Children with Injuries: Accident or Child Abuse?

1. Children with Injuries:Accident or Child Abuse? Kristine Ruggiero, CPNP, MSN, RN

2. Physical Child Abuse Any non-accidental injury inflicted by a caretaker

3. Prevalence • 152,000 children and adolescents were confirmed victims of physical abuse in the US in 2004 • Neglect is most common • Physical abuse is second to neglect • Underreported

4. Child Abuse & Neglect - U.S. 1/3 of reports are substantiated = 18 cases / 1000 children 1271 deaths in 1994

6. Child abuse statistics in the US • An estimated 906,000 children are victims of abuse & neglect every year. The rate of victimization is 12.3 children per 1,000 children • Children ages 0-3 are the most likely to experience abuse. They are victimized at a rate of 16.4 per 1,000 • 1,500 children die every year from child abuse and neglect. That is just over 4 fatalities every day. • 79% of the children killed are younger than 4.

7. Research points to several important factors associated with higher incidence of child maltreatment: poverty, domestic violence,parental substance abuse, and mothers who are teens when their first children are born. All these factors are also clearly related to child abuse reporting rates in Massachusetts. Approximately equal numbers of boys and girls are neglected, physically abused, and emotionally maltreated. A large majority of sexually abused children (74%) are girls Massachusetts statistics

8. Types of Abuse • Physical abuse • Physical neglect • Sexual abuse • Emotional abuse • Emotional neglect

9. Risk Factors • Infants and young children • Mental or physical disabilities • The “challenging” child • Dysfunctional or isolated families • Substance abuse in the home • Unrealistic parental expectations

10. Consequences of Abuse • Significant long-term medical and mental health morbidity • Children w/ head or abdominal injuries are more likely to die or b/c more severely incapacitated than are children w/ head or abdominal injuries d/t accidents • Behavioral and functional problems • Conduct disorders • Aggression • Poor academic performance • Decreased cognitive functioning

11. Indicators of Possible Abuse • Lack of concern for child’s injuries/pain • Inability/unwillingness to comfort child • Delay in seeking needed medical care • Incompatible or absent history

12. Abuse on padded areas pattern injuries many lesions Accidental on poorly padded areas non-specific patterns few lesions Bruises

13. Differential Diagnosis • Cultural influences/ beliefs such as coin rubbing or cupping • Bleeding disorders • Mongolian spots • Henoch-Schonlein Purpura

14. Fractures Suspicious of Abuse • rib • metaphyseal (corner or bucket handle) • acromion • spinous process • sternum • hands and feet • vertebral body fractures & subluxations • complex skull fractures

15. posterior lateral Rib Fractures transverse process of adjacent vertebrae is the fulcrum

16. CHMC Rib Fracture Study • retrospective • 39 infants • < 1 year

17. Classic abuse injury shaking the trunk yanking the extremities Metaphyseal Fractures

18. Findings that Suggest Abuse • multiple fractures • fractures in different stages of healing • fracture not adequately explained • Occult fracture • fracture in an infant

19. Dating Fractures • soft callus (from osteoclasts) appears in • 7-10 days in infants • 10-14 days in older children • affected by fracture instability & repeat injury • metaphyseal fractures are difficult to date unless there is periosteal new bone growth

20. Non-abusive Causes of Fractures • Birth trauma: • clavicle, humerus, skull, rib, femur-w/ Neuro- muscular disease • Prematurity: • osteopenia (a decrease in BMD, can lead to osteoporosis) • Rickets • The predominant cause is a Vitamin D deficiency, but lack of adequate calcium in the diet may also lead to rickets. This can lead to bone deformities and fractures. • Neuromuscular defects • osteoporosis, contractures, decreased or absent pain perception

21. Non-abusive Causes of Fractures Osteogenesis imperfecta (OI) is a genetic disorder characterized by bones that break easily, often from little or no apparent cause. A classification system of different types of OI is commonly used Collagen is the major protein of the body’s connective tissue. It is part of the framework that bones are formed around. In recessive OI, mutations in other genes interfere with collagen production. The result in all cases is fragile bones that break easily.

22. Osteogenesis imperfecta1/50,000 live births haveOI Type IV Child abuse1/1000 abused childrenhave fractures Prevalence of Abuse & O I

23. Conditions Mistaken for Fractures • Congenital syphilis (0-2 years) • If the symptoms of syphilis go unseen in infants so that they develop the symptoms of late-stage syphilis-- damage to their bones, teeth, eyes, ears, and brain • Osteomyelitis • an infection of bone or bone marrow, usually caused by bacterial infection • Drug toxicity • Methotrexate

24. Conditions Mistaken for Fractures • Scurvy that results from insufficient intake of vitamin C (which is required for correct collagen synthesis) • Dark purplish spots on the skin (especially legs) • Spongy gums, often leading to tooth loss. • Bleeding from all mucous membranes • Pallor, Bleeding gums, and Sunken eyes • Bone fractures • Rickets

25. Fractures: Abuse vs Non-abuse • Abused children: young and multiple fractures • 55%-70% of fractures occur before age 1 year • > 50% have multiple fractures • Non-abused children: older with fewer fractures • >98% of fractures seen after 18 months of age • multiple fractures are uncommon

26. Other Abusive Injuries • Burns • Blunt abdominal trauma • Liver, spleen, pancreas, bowel • Shaken Baby Syndrome (Head injury) • Intra-cranial injury • retinal hemorrhage (80%) • Absent is external signs of trauma

27. Diagnosis of Shaken Baby Syndrome • Consider SBS in infants with: • intracranial injury after minor trauma • scan infants with symptoms indicative of head injury • retinal hemorrhages • Does the history explain the injuries?

28. Injuries that result in intracranial trauma falls < 3’ falls >3’ & <6’ falls > 6’ couch, bed kitchen counter porch standing, chair changing table top of slide coffee table bunk bed, stairs baby walker Highly Unexpected Reasonableunlikely but possible

29. Significance of Retinal Hemorrhages in Head Injured Children • Very unusual after accidental head injury • high velocity injuries • injuries with high rotational component • stairway fall in walker? • CPR may rarely cause small hemorrhages • Other conditions may cause RH but abuse is most likely if head injury is also present

30. The child… • Shows sudden changes in behavior or school performance • Has not received help for physical or medical problems brought to the parent’s attention • Has learning problems that cannot be attributed to specific physical or psychological causes • Is always watchful, as though preparing for something bad to happen • Lacks adult supervision • Is overly compliant, passive or withdrawn • Comes to school or other activities early, stays late and does not want to go home

31. The caregiver… • Shows little concern for the child • Denies the existence of or blames the child’s problems in school or at homeas • Asks teachers or other caretakers to use harsh physical discipline if the child misbehaves • Sees the child as entirely bad, worthless or burdensome • Demands a level of physical or academic performance the child cannot achieve • Looks primarily to the child for care, attention, and satisfaction of emotional needs

32. Work-up of Suspected Abuse • History • Consistent with the injury and development abilities? • Past history • Social Evaluation • dysfunctional family, substance abuse • handicapped child, premature, etc. • Complete physical examination • Photographs (do not need parental consent) and measurements

33. Work-up of Suspected Abuse • Laboratory • platelets, coagulation studies, liver function tests • Skeletal Survey, +/- bone scan • if under 2 or 3 years of age • Head C-T / MRI & Ophthalmologic examination • consider if under 1 y/o • Evaluate for abdominal or other injuries • Social service and police referral/report (51 A)

34. Skeletal Survey • skull: frontal and lateral • spine: frontal and lateral • chest • extremities • additional views as needed

35. Bone Scan • compliments the skeletal survey • non-displaced/subtle fractures • rib fractures • poor for skull & spine • metaphyses difficult to interpret

36. Inform the family of your concerns • These injuries were probably not caused by the events that you are describing. • I’m concerned that someone may be harming your child. Do you have any of these same concerns?

37. Mandated agencies • Juvenile system Protects the child • child protective services • juvenile court • Criminal justice system Prosecutes crimes • police • criminal court

38. The Nurse’s Role in Child Abuse Detection/Evaluation • Recognition of suspicious injuries • Report suspected abuse • Remain objective • Advocate for the child

39. Consequences of child abuse and neglect • The cycle continues: nearly 1/3 of abused and neglected children will eventually victimize their own children • 80% of young adults who had been abused met the diagnostic criteria for at least 1 psychiatric disorder at the age of 21 (including depression, anxiety, eating disorders, & post-traumatic stress disorder)  • The rate of child abuse is estimated to be 3 times greater than is reported. • The rate of victimization is 12.3 children per 1,000 children • Children ages 0-3 are the most likely to experience abuse. They are victimized at a rate of 16.4 per 1,000 • 79% of the children killed are younger than 4. • These statistics are from the Administration for Children & Families of the US Department of Health & Human Services “Child Maltreatment Report 2003” 

40. The Link Between Child Abuse & Substance Abuse • Children who have been sexually abused are 2.5 times more likely develop alcohol abuse • Children who have been sexually abused are 3.8 times more likely develop drug addictions • Nearly 2/3’s of the people in treatment for drug abuse reported being abused as children

41. Munchausen Syndrome by proxy • A caregiver who feigns or induces an illness in another person • To gain power and control over the victim as well as attention or sympathy from others • The caregiver is usually a parent, guardian, or spouse, and the other person is usually a vulnerable child or adult.

42. Munchausen syndrome by proxy clinical manifestations • A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling and unexplained • Physical or laboratory findings that are highly unusual, discrepant with history, or physically or clinically impossible. • A parent who appears to be medically knowledgeable and/ or fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients’ problems • A highly attentive parent who is reluctant to leave their child’s side and who themselves seem to require constant attention • A parent who appears to be unusually calm in the face of their child’s serious medical course, while being highly supportive and encouraging of the physician, or one who devalues staff and demands further interventions, second opions and transfers to other facilities

43. Munchausen syndrome by proxy • The suspected parent may work in the health care field • The s/sx of a child’s illness do not occur in the parent’s absence (hospitalization and careful monitoring may be necessary to establish this causal relationship) • A + family hx of similar illness/ death of a sibling • A parent w/ sxs similar to their child’s own medical problems or an illnes hx that itself is puzzling and unusual • A suspected emotionally distant relationship b/t parents; the spouse often fails to visit the pt and has little contact w/ physicians even when the child is hospitalized • A parent who reports dramatic, negative events, such as house fires, burglaries or car accidents that affect them while their child is undergoing tx • A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgement of their abilities

44. Munchausen by proxy • There is no mental health test or evaluation that can rule in or out MBP . • There is no “profile” of personal characteristics that determine if someone is a MBP perpetrator • MBP confirmation-or disconfirmation involves the gathering and specialized evaluation of all possible information

45. Any Questions?? • Sources:  • Prevent Child Abuse America: Current Trends in Child Abuse Reporting & Fatalities: The 2000 Fifty State Survery • National Center on Child Abuse Prevention Research: Prevent Child Abuse America; Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1997 Annual Fifty State Survey • Lung, C. & Daro D. (1996) Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1995 Annual Fifty State Survey. Chicago: National Committee to Prevent Child Abuse. http://www.childabuse.com/fs9.htm • US Department of Health & Human Services Administration for Children & Families. Child Maltreatment 2003: Summary of Key Findings • National Clearinghouse on Child Abuse & Neglect Information. Long-term Consequences of Child Abuse & Neglect 2005 • US Department of Justice • Child Abuse & Neglect Study by Arthur Becker-Weidman PhD • National Institute on Drug Abuse 2000 Report