Child abuse and neglect

Child abuse and neglect

Dr. Punnarayan Shrestha MBBS, MD, Paediatrician, KCH

Introduction:

Child abuse is defined as maltreatment to child and it includes abusive actions or act of commission (abuse) and lack of actions or act of omission (neglect), that result in morbidity or mortality. It may cause mild physical injuries to long term psychological trauma or even death of the child. The act of commission includes physical abuse, sexual abuse and emotional abuse. The act of omission includes not providing adequate food, love, medical care etc.

It is very difficult to get exact data of child abuse or neglect because child himself is unable to expose the problem and most of the time caregiver abuses the child he tries to hide the problem. In America in 2009 approximately 3.3 million child abuse cases were reported but estimated were 6 million. Among them 78.3% were neglect, 10.8% physical abuse and 7.6% were sexual abuse. More than 5 children die every day in US as a result of abuse and 80% children that die from abuse are under 4 year. About 50-60% death due to maltreatment are not recorded as death due to maltreatment. About 30% abused children will later abuse their children. (Source: US dept. Of Health and Human sciences, child maltreatment 2009).

In Nepal, CWIN reported 3584 different type of child abuse cases over six month (Jan-Jun 2008). Among 432 cases of child domestic violence 16% were of in school. About 5000-7000 girls are believed to be trafficked every year to India (UNICEF 2000 report).

Classification:

  1. Physical abuse: examples; bruises, bite, burn, punctures, laceration, hair pulling, hematoma, internal organ damage, subdural hematoma etc.
  2. Sexual abuse:- touching, fondling or licking of breast or genitalia.

– Exposure of sexual anatomy

– Involvement in pornography including photography and erotic talk.

– Involvement in prostitution

– Sexual action

  1. Emotional abuse: examples; insult, terrorizing, spurning, isolating etc.
  1. Neglect: nutritional, education, medical, clothing etc.

Risk Factors:

  1. Poverty, unemployment.
  2. Community violence, political conflict.
  3. Parental conflict, spouse abuse.
  4. Single parent, teenage parent.
  5. Substance abuse by caregiver.
  6. Psychosocial problem in families.
  7. Mentally retarded and chronically ill children.
  8. Parents who experienced abuse during childhood.

Clinical features:

Physical abuse

  1. Discrepant history- history from caretaker usually does not correlate with physical findings
  2. Delay in seeking care
  3. Marker of injuries may be present e.g. bruises, burn mark, hematoma fractures

Sexual abuse

  1. Vague nonspecific symptoms – abdominal pain, vomiting, loss of appetite, sleep disturbances, enuresis, features of anxiety or depression, conversive disorder, learning disorder, suicidal tendency, substance abuse.
  2. Physical finding- bite mark, genital injuries like hymen rupture, perineal laceration etc.

Neglect:

– Failure to thrive

– Learning difficulties

– Features of chronic medical illness

Investigations:

  1. Blood Hb, TLC; DLC, coagulation profile may be helpful to rule out infection and bleeding disorder.
  2. X-ray of suspected part to see any fracture.
  3. CT scan of head if subdural or intracranial bleeding is suspected.
  4. USG abdomen may be helpful to see internal injuries.
  5. Urine R/E – UTI may occur in case of sexual abuse.
  6. Urine pregnancy test if pregnancy suspected.

Management:

Diagnosis of child abuse is very difficult. Clinical suspicion is important. Management of child abuse should be multidisciplinary approach. Treating physician has key role to correlate all disciplinary.

Medical management includes treatment of infections.

Surgical treatment – treatment of fractures and subdural hematoma.

Gynecological consultation has to be done to manage sexually abused and pregnant girl.

Psychiatric consultation – for emotional and behavioral therapy.

Social management – child welfare agencies should be informed.

Legal advice – local police may help to prevent further violence.