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Statistics from the Department of Social Welfare The complications of Child Abuse Will Be Presented At The End Of Presentation.
Neonaticide
Definition: It is killing of a premature or full term baby within 24hours after birth. This case rarely in developed country. It is done usually by young single uneducated mother by act of commission or omission.
Cultural aspect: The Chinese, as late as the 20th century, dispatched newborn daughters because they were unable to transmit the family name.
Causes: 1) forbidden intercourse of unmarried young girl. 2) been raped and lead to unwanted child from the assailant.
Infanticide
Definition: It is killing of newly born, live born infant within 12 months after birth. Etiology: The mother with maternal psychosis (especially puerperal depression) is almost always the perpetrator.
Euthanasia
Definition: It is killing of a handicapped (physical, mental or both) child usually under 3 years by a parent. Perpretrator: The mother is usually the maker.
Causes :
low economic status of the parents that cant afford to maintenance their handicapped child. no support from government and public to help unlucky parents like an association to assist parents by giving free consultation, equipments to facilitate handicapped child. poor mental state of the parents. unfaithful parents.
Causes: 1) Great stress Many people who commit physical abuse were abused themselves as children. As a result, they often do not realize that abuse is inapproriate discipline. 2) Poor impulse control This will prevents them from thinking about the result from their actions.
Statistic: The rate of child abuse is fairly high. The most common form is neglect
(6) Murder-suicide:
Often whole family is killed usually in one accident.
(7) Murder-homicide:
The great majority of victims are girls after sexual assaults.
Risk Factors
Parental factors Family factors Child factors Environmental factors
Parental Factors
Personality characteristics and psychological well-being History of childhood abuse Substance abuse Attitudes and knowledge Age (young parents 15-20 years)
Substance abuse
Substance abuse can interfere with a parent's mental functioning, judgment, inhibitions, and protective capacity.
Age
Mothers who were younger at the birth of their child exhibited higher rates of child abuse than did older mothers. Other contributing factors, such as lower economic status, lack of social support, and high stress levels may influence the link between younger childbirth particularly teenage parenthoodand child abuse.
Family Factors
Family structure Marital conflict and domestic violence Stress Parent-child interaction
Family structure
Children living with single parents may be at higher risk of experiencing physical and sexual abuse and neglect than children living with two biological parents. Single parent households are substantially more likely to have incomes below the poverty line. Lower income, the increased stress associated with the sole burden of family responsibilities, and fewer supports are thought to contribute to the risk of single parents maltreating their children In addition, studies have found that compared to similar non-neglecting families, neglectful families tend to have more children or greater numbers of people living in the household
30 to 60 % of families where spouse abuse takes place, child maltreatment also occurs. Children in violent homes may witness parental violence, may be victims of physical abuse themselves, and may be neglected by parents who are focused on their partners or unresponsive to their children due to their own fears. A child who witnesses parental violence is at risk for also being maltreated, but, even if the child is not maltreated, he or she may experience harmful emotional consequences from witnessing the parental violence.
Stress
Stress is also thought to play a significant role in family functioning. Physical abuse has been associated with stressful life events, parenting stress, and emotional distress in various studies.
Parent-child interaction
Families involved in child abuse seldom recognize or reward their child's positive behaviors, while having strong responses to their child's negative behaviors. Abusive parents have been found to be less supportive, affectionate, playful, and responsive with their children than parents who do not abuse their children. Research on maltreating parents, particularly physically abusive mothers, found that these parents were more likely to use harsh discipline strategies and verbal aggression and less likely to use positive parenting strategies.
Child Factors
The abnormal or disable child The rejected child Other child characteristics
Children with physical, cognitive, and emotional disabilities appear to experience higher rates of maltreatment than the other children. In general, children who are perceived by their parents as "different" or who have special needs including children with disabilities, as well as children with chronic illnesses or children with difficult temperaments may be at greater risk of abuse. The demands of caring for these children may overwhelm their parents. Disruptions may occur in the bonding or attachment processes, particularly if children are unresponsive to affection or if children are separated by frequent hospitalizations. Children with disabilities also may be vulnerable to repeated abuse because they may not understand that the abusive behaviors are inappropriate, and they may be unable to escape or defend themselves in abusive situations.
Child factors such as aggression, attention deficits, difficult temperaments, and behavior problems or the parental perceptions of such problems have been associated with increased risk for all types of child maltreatment. These factors may contribute indirectly to child maltreatment when interacting with certain parental characteristics, such as poor coping skills, poor ability to empathize with the child, or difficulty controlling emotions. In addition, these same child characteristics may be reinforced by the maltreatment.
Environmental Factors
Poverty and unemployment Social isolation and social support Violent communities
Poverty and unemployment show strong associations with child maltreatment, particularly neglect. Poverty particularly when interacting with other risk factors such as depression, substance abuse, and social isolation can increase the likelihood of maltreatment. Low income creates greater family stress, which, in turn, leads to higher chances of maltreatment. Parents with low incomes, despite good intentions, may be unable to provide adequate care while raising children in high-risk neighborhoods with unsafe or crowded housing and inadequate daycare
Some other characteristics may make parents more likely to be both poor and abusive For example, a parent may have a substance abuse problem that impedes the parent's ability to obtain and maintain a job, which also may contribute to abusive behavior Poor families may experience maltreatment at rates similar to other families, but that maltreatment in poor families is more frequent
Violent communities
Children living in dangerous neighborhoods have been found to be at higher risk than children from safer neighborhoods for severe neglect and physical abuse, as well as child sexual victimization.
INVESTIGATIONS
IN A CASE OF
CHILD ABUSE
Ahmad Farhan Bin Mahabot 06-6-9
MEDICAL HISTORY
Conducting Interviews
Good rapport Professional Open-ended Qs
General to specific
Confidentiali ty
Child alone
MEDICAL HISTORY
Suggestive findings:
A
history that does not match the nature or the severity of the injury Vague parental accounts or accounts that change during the interview Accusations that the child injured him/herself intentionally Delay in seeking help Child dressed inappropriately for the situation
GENERAL SIGNS
Emotional abuse
Excessively
withdrawn and fearful Anxious about doing something wrong Extremes in behaviour Lack of attachment with the parent/caregiver Acts inapproppriately adult or infantile
GENERAL SIGNS
Physical abuse
Unexplained
injuries e.g. bruises, burns or cuts Certain pattern such marks from hand or belt Always watchful or on alert for bad things Wears inapproppriate clothing to cover injuries Admitting to punishment that seems excessive
GENERAL SIGNS
Child neglect
Wears
ill-fitting and filthy clothes Consistently bad hygiene Untreated ilness and physical injuries Left alone in unsafe environment Begs or steals food or money
GENERAL SIGNS
Sexual abuse
Trouble
walking or sitting Starting to wet at bed and having nightmares Doesnt want to change clothes in front of others Lustful act and seductive behaviour Medical conditions like STDs or pregnancy
THANK YOU
PHYSICAL EXAMINATION
Detailed documentation of concerning findings : 1. BODY DIAGRAM & PHOTOGRAPH
Nutritional neglect, Fail to meet expected growth Photo of injuries
2. CLOTHING
Signs of neglect (dirty, ill-fitting, stained, unwashed, bad odour), Wearing clothes inappropriate to the weather (to cover bruises)
REGIONAL SIGNS
This area is vulnerable to injury because of a childs small stature. It may be the closest body part to an adults hand or fist. It is where the crying, back talk, bad language, etc. is emanating from.
poor feeding,
excessive crying.
Intracranial haemorrhage occurs as a result of severe angular acceleration, deceleration & direct impact as the head strikes a solid object.
The chest is compressed resulting in rib fractures. Arms & legs move about in a whiplash movement resulting in the typical 'corner' or 'buckethandle'-fractures in the metaphyseal region.
NECK
SKULL FRACTURES
Skull fractures are common child abuse injuries, but they are also common in accidental trauma. Patterns of skull fracture that suggest child abuse are: Multiple 'eggshell' fractures Occipital impression fractures Fractures crossing sutures
LEFT: eggshell fractures in a child who died of cerebral injury after being thrown of a height RIGHT: skull fracture crossing suture in abused child
Scalp Injuries
SCALP BRUISES/SCAR
TRAUMATIC ALOPECIA
Face injuries
SLAPPING MARKS
Ear injuries
Post-auricular bruising
Bite mark
Mouth injuries
Brusing on soft palate from forced oral sex. Trauma from a direct blow to the child's mouth.
Torn frenulum
Tongue laceration --note that this child had no teeth that could have caused this.
Neck injuries
Strangulation mark
CHEST INJURIES
EXTERNAL INJURIES RIB FRACTURES
They are not evident on x-ray in the acute stage, as little displacement occurs. They are identified in the healing stage as a result of associated callus.
Common abdominal injuries in abused children are: liver laceration duodenal perforation/ hematoma pancreatic laceration.
VISCERAL INJURIES
Pancreatic laceration Liver laceration
VISCERAL INJURIES
A, A round, fading bruise over the right lower abdominal wall. Note the marked abdominal distention. B, At surgery she was found to have diffuse peritonitis, and two large rents were discovered in the jejunal mesentery. C, A long segment, found to be necrotic with a perforation, and adjacent bowel that appeared nonviable were resected.
THANK YOU!
Limbs :
Bruises around joints ( especially
wrist,forearm,upper arm,thighs and ankles ) from gripping in order to swing or shake the infant Fractures at any site in diaphysis , may be multiple Spiral fractures indicate twisting injury Traction Avulsion of parts of metaphysic and slipped epiphysis Joint effusions
Bites :
Abuser bites, self- inflicted bites and other children bites must be distinguished. Favorite sites : Arms,back of hands,cheeks,shoulders,buttocks Shape : Two opposing semicircles with abrasion,contusion,or both Size : Dental arch size determines whether it is done by adult,child,or animal
Burns
1. Dry burns - Burns in unlikely sites e.g. buttocks and perineum.Children may be sat on hot plates,branded with irons or hot metals. - Cigarette burns on areas normally covered by clothing usually multiple and of different ages. 2. Scalds - Over hot bath water - Deliberate pouring of hot water - Dipping in hot liquid
Poisoning :
Occurs more commonly in baby sitters.The drugs used more are antihistamines,cough mixtures and laxatives.
Scald example 1
Scald example 2
For children younger than 2 years suspected of having been physically abused, a skeletal survey is recommended to rule out skeletal injury. To evaluate for missed physical abuse and unsuspected fractures Provide the diagnosis of abuse in 50% of the children with positive skeletal survey results
1.Long-bone injuries
Direct blow /shear force
2.Rib fractures
Compressive force
3.Head injuries
Forceful shaking
Fracture may cross the diaphysis in an oblique or transverse plane Fracture may occur at metaphysis known as classic metaphyseal lesion(corner/bucket handle lesion)
Highly specific and classic metaphyseal lesion (CML) occurs when a torsional force is applied to the immature primary spongiosa adjacent to a cartilaginous growth plate. Fractures of the posterior rib, scapula, spinous process, and sternum(bones which are ordinarily difficult to break) Fractures in different stages/ages of healing Fractures are usually multiple
Subarachnoid hrg
Subdural hrg
More sensitive to small subdural and subarachnoid haemorrhages, contusions of cortex and deep white matter lesions. Used when CT findings is confusing such as:
for differentiating a hypoattenuating subdural hematoma from cerebrospinal fluid (CSF) detecting small and chronic extra-axial fluid collections.
shear injury
gray matter white matter junction
contusion edema
corpus callosum
midbrain
assists in identifying new rib fractures and subtle long bone fractures not apparent on the skeletal survey especially at the costovertebral junction
Has high sensitivity and low specificity in cases of child abuse. Correlation with x-ray is always necessary
Child Abuse
Complications Health and physical effects Intellectual and cognitive development Emotional, psychological, and behavioral consequences Fine / Penalty
Punishable under the Child Act (2001) and the Penal Code (revised 1997). Offenders may be liable to a maximum fine of RM 50,000 ( about 100,000 EGP ) or up to 20 years imprisonment, or both depending on the offence. Offenders may also be punished with whipping in addition to the fine and/or imprisonment
The immediate effects of bruises, burns, lacerations, and broken bones Longer-term effects of brain damage, hemorrhages, and permanent disabilities.
Prevention : Recognize the warning signs of abuse Have alcohol or drug problems Have a history of abuse or was abused as a child Have emotional problems or mental illness Have high stress factors, including poverty Not look after the child's hygiene or care Not seem to love or have concern for the child
Counseling or parenting classes may prevent abuse when any of these factors are present. Watchful guidance and support from the extended family, friends, clergy, or other supportive persons may prevent abuse or allow early intervention in cases of abuse.
References
http://emedicine.medscape.com/article/4071 44-overview http://emedicine.medscape.com/article/9156 64-overview Lectures of forensic medicine textbook by staff members of department of forensic medicine and clinical toxicology, faculty of medicine, Alexandria University.