Maltreated Child
Objectives
Describe major categories of child abuse
Relay risk factors placing children at risk
for abuse
Describe long-term effects of abuse
Describe and interpret assessment findings
that increase suspicion for abuse
Identify appropriate nursing interventions
for the child subject to abuse.
Quiz
1. What are two factors putting a child at
risk for abuse?
2. Which one of these is least suspicious for
Munchausen by proxy?
A. 3yo boy with complaints of repeated
vomiting episodes and poor weight gain that
resolves when hospitalized, mother has
personal Hx of pseudo-seizures.
B. 2yo child with ALTE (Apparent Life
Threatening Event) witnessed in day care and
church nursery, family has previous CPS report
of neglect.
C. 13 month old infant with frequent episodes
Quiz
3. What is a common physical assessment finding
in an infant with shaken baby syndrome?
A. Extensive bruising.
B. B. Fever.
C. C. Retinal bleeds seen with ophthalmoscope.
D. D. Elevated WBCs.
Quiz
5. Which X-ray finding would trigger
further assessment for child abuse?
A. Distal right radius & metacarpal fracture
after a fall playing basketball.
B. Left clavicle fracture in an LGA (4.2kg)
newborn after vaginal delivery with shoulder
dystocia.
D. Spiral fracture of the femur in a 10 month
old child.
What is Physical
Abuse?
The deliberate maltreatment of another individual
that inflicts pain or injury or may result in permanent
or temporary disfigurement or even death.
Most common types of child abuse:
Hitting, slapping, kicking, or punching
Whipping with belts, shoes, cords, etc.
Inflicting burns
Immersing child or body part in scalding water
Shaking
Tying the child to the bed or other object
Throwing the child against a wall, down the stairs etc.
Choking or gaging the child
Deliberately administering excessive doses of drugs
Risk
Factors
Age under 3 years
Parent was abused as a
child
Spousal abuse
Isolated from family or
friends
Chronic illness
Stress in families
Stepparents or paramour
in household
Drug or alcohol abuse
Social /economic group
Risk
Factors
History of mental illness,
domestic violence,
incarceration, or substance
abuse
Inadequate childcare or
supervision
Inadequate familial support
Access to firearms
High exposure to media
violence
If child has ADHD or other
developmental behavioral
issues
Use of corporal punishment
or other inappropriate
discipline methods
7 Deadly Sins of
Childhood:
1. Colic / incessant crying
2. Awakening at night
3. Separation anxiety
4. Normal exploratory behavior
5. Normal negativism
6. Poor appetite
7. Toilet training resistance or
accidents
Red
Flags
Injury is not
congruent with
description of
incident or
developmental
level of child
Stories not
consistent
Delay in seeking
care for a
significant injury
Clinical Manifestations
Multiple bruises in various stages of healing
Scald burns with clear lines of demarcation and in a glove or
stocking distribution
Rope, belt, or cord marks, usually seen on the mouth, butt,
back, legs, and arms
Burn scars in various stages of healing
Multiple fractures in various stages of healing
Spiral fractures not explained by accident
Shortness of breath and distress upon being moved
Cranial injuries
Abdominal injury
Other Suspicious
Findings
Human Bite
Marks
ng
Missi
Hair
Marks a
nd / or
Scratch
es
Other Suspicious
Findings: Burns
Is this abuse?
Shaken
Baby
Syndrome
Caused by shaking an
infant or child
10-12% of deaths from
abuse
1/3 survive with no
problems
1/3 suffer permanent
damage
1/3 die
Often crying is the
precipitating factor
http://www.youtube.com/watch?
v=THhFoYk7U40
Infant Anatomy
Underdeveloped bone
+
Underdeveloped
tissue
+
Underdeveloped neck
=
Increased risk for:
Brain Damage
Cerebral
Hemorrhages
Cerebral
Blood Clots
Retardation
Neck / Spinal Injury
Paralysis
Blindness & Deafness
Death
Shaken Baby
Syndrome
Clinical Manifestations
of SBS
Often no external signs
Subdural hemorrhage
Retinal hemorrhages
Apnea, seizures
Vomiting
Irritability
Poor suck / swallow / breathe (poor feeding)
Retinal Hemorrhages
D. Elevated WBCs.
Sexual Abuse
The exploitation of a
an adult.
A child is anyone who has not reached the age of consent,
EVEN IF A TEENAGER.
1 in 3 girls and 1 in 6 boys will be sexually abused by their
18th birthday.
The average age of children when they are sexually abused
is 4 years.
Most common abuser is the childs parent or guardian, a
Risk Factors in
Adults
Addiction, poor impulse control, low self
esteem, other personality disorders
Poor parenting experiences
Marital stressors
Environmental stressors
Social isolation
Inappropriate expectations for the
developmental level of the child
Sexual Abuse:
Clinical
Manifestations
Vaginal discharge
Fear of strangers
Blood-stained underpants
or diaper
Constant masturbation
Curling into fetal position
Bed-wetting
Unwillingness to be
around someone
Excessively seductive
behavior
UTI / STI
Sexual Abuse:
Clinical
Manifestations
Abrupt change in
school performance
Change in eating
habits
Abrupt changes in
behavior
(withdrawal)
Somatic complaints
(headache /
stomachaches)
http://www.youtube.com/watch?
v=AULaJdMPmIw
Emotional Abuse
Involves shaming, ridiculing,
embarrassing, or insulting the child.
May include destruction of property or
harming, killing, or giving away the childs
pet.
Intent of emotional abuse is to frighten or
control.
Witness to domestic violence
Clinical Manifestations
Change in behavior or school performance
Fear of avoidance of certain people, genders, or
situations
Anger and violent play
Sedation from overmedication
Exacerbation of chronic illness d/t
withholding of
medication
Inappropriate clothing for the season
Clinical
Manifestations
Poor physical growth
Failure to meet appropriate developmental
milestones and developmental delays
Child has difficulty relating to adults
Impaired communication skills
Behavioral signs: withdrawn, generalized
anxiety, fear, shame, aggression,
delinquency, depression; extreme efforts
to please
Munchausen by Proxy
Parent or caretaker fabricates the signs and
symptoms of disease
Causes the child unnecessary and potentially
Characteristics of
Mothers
Appear concerned and attentive / seldom leave
childs side
Offers to asset with care, including specimen
collection and meds
Trained in health related field
Intelligent and articulate
Absent father
Meets unmet needs for nurturing
Warning
Signs
Bizarre signs and
symptoms with no
apparent pathological
explanation
Symptoms recur or
absence of mother
Never seen a case like
this before
Polymicrobial bacteremia
Seeks care at multiple
settings
Neglect
Most common type of child abuse but can be hard to
determine
Emotional neglect is characterized by the caretakers
emotional unavailability to the child.
Cold interactions that lack sensitive personal attention
What if the parent is mentally ill, or abusing illegal substances?
Child Abuse
Long Term
Effects
Erickson
Maslow
Adverse Childhood
Experiences Study
Studied effects of Adverse Childhood Experiences
(ACE) on health outcomes in adults.
Included: physical, emotional, sexual abuse,
growing up with parental mental illness & drug
use, incarceration, parental divorce & domestic
violence.
Those with score of 4 or more, higher risk of
depression (4.5x), COPD (2.5x), suicide (12x).
Those with scores 7 and higher: 3.5x risk of CAD,
3x risk of lung CA.
Nursing
Responsibilities
Detection
Documentation
Location, color, size, shape of any injury
Childs anxiety level and response to others
Statements made by child/parent
NONJUDGEMENTAL &
SUPPORTIVE!
Father as
passive o
Age
bserver
inadequat
e familial
r
e
h
t
o
M
support
Alcoholic
s:
n
g
i
S
l
a
c
i
s
y
h
P
r
e
h
tabbed
t
S
o
M
Single
- Burn marks
Mothe
r abus
ed
in past
- Breathing
difficulty?
ped
- Under develo
Isolate
s
lm
a
p
n
o
s
r
d
Bliste
s
p
e
c
i
b
d
n
a
s
d
n
of ha