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CHILD CHILD MALTREATMENTMALTREATMENTIDENTIFICATION IDENTIFICATION

PART 1PART 1

Version 1.25 (Updated October 2013)

TRAINER: TRAINER:

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WelcomeWelcome

Learning Objectives and CompetenciesLearning Objectives and Competencies

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Neglect 63%

Phys Ab 17%

Other 14%

Psych Ab 7%

Sex Ab 9%

Med Negl 2%

Types of Maltreatment Identified by CPS in 2005

899,000 children

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National numbers…….National numbers…….

In 2005, 899,000 children were victims of In 2005, 899,000 children were victims of abuse or neglectabuse or neglect

For 2005, a nationally estimated 1460 For 2005, a nationally estimated 1460 children died of abuse or neglect – a rate children died of abuse or neglect – a rate of 1.96 children per 100,000 in the of 1.96 children per 100,000 in the national population national population

(US DHHS, Adm. Of Children, Youth & Families, 2005)(US DHHS, Adm. Of Children, Youth & Families, 2005)

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What is Child Abuse?What is Child Abuse? Legal definitions: Legal definitions:

W&I Code (a-j) – used for W&I Code (a-j) – used for determining juvenile court jurisdictiondetermining juvenile court jurisdiction

Penal Code (11164 & 11165) – used Penal Code (11164 & 11165) – used for determining if abuse or neglect for determining if abuse or neglect occurred occurred

Health and Safety CodeHealth and Safety Code

66

ExerciseExercise

W & I CodeW & I Code

Code of EthicsCode of Ethics

77

Context for Context for Child Child MaltreatmentMaltreatment Cultural contextCultural context Child rearing standardsChild rearing standards Environmental factorsEnvironmental factors

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COLLABORATIONCOLLABORATION

WHO IS ON YOUR WHO IS ON YOUR TEAM?TEAM?

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CHILD NEGLECTCHILD NEGLECT

1010

Why Child Neglect is ImportantWhy Child Neglect is Important

It’s common in child welfareIt’s common in child welfare

MorbidityMorbidity

MortalityMortality

Our opportunity to interveneOur opportunity to intervene

Our responsibility to interveneOur responsibility to intervene

The lawThe law

1111

Child neglect affectsChild neglect affects

Emotional healthEmotional health

Social developmentSocial development

Cognitive developmentCognitive development

Physical healthPhysical health

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62.8% of victims experience neglect. 62.8% of victims experience neglect. If we add medical neglect, this number If we add medical neglect, this number

goes up to 64.8%! goes up to 64.8%! (U.S. DHHS, Adm. Of Children, Youth & Families, 2005)(U.S. DHHS, Adm. Of Children, Youth & Families, 2005)

Child neglect continues to be the largest Child neglect continues to be the largest single category of child maltreatment single category of child maltreatment representing over 58% of the 2.97 million representing over 58% of the 2.97 million reports of child maltreatment nationwide.reports of child maltreatment nationwide.

(Chalk, Gibbons, & Scarupa, 2002)(Chalk, Gibbons, & Scarupa, 2002)

Neglect is # 1

1313

Fatalities due to Child Fatalities due to Child MaltreatmentMaltreatment

~1,460 a year

1414

Maltreatment deaths were more Maltreatment deaths were more

associated with neglect (42.2%) than with associated with neglect (42.2%) than with any other type of abuse. any other type of abuse.

Fatalities resulting from multiple Fatalities resulting from multiple maltreatment types account for another maltreatment types account for another 27.3%27.3%

Children under age 4 account for 76.6% of Children under age 4 account for 76.6% of all child abuse deathsall child abuse deaths

Children under 1 account for 42% of all Children under 1 account for 42% of all child abuse fatalitieschild abuse fatalities

(U.S. DHHS, Adm. Of Children, Youth & Families. 2005)(U.S. DHHS, Adm. Of Children, Youth & Families. 2005)

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How we define child How we define child neglect neglect

Shapes our response to the Shapes our response to the problemproblem

1616

What is it?What is it?Act of omission or commission which Act of omission or commission which results in minimal sufficient standards results in minimal sufficient standards of care of minor(s) not being met.of care of minor(s) not being met.

Basic needs include: adequate food, Basic needs include: adequate food, clothing, health care, supervision, clothing, health care, supervision, protection, education, nurturance, love, protection, education, nurturance, love, & a home.& a home.

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How do we know what children How do we know what children need?need?

Scientific evidenceScientific evidence epidemiological data (e.g., infant car seats)epidemiological data (e.g., infant car seats)

Community standards, valuesCommunity standards, values Not without questionNot without question

ExperienceExperience (e.g., history of severe asthma)(e.g., history of severe asthma)

Common senseCommon sense (e.g., hunger)(e.g., hunger)

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New Knowledge New Knowledge New Forms of NeglectNew Forms of Neglect

exposure to 2nd hand smokeexposure to 2nd hand smoke inadequate treatment of HIV/AIDSinadequate treatment of HIV/AIDS not using car seats/beltsnot using car seats/belts access to a gunaccess to a gun exposure to domestic violenceexposure to domestic violence unsupervised Internet access ?unsupervised Internet access ?

1919

Why do we want to define Why do we want to define child neglect?child neglect?

To protect children To protect children & improve their well-being& improve their well-being

NOTNOT

to blame parentsto blame parents

2020

AdvantagesAdvantages of a Child-focused, of a Child-focused, Broad DefinitionBroad Definition

Moves us beyond the narrow focus on Moves us beyond the narrow focus on parents to consider other contributorsparents to consider other contributors

Leads us to consider a broader array of Leads us to consider a broader array of services, responsesservices, responses

A more constructive, less blaming A more constructive, less blaming approachapproach

Fits with our broad interest in the health, Fits with our broad interest in the health, safety & well-being of childrensafety & well-being of children

2121

General NeglectGeneral Neglect

Penal Code

300 (b) Welfare & Institutions Code

2222

SEVERE NEGLECTSEVERE NEGLECT Withholding food/water on a prolonged, Withholding food/water on a prolonged,

willful basiswillful basis Severe malnutritionSevere malnutrition Non-organic failure to thriveNon-organic failure to thrive Failure to provide medical treatment Failure to provide medical treatment

which will result in permanent and/or which will result in permanent and/or severe illness or death.severe illness or death.

Defined in PC 11165.2. (a)Defined in PC 11165.2. (a)

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Contributors to Neglect

Neglect

Child

Parent

Family

Community

Society

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Poverty & Poverty & ChildChildNeglectNeglect

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Poverty & neglectPoverty & neglect

3rd National Incidence Study3rd National Incidence Study

Rate of neglect Rate of neglect 44 x44 x higher in higher in ffamilies earning < $15,000/ yearamilies earning < $15,000/ year

(Sedlack & Broadhurst, 1996)

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Elements of NeglectElements of Neglect

Poverty as an issuePoverty as an issue BIASBIAS Poverty itself does not constitute neglectPoverty itself does not constitute neglect Other factors: chaos, lack of interpersonal Other factors: chaos, lack of interpersonal

or job skills, disorganization, apathy, drug or job skills, disorganization, apathy, drug addictionaddiction

Others?Others?

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BEHAVIORAL BEHAVIORAL INDICATORS OF INDICATORS OF

NEGLECTNEGLECT

2828

Large percentage of neglected children Large percentage of neglected children are developmentally delayedare developmentally delayed

May present as unresponsive, placid, May present as unresponsive, placid, dull, uninterested in their surroundingsdull, uninterested in their surroundings

May appear hungry or tiredMay appear hungry or tired May be out of controlMay be out of control May have school/learning issuesMay have school/learning issues

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What does neglect look What does neglect look like?like?

AbsenceAbsence Lack of supervisionLack of supervision ““dirty” homedirty” home Dental or medicalDental or medical PsychologicalPsychological Chronic lice/scabiesChronic lice/scabies FTTFTT Drug exposure (in utero and beyond)Drug exposure (in utero and beyond)

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3131

What can neglect look What can neglect look like?like?

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Challenges & dilemmas Challenges & dilemmas of neglectof neglect

Different Different standards, values standards, values and norms re: and norms re: child rearing in child rearing in different cultural different cultural groupsgroups

Marginal child Marginal child rearing issuesrearing issues

Ross & Meezan Ross & Meezan studystudy

3333

Intervention and Treatment Intervention and Treatment Can Work!Can Work!

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Severe Neglect & ResilienceSevere Neglect & Resilience

At age 4At age 4, , excellentexcellent catch up in growth & catch up in growth & dev. for children who arrived < 6 dev. for children who arrived < 6 monthsmonths

For those who arrived > 6 months, For those who arrived > 6 months, goodgood catch up in development catch up in development

McCarthy General Cognitive Index = 92 McCarthy General Cognitive Index = 92 (vs. 109 for UK adoptees)(vs. 109 for UK adoptees)

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EMOTIONALEMOTIONALABUSEABUSE

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DEFINITIONS OF DEFINITIONS OF EMOTIONAL ABUSEEMOTIONAL ABUSE

PENAL CODEPENAL CODE

W & I CODEW & I CODE

3737

Challenges with Challenges with Emotional Emotional

Abuse InvestigationsAbuse Investigations

Difficult to define and evaluateDifficult to define and evaluate Difficult in the Court processDifficult in the Court process Often combined with other factors of Often combined with other factors of

abuseabuse Often requires great effort to get Often requires great effort to get

documentationdocumentation

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What does it look like?What does it look like?

RejectionRejection IsolationIsolation TerrorizingTerrorizing Ignoring/deprivingIgnoring/depriving CorruptingCorrupting HumiliatingHumiliating ConfusingConfusing scapegoatingscapegoating

•Setting unrealistic expectations

•Verbally assaulting

•Putting child in “double binds

•Parental unpredictability

•Exposure to DV

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Impact of Emotional Impact of Emotional Abuse on DevelopmentAbuse on Development

Research findings!Research findings!

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PHYSICAL PHYSICAL ABUSEABUSE

4141

Physical Abuse:Physical Abuse:

Non-accidental, inflicted injury/traumaNon-accidental, inflicted injury/trauma WIC 300 (a) – physical abuseWIC 300 (a) – physical abuse WIC 300 (e) – severe physical abuse of a WIC 300 (e) – severe physical abuse of a

child under 5 years oldchild under 5 years old Injuries causing death, permanent disfigurement, Injuries causing death, permanent disfigurement,

significant bleeding, deep bruising, significant significant bleeding, deep bruising, significant internal or external swelling, fractures, internal or external swelling, fractures, unconsciousness, prolonged withholding of food.unconsciousness, prolonged withholding of food.

SUBSTANTIAL RISK of physical harmSUBSTANTIAL RISK of physical harm

4242

Physical Abuse in a Physical Abuse in a Cultural ContextCultural Context

Do our personal Do our personal values, experiences values, experiences and biases influence and biases influence our decisions?our decisions?

4343

Elements to consider in Elements to consider in evaluating abuse:evaluating abuse:

Location of injury on child’s bodyLocation of injury on child’s body Location/scene of the incidentLocation/scene of the incident Type(s) of injuryType(s) of injury Severity/extent of current injury/injuriesSeverity/extent of current injury/injuries Frequency of injuries over timeFrequency of injuries over time Explanation of injury/injuriesExplanation of injury/injuries Child’s overall appearanceChild’s overall appearance

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Elements, cont’dElements, cont’d

Chronological age of childChronological age of child Developmental abilities of childDevelopmental abilities of child History of unreported maltreatment of these History of unreported maltreatment of these

children by anyone children by anyone oror by these adults of any by these adults of any other childrenother children

History of CWS involvementHistory of CWS involvement Parent/caregiver’s own history of Parent/caregiver’s own history of

abuse/neglectabuse/neglect Parent/caregiver substance abuseParent/caregiver substance abuse

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Characteristics of ChildCharacteristics of ChildTypical TriggersTypical Triggers

Colic; incessant cryingColic; incessant crying Awakening at nightAwakening at night Separation anxietySeparation anxiety Normal exploratory behaviorNormal exploratory behavior Normal negativismNormal negativism Poor appetitePoor appetite Toilet training resistance or accidentsToilet training resistance or accidents

4646

Information Gathering – Information Gathering – Parent/CaretakerParent/Caretaker

People do liePeople do lie People do take children to ER after abuse People do take children to ER after abuse

butbut there may be a delay in seeking care there may be a delay in seeking care People can love their kids & abuse themPeople can love their kids & abuse them May take truth, change it a littleMay take truth, change it a little Changing/contradictory stories very Changing/contradictory stories very

suspicioussuspicious Absence of explanation suspiciousAbsence of explanation suspicious

4747

Information Gathering, Information Gathering, cont’dcont’d

Blaming sibs suspiciousBlaming sibs suspicious Incident described not consistent Incident described not consistent

with the developmental abilities of with the developmental abilities of the childthe child

No witnesses to incidentNo witnesses to incident ““Trigger Event” describedTrigger Event” described ““Unknown” perpetrator high riskUnknown” perpetrator high risk

4848

Information Gathering- Information Gathering- Medical PersonnelMedical Personnel

What is the nature of the injury?What is the nature of the injury? Is injury consistent with explanation?Is injury consistent with explanation? What mechanism would cause this injury?What mechanism would cause this injury? Spell it – what does it mean?Spell it – what does it mean? Put it in writing.Put it in writing. How old is the injury?How old is the injury? Would child be in pain?Would child be in pain? Cry out when injured/reaction?Cry out when injured/reaction?

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TYPES OF TYPES OF INJURIESINJURIES

5050

Bruises/ Pattern BruisingBruises/ Pattern Bruising Broken Bones/FracturesBroken Bones/Fractures BitesBites BurnsBurns

ContactContact LiquidLiquid ImmersionImmersion FlameFlame

Internal InjuriesInternal Injuries Head InjuryHead Injury

5151

BruisesBruises

5252

5353

5454

5555

5656

5757

5858

5959

6060

6161

6262

6363

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Empathy ExerciseEmpathy Exercise

How would you feel…How would you feel…ChildChildParentParentSocial WorkerSocial WorkerMedical ProfessionalMedical Professional

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FracturesFractures

6666

The most common nonaccidental The most common nonaccidental fractures in children of all ages involve fractures in children of all ages involve the skull, the long bones, and the ribs.the skull, the long bones, and the ribs.

In infants, the most common fractures In infants, the most common fractures are in the skull, ribs, and metaphyses.are in the skull, ribs, and metaphyses.

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Twenty per cent of fractures in abused Twenty per cent of fractures in abused

children involve the femur.children involve the femur.

20% of femoral fractures seen in children 20% of femoral fractures seen in children ages 2 to 3 are due to abuseages 2 to 3 are due to abuse

60 % of femoral fractures seen in 60 % of femoral fractures seen in children under 1 are due to abuse.children under 1 are due to abuse.

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There may be a delay in seeking medical There may be a delay in seeking medical treatment in cases of abuse. treatment in cases of abuse.

In many abuse cases, minor falls are In many abuse cases, minor falls are blamed for fractures and other serious blamed for fractures and other serious injury.injury.

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Many studies have documented that Many studies have documented that minor falls do not usually produce serious minor falls do not usually produce serious injury.injury.

In one study of 246 children, only 3% In one study of 246 children, only 3% suffered fractures, and none involved the suffered fractures, and none involved the femur.femur.

Pediatric Trauma Center DataPediatric Trauma Center Data 01/00-03/0601/00-03/06 All Falls by Major All Falls by Major

E-codesE-codes

7272

N=2417 N=2417 By major mechanism By major mechanism

subgroupssubgroups

01/00-03/0601/00-03/06 All FallsAll Falls

N=2417 N=2417 By Mortality Rate By Mortality Rate

(.008% to .016%*)(.008% to .016%*)

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Pediatric Trauma Center Pediatric Trauma Center DataData

*Of the four deaths, two were clearly a result of a fall from height—one from a 3rd story and one from a 2nd story. The other two deaths were complex cases and the etiology was not clear.

7474

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Self careSelf care

Be prepared, burns are difficult to Be prepared, burns are difficult to look at.look at.

Likewise, this is parallel to your need Likewise, this is parallel to your need to take care of yourself as a child to take care of yourself as a child welfare workerwelfare worker

High burnout if you don’t!High burnout if you don’t!

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Burn TypesBurn Types

Thermal :Thermal : ScaldsScalds

Flowing/splashing/splattering liquidFlowing/splashing/splattering liquidImmersionImmersion

ContactContactSmoldering sourceSmoldering sourceHot solidHot solid

FlameFlameRadiant Radiant

7878

Burns represent 10% of all physical Burns represent 10% of all physical abuse cases.abuse cases.

The peak age of burn victims is 13 to 24 The peak age of burn victims is 13 to 24 months.months.

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Severity FactorsSeverity Factors Exposure timeExposure time Temperature of heat sourceTemperature of heat source Thickness of skinThickness of skin Type of ExposureType of Exposure

Heat content/specific heat of sourceHeat content/specific heat of source Heat conductivity within sourceHeat conductivity within source Heat emission from surface of sourceHeat emission from surface of source Coupling media between heat source & Coupling media between heat source &

skinskin

8080

Burn Profile ChecklistBurn Profile Checklist

Attributed to siblingAttributed to sibling Unrelated adult Unrelated adult

seeking medical seeking medical attentionattention

Differing historiesDiffering histories Treatment delay >24 Treatment delay >24

hrhr History of injuriesHistory of injuries Inappropriate affect-Inappropriate affect-

parent or childparent or child

History incompatible History incompatible with injury or with injury or developmental developmental abilitiesabilities

Mirror image burnsMirror image burns Localized to Localized to

perineum, genitalia, perineum, genitalia, buttocksbuttocks

Older than historyOlder than history Other injuriesOther injuries

8181

8282

8383

Multiple Multiple similar similar burnsburns

Burn TypesBurn Types

ThermalThermal ContactContact

8484

8585

8686

8787

8888

asphaltasphalt

8989

Tap water scald burns account for 87% of Tap water scald burns account for 87% of inflicted burns.inflicted burns.

They are often associated with toilet They are often associated with toilet training accidents.training accidents.

9090

Reference Temperatures, degrees FReference Temperatures, degrees F((pain precedes burning!)

101101 Comfortable Infant BathingComfortable Infant Bathing 104-106104-106 Hot tubHot tub 109-113109-113 Painful for adultsPainful for adults 113113 22ndnd degree burn; 6 hours degree burn; 6 hours 120120 22ndnd degree burn; 10 minutes degree burn; 10 minutes 127127 22ndnd degree burn; 1 minute degree burn; 1 minute 130130 22ndnd deg; 10 sec (child), 30 sec (adult) deg; 10 sec (child), 30 sec (adult) 140140 22ndnd deg; 1 sec (child), 3 sec (adult) deg; 1 sec (child), 3 sec (adult) 156156 33rdrd degree burn; 1 second child degree burn; 1 second child

9191

Calvin and HobbesCalvin and Hobbes

9292

Stocking & glove injury:Stocking & glove injury:Foot immersionFoot immersion

9393

DonutDonutdiagram diagram

9494

Pull down scalds

Flowing water runs downhill

9595

170170o o F faucet waterF faucet waterToddler left in tub.Toddler left in tub.

Parents find Parents find standing, holding standing, holding open hot water open hot water handle.handle.

Injury fits history,Injury fits history,but neglect?but neglect?

9696

Clues to Abuse: Clues to Abuse: Explanation of injury Explanation of injury

HistoryHistory Not consistent with age / ability of Not consistent with age / ability of

childchild Only 1 in 11 10-month-olds tested Only 1 in 11 10-month-olds tested

could climb into a bathtubcould climb into a bathtub

(Allasio & Fischer)

9797

Explanation of Explanation of injury: injury: Does it Fit?Does it Fit?

Heights/depths/volumeHeights/depths/volume Types handles/ease of Types handles/ease of

turningturning Does water accumulate Does water accumulate

with open drain?with open drain? How fast/hot as tub How fast/hot as tub

fills?fills? Bathroom layoutBathroom layout Other basinsOther basins

9898

Other hot fluids: Oil splatterOther hot fluids: Oil splatter(Heat content greater than water;(Heat content greater than water;fluid more viscous)fluid more viscous)

9999

100100

Cultural Folk TreatmentsCultural Folk Treatments

Moxibustion – Asian medicine practice of Moxibustion – Asian medicine practice of burning herbs to the abdomenburning herbs to the abdomen

Cao Gio – SE Asian practice of rubbing hot Cao Gio – SE Asian practice of rubbing hot coins over the back of chest to cure fever, pain, coins over the back of chest to cure fever, pain, congestioncongestion

Cupping – Mexican/S. American practice of Cupping – Mexican/S. American practice of placing warm cup over the chest to draw out placing warm cup over the chest to draw out illnessillness

101101

102102

103103

104104

Injuries to the Face, Injuries to the Face, Ears, Mouth and NeckEars, Mouth and Neck

105105

106106

107107

108108

109109

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Day 2: WELCOME BACKDay 2: WELCOME BACK

REVIEW OF PREVIOUS REVIEW OF PREVIOUS DAYDAY

AGENDA FOR TODAYAGENDA FOR TODAY

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Abusive Head Trauma Abusive Head Trauma

112112

Head injuries are the primary cause of Head injuries are the primary cause of death in infants in child abuse cases.death in infants in child abuse cases.

Head injury is the leading cause of death Head injury is the leading cause of death in child abuse cases.in child abuse cases.

113113

Abusive Head TraumaAbusive Head Trauma

Head trauma means injury to the face, Head trauma means injury to the face, scalp, skull, meninges and/or brain as a scalp, skull, meninges and/or brain as a result of mechanical forceresult of mechanical force

May be a result of direct impact, May be a result of direct impact, asphyxiation, or shakingasphyxiation, or shaking

114114

ConcussionConcussion is the most common brain injury is the most common brain injury and usually has a brief period of loss of and usually has a brief period of loss of consciousness with memory loss for the event.consciousness with memory loss for the event.

Diffuse axonal injury Diffuse axonal injury is the term for a more is the term for a more severe brain injury. Unconsciousness is severe brain injury. Unconsciousness is immediate and lasts more than 6 hours.immediate and lasts more than 6 hours.

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116116

117117

The skull of the small child is thinner than The skull of the small child is thinner than

that of an adult. The larger head size and that of an adult. The larger head size and lesser muscle strength results in more lesser muscle strength results in more acceleration-deceleration injury.acceleration-deceleration injury.

Skull fractures Skull fractures do not predict the amount of do not predict the amount of brain injury – large fractures can be brain injury – large fractures can be associated with minor brain injury and severe associated with minor brain injury and severe brain injury can occur without a fracture.brain injury can occur without a fracture.

118118

Skull fractures may be simple or Skull fractures may be simple or complex. complex.

Approximately 1/3 of skull fractures in Approximately 1/3 of skull fractures in children under 3 are nonaccidental.children under 3 are nonaccidental.

119119

Chest InjuriesChest Injuries

120120

121121

Abusive Abdominal Abusive Abdominal TraumaTrauma Abdominal injuries are the second leading Abdominal injuries are the second leading

cause of mortality in child abuse cases.cause of mortality in child abuse cases. Average age is older, approximately 2 years.Average age is older, approximately 2 years. Boys outnumbered girls 2:1 as victims of this Boys outnumbered girls 2:1 as victims of this

form of abuse.form of abuse. Approximately 50% mortality rate, mostly due Approximately 50% mortality rate, mostly due

to delay in seeking care or misleading to delay in seeking care or misleading histories at presentation delaying appropriate histories at presentation delaying appropriate diagnosis.diagnosis. (Kaplan, 2006)(Kaplan, 2006)

122122

Internal Organs include:Internal Organs include:

LiverLiver StomachStomach PancreasPancreas SpleenSpleen KidneyKidney Spinal columnSpinal column DuodenumDuodenum

123123

EpidemiologyEpidemiology

3 most common mechanisms (n=927):3 most common mechanisms (n=927): Motor vehicle accidentsMotor vehicle accidents 61%61% AbuseAbuse 16%16% FallsFalls 13.5%13.5%

Mortality 6X greater in abuse than fallsMortality 6X greater in abuse than falls

(Trokel et al, 2004)(Trokel et al, 2004)

124124

General Features of General Features of Abusive Abdominal InjuryAbusive Abdominal Injury

Result from punch, kick, or decelerationResult from punch, kick, or deceleration Toddlers and young children at particular Toddlers and young children at particular

riskrisk Victims often unable to verbalize Victims often unable to verbalize

complaintscomplaints Children don’t expect and don’t protectChildren don’t expect and don’t protect Often no external signsOften no external signs

125125

Parents don’t provide an accurate historyParents don’t provide an accurate history May not have immediate symptomsMay not have immediate symptoms Where there is an abusive head trauma, Where there is an abusive head trauma,

abdominal injury may be overlookedabdominal injury may be overlooked MORE FATAL THAN ACCIDENTAL MORE FATAL THAN ACCIDENTAL

INJURY!INJURY! 53% to 24% in Ledbetter et al (1988) study53% to 24% in Ledbetter et al (1988) study

N=156 patients <13 years old with blunt N=156 patients <13 years old with blunt abdominal injuryabdominal injury

(Kaplan, 2006)(Kaplan, 2006)

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EMBEDDED EMBEDDED EVALUATIONEVALUATION

Time to see what you have learned so far!

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Life and DeathLife and Death

““We rarely hear about county social workers until they We rarely hear about county social workers until they make a mistake…make a mistake…

Unfortunately we can’t pass laws demanding they make Unfortunately we can’t pass laws demanding they make no mistakes. All we can do is demand the highest no mistakes. All we can do is demand the highest training, and impress upon child protection officials that training, and impress upon child protection officials that the decisions they make are among the most critically the decisions they make are among the most critically important in our society.” important in our society.”

(Union Tribune July 26, 1998)

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CLOSURECLOSURE

THANK YOU AND GOOD LUCK TO YOU THANK YOU AND GOOD LUCK TO YOU IN YOUR CHILD WELFARE WORK WITH IN YOUR CHILD WELFARE WORK WITH

CHILDREN AND THEIR FAMILIESCHILDREN AND THEIR FAMILIES