(Department for Children, Schools and Families 2008).

Foreman (2006) identified that the commonest methods for inducing illness appear to be poisoning, including misuse of prescription medicines, and suffocation, which may both be present in patients admitted to ICUs.

Features of Physical Abuse

These include abrasions, bites (human), bruises, burns, cold injuries, cuts, eye injuries, fractures, hypothermia, intra-abdominal injuries, intracranial injuries, intrathoraic injuries, lacerations, ligature marks, oral injuries, petechiae, retinal haemorrhage, scalds, scars, spinal injuries, strangulation, subdural haemorrhage (NICE 2009). It is also important to acknowledge that when nursing black or ethnic minority children with a dark skin colour it may be more difficult to identify bruising or easier to misdiagnose children with Mongolian blue spots (congenital dermal melanocytosis, a pigmented area which may look like a bruise) as having been abused when clearly they have not. Any health professional involved with a child who has a Mongolian blue spot(s) should fully document such findings in the child’s record. As with any differential diagnosis it is important that the child is examined by a consultant or named doctor with expertise in this area for a careful and thorough assessment.

The evidence on the extent of abuse among disabled children in the United Kingdom suggests that disabled children are at increased risk of abuse and that the presence of multiple disabilities appears to increase the risk of both abuse and neglect (HMG 2010). As a result of these findings dedicated practice guidance was published (Department for Children, Schools and Families 2009).

Neglect

Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health and development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:

• Provide adequate food, clothing and shelter (including exclusion from home or abandonment).
  
• Protect from physical and emotional harm or danger.
  
• Ensure adequate supervision, including the use of care-takers.
  
• Ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs (HMG 2010). Neglect may also occur as a discrete incident with serious life-threatening consequences, for example, leaving a very young child home alone, with inappropriate carers or allowing a young child to play on the road by themselves. Examples which might trigger an alert in the ITU nurse could be a child admitted with immersion near-drowning, a late-night traffic incident or ingestion of medicine such as methadone as a result of inadequate supervision.

Features of Neglect

These include abandonment, bites (animal/insect), clothing, poor hygiene (e.g. dirty child, strong body odour), failure to thrive (centile position), faltering growth, poor state of footwear or wearing too small/large shoes, head lice, lack of engagement in health promotion programmes, health reviews, home conditions, persistent infestations, incomplete immunisation or developmental screening programme, absence of basic necessities, lack of supervision, poor adherence to prescribed medication, poor parental interaction with medical services, scabies, sunburn (care or sun-block not applied) or untreated tooth decay (NICE 2009).

Sexual Abuse

This involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape or buggery) or non-penetrative acts. They may include non-activities, such as involving children in looking at, or producing, pornographic material or watching sexual activities or encouraging children to behave in sexually inappropriate ways (Department for Children, Schools and Families 2010).

Features of Sexual Abuse

Anal symptoms and signs (anogenital injuries, dysuria, foreign bodies), genital symptoms and signs (pregnancy, sexual exploitation, sexualised behaviour (see Emotional, behavioural, interpersonal and social functioning), sexually transmitted infections, vaginal discharge) (NICE 2009). The child in ITU admitted for other reasons may have a history of having suffered abuse of this nature if found to have an unusual anal/genital discharge or have unusual anal/genital features. Although a deeply uncomfortable suspicion, it is preferable to raise concerns and be subsequently reassured than to recover a child who is subsequently discharged into the same abusive circumstances.

Emotional Abuse

This is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate or valued insofar as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s development capability as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying, causing children frequently to feel frightened or in danger, or the exploitation of children or corruption of children. Some level of emotional abuse is involved in all types of ill treatment of a child, though it may occur alone (Department for Children, Schools and Families 2010).

Features of Emotional Abuse

Age-inappropriate behaviour, aggression, body-rocking, changes in emotional or behavioural state, cutting, dissociation, drug-taking, eating and feeding behaviour, encopresis, fearfulness, runaway behaviour, low self-esteem, self-harm, sexual behaviour, smearing (of faeces), wetting (NICE 2009). The heavily sedated child in ITU cannot manifest many of these features but there may be evidence of self-harm and the features identified above may be seen in siblings.

Parent or Carer–Child Interactions

The ICU is a stressful environment and people react in different ways to it. However, experienced children’s nurses have experienced a range of reactions from parents and carers and some may seem to be unusual or inappropriate. The children’s nurse needs to be aware of the possibility that these reactions may alert to cases of domestic abuse or be evidence of emotional unavailability and unresponsiveness. During bedside discussions the parents may provide evidence of age-inappropriate expectations or the child may be unusually defensive or openly hostile to the staff. A detailed history may indicate that the family are isolated or that there are marital disputes where the child is used as a bargaining tool. There is a range of indicators to suggest that the parent–child relationship may not be good; these also include rejection, scapegoating, inappropriate socialisation and response to wetting (NICE 2009). Given the circumstances, the quality of interaction between the sedated child and the parent may not be observed but the quality of interaction between family members and siblings may trigger alarm.

Domestic Violence (DV)

This may be defined as any violence between current and former partners in an intimate relationship, wherever and whenever the violence occurs. The violence may include physical, sexual, emotional and financial abuse (Home Office 2009). Children living in homes where there is domestic violence are now generally recognised as being indirect victims of that violence even when it is not directed at them and is now included in emotional abuse definitions (Department for Children, Schools and Families 2010). In some cases children may be patients on the ICU as a result of either being direct victims of their carer’s violence or as a result of attempting to protect their non-violent carer and having suffered physical harm. Other children may be admitted to the ICU through self-harming behaviours (overdose, cutting) or risky behaviours (joy-riding, binge-drinking) as a direct response to witnessing harm to their non-violent carer.

In other situations an adult patient may be admitted as a result of a domestic assault and their child or children are visitors. In all such cases safety planning must be undertaken in respect of the adult victim, any children involved and staff working on the unit. Named professionals and patient and staff safety teams will assist in action planning.

Impact of Domestic Violence

• Accounts for one quarter of all recorded violent crime.
  
• 1 in 4 women and 1 in 6 men will be victims.
  
• On average two women a week are killed by a current or former partner.
  
• Risks of DV do not differ significantly by ethnicity.
  
• Lesbian, gay, bisexual and transgender communities experience DV in similar proportions (1:4).
  
• A third of children know what is happening; this figure rises to 50% if the violence is repeated.
  
• Children may attempt to stop the DV and put themselves at risk.

Effects of DV on Children

Growing up with DV can have a negative impact on school attainment and the likelihood of school exclusion. DV is not uniform; it has different consequences for victims according to culture, gender and community.

Impact of DV on the Child

• DV features in 19% of child contact applications.
  
• Among children living in refuges 70% report being abused.
  
• Some men involve their children in abusing their mother.
  
• Children may feel powerless or guilty.
  
• Post-traumatic stress syndrome (PTSD).
  
• May affect school attendance and achievement.
  
• May interfere with social relationships.
  
• Often the child will use denial and silence to cope.

Signs and Symptoms of DV

Babies under 1 year show distress characterised by poor health, poor sleeping habits and excessive crying as they may be caught up in the violence or physical abuse. Older children may exhibit PTSD – this has been identified in 80% of uninjured children witnesses and disturbing images and memories of the event are imprinted and return unbidden. The event may be re-experienced in full as a flashback in response to environmental triggers or memories.

Some boys copy behaviour or worry they will become an abuser, while girls are more likely to internalise their feelings. Some children will feel guilt that the abuse was their fault for ‘being naughty’.

DV affects the way in which children behave; some become numb and detached, while others become highly compliant. Some children respond by becoming highly aroused, hyper-alert and jumpy with impaired concentration and memory. Many children exhibit disturbed sleep patterns.

Risk Factors of DV

• Previous DV: 35% have a second incident within 5 weeks.
  
• Minor violence is a predictor of escalation to major violence.
  
• Separation: 22% are assaulted after separation.
  
• Substance misuse: 32% said their attacker had been drinking.
  
• Certain drugs (e.g. cocaine or crack cocaine) more likely to be associated with violence.
  
• Pregnancy: 33% of DV starts or escalates in pregnancy.
  
• Of all female homicides 45% are victims of DV (8% male victims).
  
• On average a woman will be assaulted 35 times before she tells a professional.

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