What is Child Abuse:

Any action of commission or omission by individuals, institutions or society as a whole and any condition resulting from such actions or inactions, which deprive children of their equal rights and liberties and/or interfere with their optimal development, constitute by definition abusive or neglectful acts or conditions.
Child Abuse Prevention and Treatment Act (public law 93 – 247):
Defines it (Child abuse) as the physical or mental injury, sexual abuse, negligent treatment or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate that child’s health and welfare is harmed or threatened thereby.

Child abuse is not a disease but a family dysfunction most of the times due to disturbed relationships, failure on the part of parents, family or society.

TYPES OF CHILD ABUSE:

Physical abuse
Sexual abuse
Psychological emotional and verbal abuse
Munchausen syndrome by proxy
Neglect

Epidemiology:

Victimization rate is 11.8 per 1000 children (1%).
In the home survey, 5 – 14%.
The National Child Abuse and Neglect Data system (NCANDS) indicated:
1) Child neglect 58.4%
2) Physical abuse 21.4%
3) Sexual abuse 11.3%
4) Emotional abuse 5 %?

Physical Abuse (non-accidental injury):
10% of injured children below 5 years of age are in emergency rooms due to child abuse.
1/3 are below 1 year of age and 1/3 are between 1-6 years of age.
50% of children below 1 year of age are with fractures and 15% are with burns.
More than 90% of the parents are neither psychotic nor criminals.
30-40% of parents of abused children have been abused in their childhood.
Fathers were involved in 21% cases, mothers in 21% as well, boyfriends of the mother in 9%, babysitters in 8%, stepfathers in 5% of cases of physical abuse.
2000 children deaths per year occur due to physical abuse in the USA.

Causes of Physical abuse:

Poverty (Unemployment, overcrowding)
Stress on parents due to loss of jobs, marital strive, the death of a sibling or spouse, physical exhaustion, acute or chronic illness, teenage pregnancy, single parenthood, substance abuse
No social or economic support during the crisis
Effect of increased violence in the community
Social stigmas
Military base
Schools, madrasas (sticks, chains, dark rooms etc)
Workplace (“chotas” working in tea shops, auto workshops, carpet industry, begaar camps)

High-risk children:

Premature infants
Infants with chronic medical conditions
Mentally and physically handicapped children
Colicky babies
Children with learning and behaviour problems
Orphans
Adopted children etc
Children in institutions

High-risk parents:
Young teenager parents with no experience in child development and care
Single parents
Unmarried parents and their families (infanticide of a newborn)
Discrimination against female babies
Stressed parents due to any cause

Suspect physical abuse:
If there is a delay in seeking medical help
Unexplained, unexplainable or implausible injury
Injury incompatible with the history given or with child development
History of a repeated hospital or ER admissions
Signs of previous injuries

Evaluation:

Detailed history from parents, relatives, siblings, friends etc
Date and time of injury and time of seeking medical help

Examination of child:

Growth parameters to assess nutrition
General condition (calm, withdrawn or afraid)

Bruises are the most common injury
Site: Buttocks, genitals, back, back of the hands, bilateral or symmetrical
Shape: Geometric marks, marks of whips, sticks, pedals, belts and hands etc
Age of bruise: Blue or reddish purple, yellow, green, brown

Burns (10%)
Age of burn, a shape of burns (cigarette, hot iron etc)
Type of burn (emersion in hot water causes glove and stocking burn pattern with sparing of flexion creases. Children below two years of age are unable to enter a tub and turn a knob)
Examine bruises, burns, fractures at odd places
Fractures (bone trauma in 10-20% cases)
Fractures of metaphyses, ribs, scapulae, the outer end of the clavicle, vertebrae are present
Usually, spiral due to twisting of limbs, bucket or handle type due to pulling, may be multiple or symmetrical with various healing stages

Head Injuries:
Hair (alopecia, broken ends at various lengths)
Intentional head trauma (ITH- 29%)
95% of intracranial injuries during the 1st year of life are due to ITH so in any injured infant with coma and convulsions CT scan of the brain is advised and fundoscopy for retinal haemorrhages present in 85% of cases
ICH without fracture of the skull may be due to a blow with hand or slamming against an object or shake injury (sub glial hand prints on autopsy)

Intraabdominal injuries are the 2nd most common cause of death while ITH is the 1st most common cause.
Ruptured liver, spleen, injury to intestines are very common and life-threatening.

Lab investigations:
Full blood count, coagulation profile
A skeletal survey in children below 2 years of age. Repeat it after 7-10 days to see the healing of fractures
CT scan of brain and fundoscopy in case of head trauma, ultrasound and CT scan of the abdomen
Urine and stool examination for blood
Photographs of lesions

Diagnosis:
By detailed history, physical examination and evidence of trauma
A fall from 3 ft height doesn’t normally cause linear fracture of clavicle or skull, fall from 6 ft rarely causes concussions, subdural haemorrhages or lacerations, a fall from more than 10 ft can cause severe brain injury or death
A separate interview with an abused child of more than 3 years of age

Indications for hospital admissions:
Serious injuries
Unclear diagnosis
No alternate safe place for custody
Fear of abduction of a child

Management of abused child:
In case of suspicions don’t discharge child without consulting CPS
CPS personal, social worker, law enforcement team and doctors should decide that the child should go with the parents or stay in the hospitals
If parents insist to take the child, take legal action

Prevention of child abuse:
Identification of potential (at risk) family and the introduction of the family into the management system
Introduction of helplines such as hotlines, crisis nurseries, child-rearing counselling, marital counselling, social workers’ help, individual or group psychotherapy, advisory clinics with family practitioners, enforcement of law and order, monitoring and follow up
Role of parents 
Parents have the Primary Responsibility to protect and provide careRole of the Family
Families can provide support to parents and share in taking care of the child
Role of Society
Community should
Feel responsible for the welfare and care of children and identify elements that can harm children
Make arrangements for the emergency care of the abused child and the family

Role of Media
To provide knowledge and motivation to act
Inter-professional cooperation is vital if the investigation of reported cases and intervention are to be effective
To publicize effective schemes
To probe and ask questions of the state and institutions over which it has influence

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