• Incidence of all forms of abuse increases with age; teenagers are at twice the risk of infants.
• Risk of death is much higher in children <5 yr.
• Of the 1000 to 4000 annual deaths attributable to abuse, 80% are in children <5 yr, and 40% are in children <1 yr of age. For children <6 mo of age, abuse is the second cause of death (sudden infant death is first).
PEAK INCIDENCE:
• Approximately one third before the age of 1 yr, one third between 1 yr and 6 yr, and one third above age 6 yr
• Handicapped children at a much greater risk throughout childhood
GENETICS:
• No genetic factors are known.
• Sexual abuse is equally distributed throughout all socioeconomic groups, but physical abuse and neglect are more prevalent in lower socioeconomic groups, because abuse increases with severe stress, family violence, and substance abuse.
• Approximately 30% of abused children will abuse their children.
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Presence of multiple injuries of various ages, particularly in the setting of a discrepancy in the history and severity of injury
• Injuries of childhood usually on bony prominences; soft tissue injuries more commonly inflicted by others
• Burns occur in 10% of abused children; usually result from cigarettes or immersion of buttocks or extremities in scalding hot water
• Retinal hemorrhage diagnostic for “shaken baby syndrome,” because it occurs with head injury or sudden compression of the chest (Purtscher’s retinopathy)
• Subdural bleeding exceedingly rare in children unless child has suffered shaking or significant head trauma
• Presence of sperm or acid phosphatase in the vaginal vault diagnostic of intercourse within 72 hr and indicates sexual abuse of female child
• Sexually transmitted diseases in a child highly suggestive of sexual abuse
• Disruption of normal genital anatomy often associated with recurrent sexual abuse (e.g., a lax anal sphincter, thickening or darkening of labial skin, significantly enlarged hymen opening)
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Distinction from accidental injuries is crucial.
WORKUP
• History from the child, caregivers, and other individuals living in the home to reconstruct events and determine any inconsistency or implausibility in the story (Caution is required not to taint the history with the way in which it is obtained or the interviewer’s own bias.)
• Physical examination to determine developmental parameters (height, weight) and to document extent and age of bruises
• Examinations for sexual abuse performed within the first 72 hr to be conducted by a rape-crisis team
LABORATORY TESTS
• Examine fluids in the vaginal vault for sperm and acid phosphatase if intercourse was believed to have occurred within 72 hr.
• Culture oral, vaginal, and anal orifices for sexually transmitted diseases.
• Do bleeding studies if bruising is thought to be secondary to clotting abnormality.
• Examine nutritional, hematopoietic, and endocrine parameters for patients with neglect or failure to thrive.
IMAGING STUDIES
• For children ages 2 to 5 yr: obtain a bone survey (skull, thorax, pelvis, spine, arms, and legs).
• In children older than 5 yr: obtain more focused x-rays.
• Do brain imaging if head trauma or shaking is suspected.
• Take color photographs of skin lesions if legal action is anticipated. (note: Parental consent is not required for photos documenting suspected child abuse.)
TREATMENT
NONPHARMACOLOGIC THERAPY
• Gear initial interventions toward stabilizing the injuries and preventing further abuse.
• Contact Child Protective Services. (note: Physicians are mandated to report suspected abuse.)
• Where hospitalization is not required, arrange for emergency foster care if possible.
• If a child is returned to abusive environment, 5% mortality rate and 35% severe injury rate is to be expected.
ACUTE GENERAL Rx
Pharmacologic intervention is limited to that required to stabilize the injuries.
CHRONIC Rx
• Treatment in abusive families is generally poor. A review of several studies including some 3000 families found that a third of abusive parents will continue abuse while in treatment and half may revert to abuse at end of treatment.
• Separation of child via foster care may be traumatic to the child.
• Preventive programs for young single mothers at high risk are thought more effective than other interventions.
• Treatment of sexual abusers is marred by a high recurrence rate.
• In <5% of cases the abuse is related to a psychotic illness that can be treated directly.
DISPOSITION
• Victims of abuse and neglect may die or suffer lifelong emotional or physical disability.
• Abused children are more aggressive and have greater interpersonal difficulties. As adults they suffer from depression, anxiety, and substance abuse at twice the rate of the general population, and 30% are likely to abuse their children. Risk for suicide attempt is 2-5 times that of general population.
• Victims of sexual abuse will experience problems with sexual identity and function. Of women with borderline personality disorder, 60% have suffered physical or
sexual abuse.
• Risk of death is much higher in children <5 yr.
• Of the 1000 to 4000 annual deaths attributable to abuse, 80% are in children <5 yr, and 40% are in children <1 yr of age. For children <6 mo of age, abuse is the second cause of death (sudden infant death is first).
PEAK INCIDENCE:
• Approximately one third before the age of 1 yr, one third between 1 yr and 6 yr, and one third above age 6 yr
• Handicapped children at a much greater risk throughout childhood
GENETICS:
• No genetic factors are known.
• Sexual abuse is equally distributed throughout all socioeconomic groups, but physical abuse and neglect are more prevalent in lower socioeconomic groups, because abuse increases with severe stress, family violence, and substance abuse.
• Approximately 30% of abused children will abuse their children.
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Presence of multiple injuries of various ages, particularly in the setting of a discrepancy in the history and severity of injury
• Injuries of childhood usually on bony prominences; soft tissue injuries more commonly inflicted by others
• Burns occur in 10% of abused children; usually result from cigarettes or immersion of buttocks or extremities in scalding hot water
• Retinal hemorrhage diagnostic for “shaken baby syndrome,” because it occurs with head injury or sudden compression of the chest (Purtscher’s retinopathy)
• Subdural bleeding exceedingly rare in children unless child has suffered shaking or significant head trauma
• Presence of sperm or acid phosphatase in the vaginal vault diagnostic of intercourse within 72 hr and indicates sexual abuse of female child
• Sexually transmitted diseases in a child highly suggestive of sexual abuse
• Disruption of normal genital anatomy often associated with recurrent sexual abuse (e.g., a lax anal sphincter, thickening or darkening of labial skin, significantly enlarged hymen opening)
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Distinction from accidental injuries is crucial.
WORKUP
• History from the child, caregivers, and other individuals living in the home to reconstruct events and determine any inconsistency or implausibility in the story (Caution is required not to taint the history with the way in which it is obtained or the interviewer’s own bias.)
• Physical examination to determine developmental parameters (height, weight) and to document extent and age of bruises
• Examinations for sexual abuse performed within the first 72 hr to be conducted by a rape-crisis team
LABORATORY TESTS
• Examine fluids in the vaginal vault for sperm and acid phosphatase if intercourse was believed to have occurred within 72 hr.
• Culture oral, vaginal, and anal orifices for sexually transmitted diseases.
• Do bleeding studies if bruising is thought to be secondary to clotting abnormality.
• Examine nutritional, hematopoietic, and endocrine parameters for patients with neglect or failure to thrive.
IMAGING STUDIES
• For children ages 2 to 5 yr: obtain a bone survey (skull, thorax, pelvis, spine, arms, and legs).
• In children older than 5 yr: obtain more focused x-rays.
• Do brain imaging if head trauma or shaking is suspected.
• Take color photographs of skin lesions if legal action is anticipated. (note: Parental consent is not required for photos documenting suspected child abuse.)
TREATMENT
NONPHARMACOLOGIC THERAPY
• Gear initial interventions toward stabilizing the injuries and preventing further abuse.
• Contact Child Protective Services. (note: Physicians are mandated to report suspected abuse.)
• Where hospitalization is not required, arrange for emergency foster care if possible.
• If a child is returned to abusive environment, 5% mortality rate and 35% severe injury rate is to be expected.
ACUTE GENERAL Rx
Pharmacologic intervention is limited to that required to stabilize the injuries.
CHRONIC Rx
• Treatment in abusive families is generally poor. A review of several studies including some 3000 families found that a third of abusive parents will continue abuse while in treatment and half may revert to abuse at end of treatment.
• Separation of child via foster care may be traumatic to the child.
• Preventive programs for young single mothers at high risk are thought more effective than other interventions.
• Treatment of sexual abusers is marred by a high recurrence rate.
• In <5% of cases the abuse is related to a psychotic illness that can be treated directly.
DISPOSITION
• Victims of abuse and neglect may die or suffer lifelong emotional or physical disability.
• Abused children are more aggressive and have greater interpersonal difficulties. As adults they suffer from depression, anxiety, and substance abuse at twice the rate of the general population, and 30% are likely to abuse their children. Risk for suicide attempt is 2-5 times that of general population.
• Victims of sexual abuse will experience problems with sexual identity and function. Of women with borderline personality disorder, 60% have suffered physical or
sexual abuse.
Child Abuse
BASIC INFORMATION
Child abuse refers to the intentional maltreatment by a caregiver of any child under the age of 18 yr. Four categories generally defined:
1. Neglect: failure to provide basic needs such as food, shelter, supervision
2. Physical abuse: infliction of bodily injury or harm
3. Sexual abuse: passive or active use or exposure of children to sexual acts
4. Emotional abuse: humiliating, coercive behavior that retards a child’s psychologic development.
SYNONYMS
Child maltreatment
Child neglect
Sexual abuse
“Shaken baby syndrome”
“Battered child syndrome”
EPIDEMIOLOGY & DEMOGRAPHICS
INCIDENCE (IN U.S.):
• 1.2 cases/100,000 persons/yr (70% physical abuse, 25% sexual abuse, 5% neglect)
• Death rate: 1000 to 4000 children/yr
• 10% of emergency injuries for children <5 yr of age
• 2.3% of children with any life-threatening event
PREVALENCE (IN U.S.): More than 5% of children <18 yr of age
PREDOMINANT SEX:
Females may be at a slightly greater risk.
PREDOMINANT AGE:
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