury or death.

Woods, 2019

CDC, 2022

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Types of Child Maltreatment

Physical abuse: Use of intentional physical force, such as hitting, kicking, shaking, burning or other show of force against a child.

Sexual abuse: Forcing a child into sexual acts; fondling, rape.

Emotional abuse: Refers to behaviors that harm a child’s self-worth or emotional well-being; shaming, rejection, withholding love.

Neglect: Failure to meet a child’s basic needs food, clothing, education, and access to medical care.

Woods, 2019

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There are four common types of abuse.

Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities.
Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening.
Neglect is the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to.

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When to Consider Child Abuse?

If the story does not explain the nature or degree of the injury
If the story is vague or keeps changing
If the child reports or hints at abuse
A delay in seeking medical help
Repeated or multiple injuries at different stages of healing
Unusual type of injury
Inappropriate emotional state or behavior of the parents or child
Pregnancy or a STDs in a child under 16 years

Woods, 2019

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Physical Abuse

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Physical Abuse: Common Forms

Punching
Beating
Kicking
Biting
Shaking
Throwing
Stabbing
Choking
Hitting (with a hand, stick, strap, or other object)
Burning, or otherwise causing physical harm

Child Welfare Information Gateway, 2019

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Physical Abuse: Signs and Symptoms

Has unexplained injuries (burns, bites, bruises, broken bones, black eyes)
Has fading bruises or other noticeable marks
Seems scared, anxious, depressed, withdrawn, or aggressive
Seems frightened of their parents and protests or cries when it is time to go home
Shrinks at the approach of adults
Shows changes in eating and sleeping habits
Reports injury by a parent or another adult caregiver
Abuses animals or pets

Child Welfare Information Gateway, 2019

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Physical Abuse: Signs and Symptoms (Continued)

Consider the possibility of physical abuse when a parent or other adult caregiver exhibits the following:

Offers conflicting, unconvincing, or no explanation for the child’s injury.
Provides an explanation that is not consistent with the injury.
Shows little concern for the child.
Sees the child as bad, burdensome, or worthless.
Uses harsh physical discipline with the child.
Has a history of abusing animals or pets.

Child Welfare Information Gateway, 2019

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Conditions That Mimic Physical Abuse in Children

Conditions that mimic of abuse: Accidental traumas, Coagulation disorders, Connective tissue disorders, cultural and artifactual skin findings.
Congenital Disorders of Coagulation: Hemophilia, Von Willebrand Disease.
Acquired Bleeding conditions: Vitamin K deficiency, Leukemia, Aplastic anemia.
Disorders of Collagen: Osteogenesis Imperfecta, Vitamin C deficiency.

Christian & States, 2017

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Conditions That Mimic Physical Abuse in Children (Continued)

Disease that Mimics Abusive Fractures: Skeletal Dysplasias, Prematurity, Infections, Neoplasia, Caffey Disease.

Diseases that mimic Abusive Head Trauma: Hemophilia, Factor XIII deficiency, Biliary atresia, Late-onset of vitamin K deficiency, Benign enlargement of the subarachnoid spaces.

Christian & States, 2017

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Strategies of Assessing Child with Physical Abuse

"TEN 4" is a useful mnemonic device used to recall which bruising locations:

Torso
Ear
Neck and
4 (less than four years of age or any bruising in a child less than four months of age)

Injuries that are highly suggestive of abuse include retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions.

Gonzalez et al., 2020

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"TEN 4" is a useful mnemonic device used to recall which bruising locations are of concern in cases involving physical abuse: Torso, Ear, Neck and 4 (less than four years of age or any bruising in a child less than four months of age). A few injuries that are highly suggestive of abuse include retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions.

Bruising is the most common sign of physical abuse but is missed as a sentinel injury in ambulatory children. Bruising in non-ambulatory children is rare and should raise suspicion for abuse. The most common areas of bruising in non-abused children are the knees and shins as well as bony prominences including the forehead. The most common area of bruising for the abused children includes the head and face. Burns are a common form of a childhood injury that is usually not associated with abuse. Immersion burns have characteristic sharp lines of demarcation that often involves the genitals and lower extremities in a symmetric pattern, and this is highly suspicious for abuse.

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Assessment: Physical Abuse

Evaluate the injury
Obtain thorough history of present condition
Gather information about child’s behavior (before, during and after) the injury
Interview each caretaker separately and the verbal child
Note the flow, content of the statement made by each individual (parents or caretakers should be able to provide history without interruptions)

Gonzalez et al., 2020; Woods, 2019

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To diagnose a patient with child maltreatment is difficult since the victim may be nonverbal or too frightened or severely injured to talk. Also, the perpetrator will rarely admit to the injury, and witnesses are uncommon. Physicians will see children of maltreatment in a range of ways that include:

An adult or mandated reporter may bring the child in when they are concerned for abuse
A child or adolescent may come in disclosing the abuse
The perpetrators may be concerned that the abuse is severe and bring in the patient for medical care
The child may present for care unrelated to the abuse, and the abuse may be found incidentally.

Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is important to make a correct diagnosis. Important aspects of the history-taking involve gathering information about the child’s behavior before, during, and after the injury occurred. History-taking should include the interview of each caretaker separately and the verbal child, as well. The parent or caretaker should be able to provide their history without interruptions in order not to be influenced by the physician’s questions or interpretations.

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What Would the Nurse Do?

Discussion:

An 8-year-old child is brought to the emergency room after breaking his arm from a fall.

The nurse notices several burns resembling a cigarette on the child’s body.

When asked how the burns occurred the mother states that she does not know and does not smoke.

What should the nurse do to evaluate possible physical abuse?

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Sexual Abuse

“The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or interfamilial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children”

CAPTA as cited in Child Welfare Information Gateway, 2019

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Sexual Abuse: Common Forms

Fondling a child’s genitals
Penetration
Incest
Rape
Sodomy
Indecent exposure
Exploitation through prostitution
Production of pornographic materials

Child Welfare Information Gateway, 2019

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Sexual Abuse: Signs and Symptoms

Has difficulty walking or sitting
Experiences bleeding, bruising, or swelling in their private parts
Vaginal discharge
Reports nightmares or bedwetting
Experiences a sudden change in appetite
Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior

Child Welfare Information Gateway, 2019

Woods, 2019

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Sexual Abuse: Signs and Symptoms (Continued)

Runs away
Reports sexual abuse by a parent or another adult caregiver
Attaches very quickly to strangers or new adults in their environment
Suddenly refuses to go to school
Unstable emotional behaviour (withdrawal, separation anxiety, depression, poor school work, avoiding school

Child Welfare Information Gateway, 2019

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Sexual Abuse: Signs and Symptoms (Continued)

Consider the possibility of sexual abuse when a parent or other caregiver exhibits the following: �

Tries to be the child’s friend rather than assume an adult role �.
Makes up excuses to be alone with the child �.
Talks with the child about the adult’s personal problems or relationship.

Child Welfare Information Gateway, 2019

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Conditions That Mimic Sexual Abuse in Children

Physical conditions: Dermatitis and other dermatologic diseases, vasculitis, neoplasia, anatomic variants, inflammatory bowel disease, and infection leading to vaginal discharge, inflammation, or ulceration Hypersexualized behaviors in children.

Klüver-Bucy syndrome

Implicated pediatric diseases: Encephalitis, malignancy, tuberculosis, seizures, and hypoxic ischemic injury.

Christian & States, 2017

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Assessment of Sexually Abused Child

Watch for the clinical signs and symptoms.
Note behavior such as undressing in front of others, touching others' genitals, as well as trying to look at others underdressing.
Normal physical examination does not rule out sexual abuse as majority victims may have normal anogenital examination.
Strongest evidence is the child’s statement (if verbal).

Child Welfare Information Gateway, 2019

Gonzalez et al., 2020

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Critical Thinking Question

Discussion:

A 2-year old is brought to the clinic because the mother suspects that her boyfriend is sexually abusing the child.

What actions by the nurse are appropriate at this time?

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Child Neglect: Categories

Physical (e.g., failure to provide necessary food or shelter, appropriate supervision) �
Medical (e.g., failure to provide necessary medical or mental health treatment) �
Educational (e.g., failure to educate a child) �
Emotional (e.g., verbal abuse,failure to provide psychological care, permitting a child to use alcohol or other drugs)

Child Welfare Information Gateway, 2019

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Child Neglect: Signs and Symptoms

Frequent absence from school �
Begs or steals food or money �
Lacks needed medical care (including immunizations), dental care, or glasses
Consistently dirty and has severe body odor �
Lacks sufficient clothing for the weather �
Abuses alcohol or other drugs �
States that there is no one at home to provide care

Child Welfare Information Gateway, 2019

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Child Neglect: Signs and Symptoms (Continued)

Consider the possibility of neglect when a parent or other caregiver exhibits the following:�

Appears to be indifferent to the child �
Seems apathetic or depressed �
Behaves irrationally or in a bizarre manner �
Abuses alcohol or other drugs

Child Welfare Information Gateway, 2019

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Conditions that Mimic Child Neglect

Unexpected inheritable disorder and whose injuries or illness may have initially been misdiagnosed or not diagnosed
Extreme poverty
Lack of parenting education
Lack of awareness

Christian & States, 2017

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Assessment of Child who is Neglected

Physical examination
Document signs:

Poor oral hygiene with extensive dental caries
Malnutrition
Growth failure
Untreated diaper dermatitis
Untreated wounds

Gonzalez et al., 2020

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Child Neglect

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Emotional Abuse: Assessment

Mental injury is often difficult to prove, and therefore, child protective services may not be able to intervene without evidence of harm or mental injury to the child.

Emotional abuse is almost always present when other types of maltreatment are identified.

Child Welfare Information Gateway, 2019

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Emotional Abuse: Common Forms

A pattern of behavior that impairs a child’s emotional development or sense of self-worth

Constant criticism
Threats, or rejection as well as withholding love, support, or guidance
Belittling, bullying

Child Welfare Information Gateway, 2019

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Emotional Abuse: Signs and Symptoms

Demonstrates extremes in behavior (e.g., overly compliant or demanding, extremely passive, or aggressive �
Inappropriately adult behavior (e.g., parenting other children) or inappropriately infantile (e.g., frequently rocking or head-banging)
Delayed in physical or emotional development �
Shows signs of depression or suicidal ideation �
Inability to develop emotional bonds with others

Child Welfare Information Gateway, 2019

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Emotional Abuse: Signs and Symptoms

Consider the possibility of emotional maltreatment when the parent or other adult caregiver exhibits the following:

Constantly blames, belittles, or berates the child �
Describes the child negatively �
Overtly rejects the child

Child Welfare Information Gateway, 2019

Shaken Baby Syndrome: Treatment

Emergency treatment includes life-sustaining measures such as respiratory support and surgery to stop internal bleeding and bleeding in the brain.

Respiratory support includes performing pediatric CPR, oxygenation, careful respiratory monitoring and thorough assessment

Healthline, 2016

MedlinePlus, 2021

National Institute of Neurological Disorders and Stroke, 2022

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Shaken Baby Syndrome: Nurses Role

Primary prevention:

Teaching about normal developmental outcomes, discuss about the normal expectations and normal feelings and what to expect as infant continues to grow.
Teaching techniques on dealing with inconsolable crying.
Help the parents to plan concrete emergency action plans during frustration, anger during inconsolable crying.

Secondary interventions: Identify high-risk families and provide support and interventions.

Allen, 2014

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Nurses in the neonatal care unit can help prevent abusive head trauma through primary and secondary prevention mechanisms. Primary prevention of abusive head trauma targets involving parents in the care of their infant and teaching parents about the normal developmental outcomes tailored to their infant. Parental involvement in the care of the infant is to help parents feel less helpless or inadequate as parents. Holding and providing care also allows the parents to understand the development of the infant and what to expect as the infant continues to grow. Discussions about normal expectations and normal feelings to expect when taking home a newborn should also be discussed with new parents. Nurses also need to discuss techniques on dealing with inconsolable crying and help parents create a concrete emergency action plan that can be implemented if parents begin to feel overwhelmed, frustrated, or angry when their infant is inconsolable. Secondary prevention interventions may be necessary if needs are identified during family meetings. This would include identification of high-risk families and providing additional interventions. For premature infants or infants with neurological conditions, high-risk families may lack understanding about normal expectations for development or have unrealistic insights into the behaviors of preterm infants

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Shaken Baby Syndrome: Preventive Education

Never shake a baby or child in play or in anger
Do not hold the baby during an argument
If becoming annoyed or angry with the baby, put the baby in their crib and leave the room
Try to calm down
Call someone for support (if needed)
Contact a local crisis hotline or child abuse hotline for help and guidance
Seek the help of a counselor and attend parenting classes

Healthline, 2016

MedlinePlus, 2021

National Institute of Neurological Disorders and Stroke, 2022

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Red Flags

All the signs of:

Physical abuse
Possible neglect
Possible sexual abuse
Possible emotional abuse
Possible sexual exploitation or human trafficking

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

(AHRQ, 2020)

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Cultural Considerations: Examples

In country like Nepal, a significant number of toddlers, more than half, aged between one and two or more, are disciplined with the use of physical force.

Unicef, 2018

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References:

Allen K. A. (2014). The neonatal nurse's role in preventing abusive head trauma. Advances in neonatal care : official journal of the National Association of Neonatal Nurses, 14(5), 336–342. https://doi.org/10.1097/ANC.0000000000000117

Centers for Disease Control and Prevention. (2022, April 6). Injury Center: Child Abuse and Neglect. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html

Child Welfare Information Gateway. (2018). Parenting children and youth who have experienced abuse or neglect. Washington, DC: U.S. Department of Health and Human Services. https://www.childwelfare.gov/pubs/parenting-CAN/

Child Welfare Information Gateway. (2019). What is child abuse and neglect? Recognizing the signs and symptoms. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. https://www.childwelfare.gov/pubs/factsheets/whatiscan/

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References:

Christian, C.J., States, L. J. (2017). Medical Mimics of Child Abuse. American Journal of Roentgenology. Vol 208 (5). Pp. 982-99

Gonzalez D, Bethencourt Mirabal A, McCall JD, et al. Child Abuse and Neglect (Nursing) [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568689/

Healthline. (2016, January 11). Shaken Baby Syndrome. https://www.healthline.com/health/shaken-baby-syndrome

MedlinePlus. (2021, Feb 2). Shaken baby syndrome. https://medlineplus.gov/ency/article/007578.htm

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References:

National Institute of Neurological Disorders and Stroke. (2022, April 25). Shaken Baby Syndrome. https://www.ninds.nih.gov/health-information/disorders/shaken-baby-syndrome

Woods, D. (2019). Child Healthcare: Home and Society (CH. 14). Better Care. https://bettercare.co.za/learn/child-healthcare/text/0-3-contents.html

WHO. (2020, June 8). Child maltreatment. https://www.who.int/news-room/fact-sheets/detail/child-maltreatment

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