CHILD ABUSE At a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death,

, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm. Child Abuse Prevention and Treatment Act The physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the childs welfare under circumstances which indicate that the childs health or welfare is harmed or threatened. Child Welfare Act Statistics A report of child abuse is made every ten seconds. Almost five children die everyday as a result of child abuse. More than three out of four are under the age of 4. It is estimated that between 60-85% of child fatalities due to maltreatment are not recorded as such on death certificates. 90% of child sexual abuse victims know the perpetrator in some way; 68% are abused by family members. Child abuse occurs at every socioeconomic level, across ethnic and cultural lines, within all religions and at all levels of education. Theories of Child Abuse a. Special Parent: Parents Who Abuse Many of these parents were abused as children. They maybe unfamiliar with the normal growth and development of children and so have unrealistic expectations of a child. These parents may be socially isolated, with no support people readily available, and so can become overwhelmed by childrearing. Abuse is strongly associated with excessive use of alcohol, a substance that removes inhibitions and self-control. They come from violent families They were also abused by their parents They have inadequate parenting skills They are socially isolated because they dont trust anyone The are emotionally immature They have negative attitude towards the management of the abused b. Special Child: Children who are Abused They maybe more or less intelligent than other children in the family; they may have been unplanned, have birth defects, or have an attention span deficit. A category of children who are at high risk includes those who are born prematurely or who have an illness at birth. Special Circumstance: Stress It may be a response to an event that would not necessarily be stressful to an average parent. It might be something as common as a blocked toilet, an illness in the family, a lost job, a landlord asking for the rent, or a rainstorm that cancelled a planned activity. Stress generally has a greater impact when people do not have strong support people around them. Families whose internal support system is faulty or who have not formed outside systems are apt to have higher incidence of abuse. To prevent abuse, a child may assume a role reversal with the parent or become the comforting, solacing person. These children recognize very early in life that when a parent is upset, they will be hurt. They learn to comfort the parent and reduce the parents stress and anxiety, thereby avoiding the hurt. It is important to assess who is comforting whom during a child health crisis.

c.

Types of Abuse a. Physical Abuse The action of a caregiver that causes injury to a child. Often results from unreasonably severe corporal punishment or

unjustifiable punishment such as hitting an infant for crying or soiling his diapers. Intentional deliberate assaults on children include: Burning Biting Cutting Poking Twisting limbs Scalding with hot water The victim often has evidence of old injuries (e.g., scars, untreated fractures, multiple bruises of various ages) that the history given by parents does not explain adequately Warning Signs: Frequent injuries or unexplained bruises, welts, or cuts. Is always watchful and on alert, as if waiting for something bad to happen. Injuries appear to have a pattern such as marks from a hand or belt. Shies away from touch, flinches at sudden movements, or seems afraid to go home. Wears inappropriate clothing to cover up injuries, such as long-sleeved shirts on hot days. Clinical Manifestations: Bruises are the most common physical finding in child abuse May be seen on any body surface Bruising of the buttocks, genitals, back, and back of the hands are suspicious for abuse The shape of an injury may suggest the object used Paddles, belts, hands, and other instruments leave specific marks Bilateral, symmetric, or geometric injuries should raise suspicion of child abuse 10-20% of physically abused children incur bone trauma Fractures that are considered highly specific: Metaphyseal fractures, ribs, scapula, outer end of a clavicle, vertebra, or finger in children who are not yet walking Bilateral fractures Complex skull fractures Multiple fractures of varying ages 10% of physical abuse cases involve burns Shape of a burn may assist with the diagnosis when it reflects the pattern of an object or method of injury Cigarette burns produce circular burns of uniform size Immersion burn produces a uniform and distinct burn-demarcation level Most common cause of death from physical abuse is head trauma >95% of serious intracranial injuries during the first year of life result from abuse Infants may present with Coma Convulsions Increased intracranial pressure Apnea A blow from a hand can cause subdural hematomas, although no scalp marks or skull fracture may be present External marks may also be absent from metaphyseal and rib fractures because of shaking (acceleration-deceleration) or slamming the head against an object Retinal hemorrhages are seen in 85% of infants who are shaken. Intraabdominal injury from impact is the second most common cause of death in battered children Abdominal wall is flexible, so the overlying skin may be free of bruises Fist blow may result in a row of 3 to 4 1-cm oval bruises in a slight curve

May result in a ruptured liver or spleen or perforation or laceration of the small intestine Children may also present with recurrent vomiting, a distended abdomen, absent bowel sounds, localized tenderness, or shock

c.

Behavioral Signs: be defensive about injuries have low self esteem be frightened by disapproval be wary of physical contact with adults show fear of parents or other adults be nervous when other children cry wear clothing that covers their body even when the weather is warm Nursing Management: Prevent further Abuse Provide consistent care and support for the abused child Evaluate and promote family health Therapeutic Management: The parents will need counseling or an intervention of some type. In some cases, the child may be temporarily or permanently removed from the home to prevent further danger. Life-threatening abuse, or abuse resulting in permanent damage to the infant or child may result in legal action. Counseling, including play therapy, is also necessary for abused children over age 2. The child will need help dealing with the fear and pain of abuse caused by adults, who should be trusted figures.

b.

Psychological or Emotional or Verbal Abuse Verbal assaults or threats that provoke fear; poor communication that may send double meanings; and blaming, confusing or demeaning messages This type of abuse can severely damage a childs mental health or social development, leaving lifelong psychological scars. Examples: Constant belittling, shaming, and humiliating a child Calling names and making negative comparisons to others Telling a child he or she is no good," "worthless," "bad," or "a mistake." Frequent yelling, threatening, or bullying. Ignoring or rejecting a child as punishment, giving him or her the silent treatment. Exposing the child to violence or the abuse of others, whether it be the abuse of a parent, a sibling, or even a pet. Nursing Management Community programs, such as home visits by nurses and social workers, can help families change behaviors or prevent the start of abuse in high-risk families. School-based programs to improve parenting, communication, and self-image can help prevent future abuse and may help to identify abused children. Parenting classes are very helpful. Newlywed adults without children should be encouraged to take these classes before they have each child. The dynamics in the home change when each new child is born. Therapeutic Management: Children with suspected emotional abuse should be examined by a trained mental health professional. All neglected or psychologically abused children should be examined for other forms of physical abuse. It may be necessary to remove the child from the home to prevent further abuse.

Sexual Abuse It is broadly defined as any sexual contact between a child and an adult. Classifications: o MOLESTATION A vague term that includes indecent liberties such as oralgenital contact, genital fondling and viewing, or masturbation. o INCEST Sexual activity between family members. It often involves an older man and younger girl. o Rape actual penetration of an orifice of a childs body during sexual activity o Sodomy any contact between the genitals of one person, and the mouth or anus of another o Exhibitionism mental disorder characterized by a compulsion to display one's genitals to an unsuspecting stranger o PORNOGRAPHY This involves photographing or describing sexual acts by any media involving children, or distributing such material in person or by mail or fax or over the internet. Child prostitution involves arranging or participating in sexual acts with children. High Risk o 3 years of age or younger o Suffer from a developmental delay o Live in a home where substance abuse occurs o Have adolescent parents or a single parent o Are in foster care o Primary caretakers who were sexually abused themselves o Primary caretakers who are mentally ill or who have a developmental delay Warning Signs: o Trouble walking or sitting. o Displays knowledge or interest in sexual acts inappropriate to his or her age, or even seductive behavior. o Makes strong efforts to avoid a specific person, without an obvious reason. o Doesnt want to change clothes in front of others or participate in physical activities. o An STD or pregnancy, especially under the age of 14. o Runs away from home. o Verbal reports of sexual activity with an adult. o Participation in sexual expression with dolls. o Perineal, vaginal, or anal inflammation o Vaginal tears, or anal fissures o Change in school performance, school phobia, or truancy Clinical Manifestations: o Genital findings Venereal disease may be located in the mucosa of the vagina, penis, anus, or mouth. semen in the vagina of a child, torn or missing hymen, other vaginal injury or scarring, vaginal opening greater than 5 mm, and injury to the penis or scrotum

Oral findings injury to the palate or pharyngeal gonorrhea. o Anal Findings destruction of the anal sphincter, perennial bruising or abrasion, shortening or eversion of the anal canal, fissures to the anal opening, wasting of gluteal fat, and Funneling o Child has behavioral and emotional signs such as: difficulty eating or sleeping. soiling or wetting pants or bed after being potty trained. acting like a much younger child. excessive crying or sadness. withdrawing from activities and others. Nursing Management: o Encourage parents to teach children simple rules to help them avoid sexual abuse always lock doors and never show keys to others or indicate that you stay home alone when answering the telephone, say a parent is busy, not absent from home. do not go into the house if the door is open or a window is broken. identify a caller before opening the door. o Teach children never to keep secrets and the difference between "good" and "bad" touches. Parents need to begin this work at home

o o o o

Begs or steals food Causes trouble in school; often hasnt done homework Uses alcohol or drugs Engages in vandalism and sexual misconduct

Summary of Nursing Care Goals Responsibilities

Prevent abuse

Identify families at risk for potential abuse Promote parental attachment to child Emphasize child-rearing practices, especially effective methods of discipline Increase parents feeling of adequacy and selfesteem Encourage support systems that lessen stress and total responsibility of child care on one or both parents Be available for assistance Be alert to signs that may indicate abuse or neglect Report suspicions to appropriate authorities Keep factual objective records of the childs physical condition; behavioral response to parents, others, and environment; and interviews with family members. Perform physical assessment Assess emotional state and evaluate behaviors Assist with diagnostic procedures Assist in removing child from unsafe environment and establishing a safe environment Establish protective measures for the hospitalized child as indicated. Provide consistent caregiver Demonstrate acceptance of child while not expecting same in return Show attention while not reinforcing inappropriate behavior Plan appropriate activities with nurse, other adults, and other children; use play to work through relationships Avoid displacing anger on child, such as shouting or yelling, as method of dealing with own frustration toward childs negative behavior. Praise childs abilities in order to promote his self-esteem.

Identify suspected cases of child abuse or neglect

Determine extent of injuries Protect from further abuse

d.

Neglect Child neglecta very common type of child abuseis a pattern of failing to provide for a child's basic needs, whether it be adequate food, clothing, hygiene, or supervision. Child neglect is not always easy to spot. Sometimes, a parent might become physically or mentally unable to care for a child, such as with a serious injury, untreated depression, or anxiety. Other times, alcohol or drug abuse may seriously impair judgment and the ability to keep a child safe. Classifications: o Physical Neglect failure to provide for a childs minimum health care needs o Emotional Neglect failure to provide basic nurturing and affection; failure to seek proper psychological care, permission to indulge in drug or alcohol abuse, other maladaptive behavior. o Educational Neglect failure to send the child to school and ensure that a child is not truant, regardless of economic situation. Older children might not show outward signs of neglect, becoming used to presenting a competent face to the outside world, and even taking on the role of the parent. But at the end of the day, neglected children are not getting their physical and emotional needs met. Warning Signs: o Clothes are ill-fitting, filthy, or inappropriate for the weather. o Hygiene is consistently bad (unbathed, matted and unwashed hair, noticeable body odor). o Untreated illnesses and physical injuries. o Is frequently unsupervised or left alone or allowed to play in unsafe situations and environments. o Is frequently late or missing from school.

Promote therapeutic environment during hospitalization

Relieve anxiety in child

Treat child as one who has a specific physical problem for hospitalization, not as abused victim Avoid asking too many questions; use play, especially family or dollhouse activity, to investigate kind of relationships perceived by child; child should relate to one consistent person regarding events of abuse Foster healthy aspects of parent-child relationship, encourage child to talk about parents in positive sense; avoid criticizing parents actions to child Beside physical needs related to injury or neglect, focus on developmental needs such as sensory stimulation and education Accept temporary regression as necessary mechanism to cope with present crisis

Promote wellness in child

Promote a sense of parental adequacy during childs hospitalization

Orient parents to hospital unit and help them feel welcomed and an important part of childs care and recovery Reinforce competent child-care activities Focus on the abuse as a problem that requires therapeutic intervention, not as a behavior characteristic or deficiency of the parent. Emphasize with difficulties of rearing children, especially with additional life crises, while not condoning the act of abuse or neglect. Prepare for discharge as soon as disposition is finalized If child is being placed in foster home, encourage family members to visit child before discharge; stress to them the childs need to regress in order to complete missed stages of development If child is returning to his own home, encourage parents to visit as much as possible; plan for close supervision and counseling of the family If parents rights are being terminated permanently, help child grieve this loss, especially if it entails separation from siblings (long term counseling is optimum goal). Collaborative efforts of multidisciplinary team to continually evaluate progress of child in foster home or in return to own family As public health or school nurse, actively look for signs of continued abuse or neglect Help parents identify those circumstances that precipitate an abusive act and ways in which to deal with the release of anger in ways other than attacking child Provide mothering by directing attention to parent, taking over child-care responsibilities until parents feel ready to participate , and focusing on parents needs Help identify a support group for parents, such as extended family or nearby neighbors; help these significant others understand their important role in also preventing further abuse. Teach realistic expectations of childs behavior and capabilities Emphasize alternate methods of discipline, such as reward and verbal disapproval Suggest methods of handling developmental problems or goals, such as toddler negativism, toilet training, and independence Teach through demonstration and role modeling rather than lecture; avoid authoritarian approach.

9.

Identify parents who were abused as children, and offer specific help to them to break the chain of child abuse. 10. Suggest that potential abusers join an effective support group. Tips for Talking to an Abused Child Avoid denial and remain calm. A common reaction to news as unpleasant and shocking as child abuse is denial. However, if you display denial to a child, or show shock or disgust at what they are saying, the child may be afraid to continue and will shut down. As hard as it may be, remain as calm and reassuring as you can. Dont interrogate. Let the child explain to you in his or her own words what happened, but dont interrogate the child or ask leading questions. This may confuse and fluster the child and make it harder for them to continue their story. Reassure the child that they did nothing wrong. It takes a lot for a child to come forward about abuse. Reassure him or her that you take what is said seriously, and that it is not the childs fault. Safety comes first. If you feel that your safety or the safety of the child would be threatened if you try to intervene, leave it to the professionals. You may be able to provide more support later after the initial professional intervention. NURSING DIAGNOSIS Pain related to burn on hand. Risk for injury related to previous abuse. Risk for other-directed violence related to admitted poor selfcontrol. Impaired parenting related to high levels of stress. Fear related to episodes of abuse. Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of calories Risk for Delayed Growth and Development related to physical or emotional neglect, lack of stimulation and insufficient nurturing Impaired Parenting related to lack of knowledge and confidence in parenting skills PRIORITIES Republic Act 7610, the anti-child abuse law requires reporting of suspected cases to authorities Remember that the nurse does not have to decide with certainty that abuse has occurred Nurses are responsible for reporting suspected child abuse with accurate and thorough documentation of assessment data Report cases to barangay officers, DSWD personnel, police within 48 hours

Plan for discharge

Prevent recurrence

Support parents

Teach parents

Lessen environmental crisis

Refer to social agencies who can provide assistance in financial support, adequate housing, employment, and so on.

Measures to Prevent Child Abuse 1. Advocate for high school courses on parenting and growth and development of children 2. Help children learn problem-solving techniques so they are not overwhelmed by mounting problems as adults 3. Foster high self-esteem in children so they are not dependent on others but are assertive (they will not become passive observer to abuse). 4. Help parents with responsible reproductive planning so children are desired. 5. Help parents locate support people in their community, such as church or social contacts. 6. Teach children to verbalize their problems and seek help for problems so they do not mount to overwhelming proportions. 7. Role-model caring behaviors with children for parents. 8. Identify children who may be viewed as special in some way by parents.