Child AbuseChild AbuseChild AbuseChild Abuse

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

Professor of NursingProfessor of Nursing

History

• Greeks- sacrificed to god

• England– children worked as chimney sweeps.

• America– children worked as coal miners.

Mary Ellen Case 1874

• First documented abuse case• Beaten and abandoned by

mother– left hours in closet

Etta Whealer social worker brought case to ASPCA

• Led to Society for Prevention of Cruelty to Children (SPCC)

Dr. Kempe1962 “The Battered Child Syndrome”

• Identified specific symptoms of abuse– Many bruises & old fractures on x-rays

• Urged MD’s to report suspected child abuse

• Lead to professional and public awareness of child abuse and neglect in the US.

Dr. Fontana

1963 “The Maltreatment Syndrome” • Identified children deprived of

food, clothing, shelter and parental love.

• Children not attaining appropriate growth & developmental milestones.

• No underlying pathological factor.

The Child Abuse Prevention and

Treatment Act 1974Provided federal funding to help fight child abuse

2008 Statistics• 3.5 million alleged abused or neglected • 905,000 actual victims

– 64.1 % Neglect– 16 % Physical– 8.8 % Sexual– 6.6 % Emotional– 2.2 % Medically Neglect

• 1,710 died = 4 children/day!!

• One child every 10 seconds being abused!! • • www.ocfs.state.ny.us/main/cps

Who are the abusers?

• 48 % male 52 % female

• 84 % being abused by parent

• 41 % MOTHER• 19 % FATHER• 17 % Both PARENTS

Abused ChildChild <18 years of age.Whose responsible adult-• Inflicts non accidental physical

injury• Creates risk of physical injury• Creates risk of emotional health• Commits or allows a sexual offense

against child• Has potential for abuse

Substance Abuse

Maltreated or Neglected Child

Child <18 years old Whose responsible adult:• Fails to provide the minimum

degree of basic needs.• Example:

Inadequate food, shelter or Abandoned child.

Emotionally Neglected Child

Child <18 years old • Failure to meet the child’s needs for

affection, attention and nurturing.• Failure to Thrive (FTT)

< 10th % in height and weight with no organic cause.

• Verbal abuse- “You’re stupid”• Kids can be aggressive and • impulsive, or have feeding

disorders

Abusive Adult

• May have been abused or neglected as a child.

• A MAJOR RISK FACTOR

• Learn aggression is appropriate.

• Difficulty controlling impulses and forming attachments

Substances Abuser

• Primary concern is habit • Little or no concern for

children.• Drug use decreases inhibitions

and impulse control• Increase in illegal activity

– Stealing or Prostitution – Involve children in prostitution

and pornography.

Social Isolation

• Lack of emotional support.

• Low self esteem.

• Moves residence frequently.

• Distrust others

Life Crisis• Multiple stressors/inadequate

coping mechanisms.• Single parents

– ↑↑ Responsibility for sole parent.

• Teenage pregnancy • “Babies having babies”

– Parents immature and fewer resources.

Homelessness

Knowledge Deficit

• View child as miniature adults.• Absence of Child Nurturing Experience• Parent had no loving relationship

– Expects baby to provide love.

• Violence and corporal punishment is accepted as discipline.

• Parents view child as bad or evil.

Unrealistic Expectations

• Limited knowledge – Unrealistic expectations of

appropriate developmental milestones

• Preemies and disabled children are @ high risk for abuse – Secondary to high tech constant

care.

Signs of Physical Abuse

Bruises- • Various stages of healing.• Bilateral and generalized. • Unilateral are usually with accidents.• Clustered patterns reflect objects

used:– Belt, hand, spoon, wire

• Face, mouth, lips, torso, back, palms, buttocks, thighs, soles of feet

Lacerations

• Mouth, lips, gums- oral sex

• Laceration of frenulum could be from forcing bottle in mouth or penis.

• External genitalia, penis, vagina, anus

Burns• Cigarettes

– circular and evenly shaped.

• Hot water submersion – “Sock like or Glove like” burn

•No splash marks.

• Stun gun– circular and uniform 0.5cm.

Fractures• Multiple fractures in various

stages of healing. • Spiral fracture = Red Flag!

• Old rib fractures/skull fractures.

• Dislocation of shoulder/elbow.

Head Injuries

• Hair pulling-bald patches.

Shaken Baby Syndrome• Whiplash from shaking• Subdural hematoma• Meningeal tear• Retinal hemorrhage• Seizures • Death

Poisoning

• Intentional giving harmful substances: Crack, cocaine, MDMA or alcohol.• Unintentional – Free Access (Neglect)

Munchausen Syndrome by Proxy• Parent fabricates illness of child• Gains attention & viewed as concerned• Signs of illness only occur when parent

• in room.

Behavioral Signs

•Social Isolation.

•Apprehension.

•Emotional lability

Sexual Abuse

2008 • 80,000 episodes/year (under reported)• Incest Molestation Rape• Child Pornography Child Prostitution

• Higher incidence with females • High risk with father, family member or

male friend • Rare for a stranger

Physical Signs of Sexual Abuse

• Sore throats• Vaginal infections• Bruises on hard/soft palate• Incontinence• Pain itching genital area• Torn stained bloody underwear• Loss in rectal tone Non-intact hymen in females

Behavioral Signs of Sexual Abuse

• Reluctant to change in gym class• Self mutilation• Excessive masturbation in young child• Withdrawal• Promiscuous behavior.• Alcohol/drug use• Eating disorders• Suicide Attempts Regressive behaviors Severe mood swings

Nursing Interventions

Provide privacy• Separate from parents• Maintain safe environment

• Monitor Verbal & Non-Verbal Cues!• Identify child’s words for genitals• Provide opportunity to talk• Abuse is not their fault• Reinforce that telling someone was right thing to do

Report ProcedureReport Phone # • 1-800-635-1522 (State Central Register) • 1-800-342-3720 (CPS hotline)

Immediately notify charge nurse/supervisor or can report independently.

• First oral report • Submit written report DSS-2221A in 48 H. • (Nursing supervisor or MD does this with

local CPS.) Report is admissible in court

DSS-2221A Report

• RN is mandated reporter.

• Class A Misdemeanor Failure to report suspected child

abuse/maltreatment

• Make report clear, objective and accurate.

History of Injury

• Date, time and place• Sequence of events• Describe parent and child

interactions – Are they appropriate?– Who does child reach out to?

• Presence of witnesses.• Interview with child and parent

individually.– Congruent reports?

Physical Examination

• SANE (Sexual Assault Nurse Examiner)

• Anatomical location of injury

• Size, shape and color of distinguishing marks.

• Pain or bone tenderness and ROM.

• State of health and hygiene Appears malnourished/unkempt

Documentation• Pictures

– Date, time, pt name, med record #. – X-rays

• Clothes– Note if torn, body fluids or bloody– Do not remove from the child if

possible

• Lab reports• Chain of custody must be• maintained.

Actions taken• What was done?

– If child admitted to hospital and CPS notified and will be involved.

• Where was child placed? – Relative’s home or foster care.

• Who was notified? – Name of case worker and case

number to be placed on chart.

• CPS must complete investigation

• in 60 days.

Protective Custody

• Temporary removal for imminent danger.

• No ample time to approach courts.• Only by authorized persons;

– Police, SPCC Agent, Social Worker or Hospital administrator.

• Transport to official agency housing.• Notify parent with written notice of

where child was placed.