Child abuse and neglect

80 Child abuse and neglect

Overview/pathophysiology

The problem of child abuse and neglect, formerly called “battered child syndrome,” is now recognized as a serious threat to children in the United States. In 2007, 3.5 million children received child protective services (CPS) investigations or assessments. An estimated 794,000 children were found to be victims of child abuse or neglect with an estimated 1760 fatalities nationally, increased from 1530 in 2006 (Administration for Children and Families [ACF], 2007). Many more children are left permanently disabled, and thousands of victims are overwhelmed by this trauma for the rest of their lives. The national rate of children being investigated or assessed decreased from 2005 to 2007, but the death rate rose each year from 2002 to 2007 except for 2005 (ACF, 2007). More recent data from Reuters Health Information (2009) notes a spike in child abuse in the United States during a recession that is increasing stress on already overwhelmed families and cash-strapped child-protective agencies. Experts estimate the actual number of incidents of abuse/neglect is 3 times greater than those reported.

Child abuse and neglect occur in all cultural, ethnic, occupational, and socioeconomic groups. It is not usually a single event but rather a pattern of behavior that occurs over time. The following factors increase the likelihood of abuse or neglect occurring in families:

• Parental characteristics: Predisposition to maltreatment (perhaps having been victims themselves), substance abuse, lack of parenting skills, poor impulse control, and emotional immaturity.
• Child characteristics: Temperament, physical or cognitive disability that predisposes child to injury, chronic illness or disability, being born to unmarried parents, or hyperactivity.
• Environmental characteristics: Divorce, marital problems, financial strain, poor housing, isolation from support of families or friends.
• Societal factors: Increased violence, children viewed as property and not valued, physical methods of punishment, lack of willingness in community to become involved in family violence issues.

The highest incidence of child abuse and neglect occurs in children younger than 4 yr, with the highest rate of victimization occurring in children from birth to 1 yr. The rate declines as children get older except for sexual abuse. In 2007, 59% of victims suffered neglect, 10.8% suffered physical abuse, 7.6% were sexually abused, 4.2% suffered emotional or psychological maltreatment, and less than 1% were medically neglected. In addition, 13.1% were victims of multiple types of maltreatment, while 4.2% of the children experienced “other” types of maltreatment such as abandonment, threats of harm to the child, and congenital drug addiction (ACF, 2007). The perpetrators most often are one or both of the parents, with mothers the more frequent perpetrator. Terms include:

• Child maltreatment: A broad term that includes intentional physical abuse or neglect, emotional abuse or neglect, and sexual abuse (younger than 18 yr) usually by an adult caregiver, most often the parent.
• Physical abuse: The deliberate infliction of physical injury or pain. It may result from punching, beating, kicking, biting, bruising, shaking, burning, or otherwise harming a child and can occur from overdiscipline or physical punishment.
• Physical neglect: Failure to provide basic necessities such as food, clothing, shelter, and a safe environment in which the child can grow and develop normally.
• Emotional abuse: Deliberate attempt to destroy or significantly impair self-esteem or competence by rejecting, ignoring, criticizing, isolating, or terrorizing the child. The most common form is verbal abuse or “belittling.”
• Emotional neglect: Failure to meet the child’s needs for affection, attention, and emotional support. The most common feature is absence of normal parent-child attachment and interaction.
• Sexual abuse: Contacts or interactions between a child and an adult for the adult’s sexual gratification, with or without physical contact. It includes pedophilia and all forms of incest and rape. It also includes fondling, oral-genital contact, all forms of intercourse, exhibitionism, voyeurism, and involvement of children in the production of pornography. It is thought to be one of the most common but underreported crimes against children.
• Medical care neglect: Failure to provide needed treatment to infants or children who generally have life-threatening or serious medical conditions.
• Munchausen syndrome by proxy: Abuse inflicted on a child in which a parent (usually the mother) fabricates symptoms and falsifies medical history or actually causes an illness that results in evaluation and treatment.
• Shaken baby syndrome (SBS)/abusive head trauma (AHT): Caused by violent shaking of an infant or young child (usually younger than 2 yr with infants 2-4 mo at greatest risk), resulting in severe injury. There are high mortality rates in infant victims, averaging 25% to 33%. Most of the remaining victims suffer permanent physical damage (brain damage, blindness, paralysis, mental retardation, seizures) of varying degrees with only about 15% escaping permanent damage (Childhelp, 2010).

Health care setting

Primary care or emergency department with possible hospitalization resulting from complications. Abuse/neglect also may be found during hospitalization for other reasons.

Assessment

Note: History is critical in making a diagnosis. Frequently in child abuse/neglect cases, the history is inconsistent with injury severity, or it changes during evaluation. It is essential that the nurse taking the history be nonjudgmental and report factual information. This is difficult to do at times, and collegial support is beneficial. History and physical examination will determine needed diagnostic tests.

Physical abuse:

Acts out violently against others; frightened of parents or caregivers; avoids changing clothes (e.g., in gym class); old, new, and multiple injuries; burn or restraint injuries; questionable bruises and welts; questionable burns (e.g., imprint or immersion); questionable fractures (e.g., spiral fracture); questionable lacerations or abrasions (e.g., human bite marks); skull fractures; or internal abdominal injuries.

Physical neglect:

Consistently hungry; poor hygiene (e.g., diaper rash or lice) or inappropriate dress for weather; consistently left without supervision; abandoned; begging or stealing for food; constant fatigue and listlessness; frequently absent or tardy for school; failure to gain weight or failure to thrive (FTT); developmentally delayed; assumes adult responsibility; given inappropriate food, drink, or medication; reportedly ingests harmful substances.

Emotional abuse or neglect:

Antisocial or destructive behavior; sleep disorders; habit disorders such as biting, head banging, rocking, or thumb sucking (in an older child); demanding behaviors; self-destructive, suicide attempt; overly adaptive behavior; emotional or intellectual developmental delays; speech disorders.

Sexual abuse:

Recurrent abdominal pain; genital, urethral, or anal trauma; sexually transmitted diseases; recurrent urinary tract infections; enuresis (involuntary discharge of urine) or encopresis (incontinence of stool not caused by organic defect or illness); pregnancy; sleep disturbances (e.g., nightmares and night terrors); appetite disturbances (e.g., anorexia or bulimia); neurotic or conductive disorders; withdrawal, guilt, or depression; temper tantrums (in older children); aggressive behaviors; suicidal or runaway threats or behaviors; hysterical or conversion reactions; excessive masturbation; sexualized play in developmentally immature children; school problems; promiscuity; reluctance to change clothes. Many children have normal genital examinations.

Munchausen syndrome by proxy:

Signs and symptoms only occur when the perpetrator (usually the mother) is present. Common presenting indicators include poisoning, seizures, apnea, bleeding, vomiting, diarrhea, fever, and even cardiopulmonary arrest.

SBS/AHT:

Often there are no external signs of injury other than change in level of consciousness. The child may have history of poor feeding, vomiting, lethargy, and irritability occurring for several days or weeks. More severe shaking may cause brain damage, seizures, blindness, paralysis, and death. On ophthalmologic examination, retinal hemorrhages are seen. Anterior fontanel may be tense or full when infant is quiet.

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Jul 18, 2016 | Posted by in NURSING | Comments Off on Child abuse and neglect

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