CHILD ABUSE AND NEGLECT

Edward M. Santos, MD, DPPS

OBJECTIVES At the end of the lecture, the student should be able to: Know the definition of child abuse and neglect Identify the different forms of child abuse Know the incidence/prevalence of child abuse Identify physical and behavioral indicators of child abuse List several short and long term outcomes of child abuse Identify methods to prevent and address child abuse.

January 5, 2012

Definition (WHO) all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the childs health, survival, development or dignity in the context of a relationship, trust , or power Definition of a Child RA No. 7610 Special Protection of Children Against Child Abuse, Exploitation and Discrimination Act CHILD o Person below 18 years of age o Person over 18 years of age unable to care for self or protect self from abuse, neglect, cruelty, or exploitation due to mental or physical disability Forms of Child Abuse Physical Abuse Emotional/ Psyhological Abuse Sexual Abuse Neglect Incidence History of abuse among adolescents: Physical Abuse = 82.9% Sexual Molestation = 11.9% Forced sex/rape = 1.8%
Source: Baseline Surveys for the National Objectives for Health, Philippines, 2000

Age Group, Sexual Abuse Cases (Child Protection Network, 2008) 0-3 years old 7.14% 4-6 years old 16.65% 7-9 years old 10.98% 10-12 years old 14.57% 13-15 years old 31.61% 16-18 years old 18.48% >18 years old 0.57% Age Group, Physical Abuse Cases (Child Protection Network, 2008) 0-3 years old 10.58% 4-6 years old 13.88% 7-9 years old 15.13% 10-12 years old 18.43% 13-15 years old 25.82% 16-18 years old 15.36% >18 years old 0.80% Mandatory Reporting (R.A. 7610) Mandated Reporters: Physician Nurse Head or administrator of health care unit, institution * Reporter is granted immunity from any liability arising from reporting. When to Report? Report any suspicion of child abuse within 48 hours either orally or in writing No obligation to prove that abuse happened Reporter in not the complainant Reporter need not nform the family concerned that they reported possible child abuse Where to Report? DSWD Central or LGU Social Worker Violence Against Women and Children Division (VAWCD), NBI Womens and Childrens Desk, PNP Barangay Council for the Welfare of Children Commission on Human Rights

DSWD Reports

Contrasting Statistics

PHYSICAL ABUSE
Definition (WHO, 2000) Result from an act of commission which produces actual physical harm or hold potential for harm) which is reasonably within the control of a parent or person in a position of responsibility, power or trust. May be single or repeated incident. Indicators

Physical:
Proportion of Patients per Type of Abuse (Child Protection Network)

unexplained bruises, burns, human bites, broken bones, missing hair, scratches
o Bruises are the most common manifestation of physical abuse o Bruising in a perambulatory infant o Bruising in padded and less exposed areas o Patterned bruising or burns conforming to shape of an object or ligatures around the wrist

Multiple bruises, especially if clearly of different ages

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 Behavioral:

wary of physical contact with adults, behavioral extremes (aggressive or withdrawn), frightened of parents, afraid to go home, cheating, stealing, lying ( a sign that expectations in the home are too high), layered clothing

Case 1 A 9-year old was actually hung with a rope by her mothers partner to make it appear that the girl was committing suicide after the child disclosed sexual abuse.

Multiple skin lesions Case 3 An 11-month-old boy was brought to the CPU because of burns. The caretaker explained that the burns were a result of an accidental spillage of hot water from a thermos.

Her face showed diffuse plethora and petechiae. Subconjunctival hemorrhages are also evident.

Glove pattern 1st and 2nd degree burn of the hand The hands were dipped in boiling water.

Young children who are physically abused are at high risk to be aggressive children, teens, and adults. Children identified as uncontrolled at age 3 were 2.9 times as likely as adults to be diagnosed with anti-social personality disorder, 2.2 times as likely to be repeat offenders, 4.5 times as likely to be convicted for a violent offense!

PHYCHOLOGICAL ABUSE
Her neck showed distinct circumferential ligature abrasion around her neck. Case 2 A 3-year-old girl was brought to CPU (Child Protection Unit) because of multiple injuries. The caretaker explained that the bruises were a result of the child being awkward and always tripping or falling.

Definition (WHO, 2000) Involves intentional acts which lead to a failure to provide a developmentally appropriate/ supportive environment including the availability of a primary attachment figure, or acts which themselves have an adverse effect on the emotional health and development of a child. - parental behavior, such as rejecting, terrorizing, berating, ignoring, or isolating a child, that causes, or is likely to cause, serious impairment of the physical, social, mental, or emotional capacities of the child. - includes verbal abuse and humiliation and acts that scare or terrorize the child

Physical

indicators of emotional abuse: speech disorders, lags in physical development, failure to thrive. indicators of emotional abuse: depression, anxiety, poor self esteem, lack of empathy

Behavioral

Young children need loving and nurturing environments. A baby cannot exist alone but is essentially part of a relationship. Winnicott, 1965
The girl has periorbital bruising, forehead abrasions, cheek abrasions, nose abrasion and bruise on the left side of the lips.

Failure to Develop Attachment Child will have a lifetime of difficulties with intimacy, trust, touch and bonding. Ability to contribute to society is compromised. Categories of Physical Abuse Spurning
o o o o

Belittling, denigrating or rejecting Ridiculing Singling out Humiliating in public

Terrorizing Isolating Exploiting/ corrupting Denying emotional responsiveness

NEGLECT
Definition (WHO, 2000)

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Failure to provide for the development of the child in one or more of the following spheres: health, education, emotional development, nutrition, shelter or safe living conditions. (Includes failure of proper supervision) - failure of parents or caretakers to provide needed, age appropriate care including food, clothing, shelter, protection from harm, and supervision appropriate to the childs development, hygiene, and medical care.

Physical

indicators of neglect: constant hunger, poor hygiene, excessive sleepiness, lack of appropriate supervision, unattended physical problems or medical needs, abandonment, inappropriate clothing for weather conditions. indicators of neglect: begging or stealing food, frequent sleepiness, lack of appropriate supervision, unattended physical problem or medical needs, abandonment, inappropriate clothing for weather conditions.

Behavioral

Petechiae at 3 oclock

Impact of Poverty on Early Childhood Development Increased stress Poor health High incidence of child abuse Poor access to basic services Learn to be poor Delay in development

SEXUAL ABUSE
Definition (WHO, 2000) Involves acts in which an adult uses a child for sexual gratification. These acts include inappropriate exposure to adult sexuality, direct sexual contact, or making a child available to others either directly or indirectly for immoral and illegal acts, such as through pornography. Long Term Impact of Child Sexual Abuse Emotional
o o o o o o o o o o o o o o o Depression Anxiety Somatization Hostility Substance abuse Suicidal ideation Self-destructive tendencies Negative self evaluation Guilt Perceived helplessness Distrust of others Difficulties with intimate relationships Higher tendency to be revictimized Sexual dysfunction Difficulty parenting Fresh laceration at 6 oclock

Anal swelling and laceration at 5 oclock HYMENAL HEALING Case 2 A 1 yo girl sexually abused girl A drunkard abducted the child from her mother. Father witnessed the alleged perpetrator insert his finger to the girls genitalia.

Cognitive

Interpersonal

Source: Briere and Runtz (1993) J of Interpersonal Violence 8, 312-330

Impact of Sexual Abuse on the Teen-Ager Affect their identity, intimate relationships Coping strategy: running away, attempting suicide, drug abuse, sexual promiscuity More likely to be blamed and not believed Relationship of Child Sexual Abuse to Commercial Sexual Exploitation Cases: 80-90% of girls involved in commercial sexual exploitation had a previous experience of child sexual abuse such as incest.

Absence of injury on the 3rd day of incidence

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Physical indicators of sexual abuse: difficulty in walking or

sitting, torn, stained, or bloody underclothing, pain or itching in genital area, bruises or bleeding in rectal/genital area, venereal disease.

Behavioral

indicators of sexual abuse: age-inappropriate sexual knowledge/sexual touch, abrupt change in personality, withdrawn, poor peer relationships, unwilling to change for gym or participate in physical activities, promiscuous behavior/seductive behavior, drop in school performance/decline in school interest, sleep disturbances, regressive behavior (i.e., bed wetting).

Child Maltreatment is a Medical Diagnosis. ICD 10(International Classification of Diseases) (2007 version) T74- Maltreatment syndromes T74.0 Neglect or abandonment T74.1 Physical Abuse T74.2 Sexual Abuse T74.3 Psychological Abuse T74.8 Other Maltreatment Syndromes Mixed Forms T74.9 Maltreatment Syndromes Unspecified

ADVERSE CHILDHOOD EXPERIENCES

Study It is the largest study ever done to examine the health and social effects of childhood experiences throughout the lifespan (17,421 participants). Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Mark JS. Relationship of childhood

Case 1 A 15-year-old sexually abused girl: with disclosure of penile vaginal penetration examined within 24 hours from the time of examination. With genital and anal penetration

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abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine. 1998; 14:245-258 Now with more than 50 scientific articles published What is an ACE? An ACE is contact with any of the following conditions prior to age 18: 1) Recurrent physical abuse 2) Recurrent emotional abuse 3) Contact sexual abuse 4) An alcohol and/ or drug abuser in the household 5) An incarcerated household member 6) Someone in the home who is chronically depressed, mentally ill, institutionalized, or suicidal 7) Domestic violence 8) One or both biological parents absent 9) Emotional or physical neglect Findings ACEs still have profound effect 50 years later Transformed from psychosocial experience into organic disease, social malfunction and mental illness ACEs are the main determinant of the health and social wellbeing of the nation.

12 times more likely to engage in early sex; 9 times more likely to have early pregnancy; 5 times more likely to commit suicide.

Strong graded response between number of ACEs and poor health Bronchitis/ Emphysema Asthma Ischemic Heart Disease Hypertension Tuberculosis Skin problems UTI Liver problems GI problems Ulcers, Constipation, Indigestion Depression Consequences of Child Maltreatment Health Risk Behaviours
Alcohol abuse Behavioral problems Injected/ illicit drug use Sexual risk behaviour Smoking

Mental, Reproductive, Other Social Problems

Anxiety Depression Eating Disorders Obesity PTSD School failure Unwanted pregnancy

Disease and Inquiry Conditions

Cancer Chronic Bronchitis/ Emphysema Diabetes Ischemic Heart Disease Hepatitis Skeletal Fractures STD/ HIV Stroke Suicide

PREVENTION
Where prevention comes in?

The
The higher the number of ACEs the greater the risk for the following health risk behaviors: Drinking alcohol Smoking tobacco Sexual promiscuity Using illicit drugs Overeating/ eating disorders Delinquent behavior The higher the ACE score, the risk for one or more of the following increase: Ischemic Heart Disease Chronic Obstructive Pulmonary Disease Lung Cancer Depression Liver Disease Suicide Attempts Sexually Transmitted Disease Alcoholism Risk for DV Unintended Pregnancies Fetal Death Autoimmune Disease
Adverse Childhood Experiences and Health-Risk Behaviors Among Adults in a Developing Country Setting (For publication in Child Abuse and Neglect, The International Journal)
Laurie S. Ramiro, PhD Bernadette J. Madrid, MD David R. Brown, PhD University of the Philippines, Manila UP Manila Child Protection Unit Centers for Disease and Prevention Atlanta World Health Organization

magnitude of the ACE problem is so great that primary prevention is ultimately the only realistic solution. Primary prevention requires the development of a beneficial and acceptable intrusion into the closed realm of personal and family experiences. What can we do? Stop treating symptoms and treat the cause.

We

need to do a better job of routinely screening at the earliest point for ACEs. Identify cases early and allow treatment of basic causes rather than vainly treating the symptom!

Framework for prevention of child maltreatment and associated impairment - - MacMillan, Wathen, et al, Lancet 2009

Results of the Metro Manila ACE Study Those who were sexually abused are:

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CASE VIGNETTES
Case 1: BOBBY What is bobbys diagnosis? Shaken Baby Syndrome Abusive head injury is a problem of very young children In the US: 0.2-0.3% of infants per year

In the Philippines, no data CPU (PGH) average of 9 cases of Shaken Baby Syndrome
per year

World

Studies of Abuse in the Family Environment (WorldSAFE) : 20% of Filipino mothers shook the child as a form of discipline

Primary Prevention of Child Abuse Prevent the problem before it starts: 1. Reduce risk factors Reduce poverty Reduce alcohol abuse Reduce parental conflict
* resolved on the national level

How common is child maltreatment? In the US: over 1% (data from child protection agencies) In the Philippines no systematic data collection DSWD reports: 6,701 cases in 2008 ( the number is greater than this stat because of many unreported cases) DOH Prevalence Study in 2000 o 85.9% of adolescents experienced some form of abuse in their lifetime o 82.9% physical abuse o 13.7% sexual abuse o 5.4% neglect Why was abuse not suspected initially? o The MD believed the parents story o Didnt know that bruising at that age is unusual o Had a hard time believing this family would hurt the child Abuse is more common when the parents are young, when there is only one parent, and in poor families When families dont look as mentioned above, abuse is more likely to be missed Abuse happens more in at risk families, but it can happen in families of any class, race or composition The possibility of child abuse must be considered in the differential diagnosis of all children who have suffered an injury In considering abuse, it is important to carefully clarify the circumstances and evidence, while ruling out alternate explanations If abuse remains a possibility, the physician must raise concerns with the parents/caretakers, and REFER to the responsible agencies What are the consequences? o (Jenny, et al, JAMA, 1999) o 27% of children whose initial head trauma is missed are reabused before being recognized o 40% suffer complications o 7% die What happened to Bobby? o He survived but with severe neurological damage, like 6080% of children who suffered abusive head trauma o May have been prevented- if the physician diagnosed it at the first consult. Teaching Points Child abuse is a common occurrence

2. Enhance protective factors Develop positive parenting skills Improve coping skills Provide accessible mental health services
* already available in the Barangay health centers * what NGOs do in communities

4 Best Predictors of Child Maltreatment Family revenue below poverty line Mother sole financial provider Mothers first pregnancy occurs before the age of 21 Four or more children in the family
Source: Palacio- Quintin and Ethier, 1993 not in the Philippines

Primary Prevention Programs that have been found to work: Home-visiting programs: Nurse-Family Partnership The Triple P: Positive Parenting Program Hospital-based educational programs to prevent abusive head trauma and enhanced pediatric care for families at risk of physical abuse and neglect
Source: MacMillan, Wathen, et al, Lancet 2009

Programs that Prevent Child Maltreatment School-based educational programs improve knowledge and protective behaviors.
Source: MacMillan, Wathen, et al, Lancet 2009

childrens

Secondary Prevention Early identification and treatment to stop or slow the progression of the problem o Identify families with poor parenting practices or uses harsh discipline o Intervene with aggressive parents o Identify potential cases in early stages and provide services Tertiary Prevention Treatment or rehabilitation after violence happens, e.g. child protection units Emergency medicine for victims Legal intervention with abuses Foster placement for abused child In Summary... Before (Primary Prevention) Change conditions/ policies that encourage violence Support Conditions/ policies that discourage violence Encourage positive behaviors Discourage negative behaviors (e.g. potential perpetrators) After (Secondary and Tertiary Prevention) Respond to violence when it occurs Provide services to survivors Prosecute perpetrators Encourage awareness of services.

Families who look outwardly good/phenotype can commit child

abuse The injuries should direct you to consider child abuse, not the family characteristics If you miss child abuse, complications or repeat child abuse can have serious effects. Case 2: MARIA Was Maria sexually abused? Sexually abused children may present with various physical signs, emotional symptoms or behavioral changes, depending on their age, development or whether force has been used STDs, PTSD, The longer the abuse continues and the closer the child is to the abuser, the more likely that the child will have psychosomatic symptoms 90% have normal PE findings Spontaneously made child disclosures are true

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 Many

abused children deny abuse when first asked (child fears the perpetrator)

Violence, abuse and abandonment -> runaways, street

children -> juvenile delinquency, and other crimes Depression, PTSD, drug abuse, early sexual activity, school failure and conduct disorders. What about Marias children?

Neglect persistent failure to meet a childs essential needs Defined as failure to protect from danger, failure to provide

food, failure to meet the childs emotional need for love, affection and social bonds, and failure to provide proper education Neglect associated with poverty Teaching Points Child abuse has mid range effects on child and adolescent behavior including risk taking behaviors and mental illness Abused children can become maltreating adults forming a multi generational pattern Neglect, in which childrens needs are not met, though they are not purposely harmed is a very common and potentially very dangerous form of maltreatment Most sexually abused boys and girls have normal physical exams The majority of sexual abuse disclosures are true Case 3: JOSE Adverse childhood experiences Sexual abuse Domestic violence Effects are often very broad and long lasting Immediate: injury, infection, malnutrition, death Chronic pain disorders, chronic insomnia and other chronic psychosomatic disorders of adults often have their roots in childhood experience and abuse Early identification, or prevention, could substantially reduce the long term negative outcomes Teaching Points

Child abuse has lifelong consequences for its victims, affecting

them in surprising ways even as adults Witnessing domestic violence is, in many ways, as damaging as being abused as a child Sexual abuse occurs in boys as well as girls, but tends to be less reported
CASE 4: SUSAN Rib fractures during infancy are due to abusee in 80% of nth time

Multiple fractures happening several times -> child abuse! Unusual bone fragility main alternative explanation Temporary brittle bone disease Most doctors do not believe in the existence of this disease; little is known about this disease .

Teaching Pounts The effects of abuse can be mitigated through protection and treatment Know the resources in your community for protecting children, treating abusing families, and how to use them Certain fracture patterns suggest child abuse Brittle bone diseases alter the specificity of these findings novel theories of causation are scientific sounding excuses to obscure child abuse

CONCLUSION
Providing the best outcome for possibly abused children is a complicated process that includes the following:

Identifying abuse Stopping abuse and further abuse Treating the medical and emotional
child

consequences of abuse in the

Finding a safe home for the child Supporting the family to help them take adequate care of the child

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