child abuse elisa a. mancuso rnc, ms, fns professor of nursing
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Child AbuseChild AbuseChild AbuseChild Abuse
Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS
Professor of NursingProfessor of Nursing
History
• Greeks- sacrificed to god
• England– children worked as chimney sweeps.
• America– children worked as coal miners.
Mary Ellen Case 1874
• First documented abuse case• Beaten and abandoned by
mother– left hours in closet
Etta Whealer social worker brought case to ASPCA
• Led to Society for Prevention of Cruelty to Children (SPCC)
Dr. Kempe1962 “The Battered Child Syndrome”
• Identified specific symptoms of abuse– Many bruises & old fractures on x-rays
• Urged MD’s to report suspected child abuse
• Lead to professional and public awareness of child abuse and neglect in the US.
Dr. Fontana
1963 “The Maltreatment Syndrome” • Identified children deprived of
food, clothing, shelter and parental love.
• Children not attaining appropriate growth & developmental milestones.
• No underlying pathological factor.
The Child Abuse Prevention and
Treatment Act 1974Provided federal funding to help fight child abuse
2008 Statistics• 3.5 million alleged abused or neglected • 905,000 actual victims
– 64.1 % Neglect– 16 % Physical– 8.8 % Sexual– 6.6 % Emotional– 2.2 % Medically Neglect
• 1,710 died = 4 children/day!!
• One child every 10 seconds being abused!! • • www.ocfs.state.ny.us/main/cps
Who are the abusers?
• 48 % male 52 % female
• 84 % being abused by parent
• 41 % MOTHER• 19 % FATHER• 17 % Both PARENTS
Abused ChildChild <18 years of age.Whose responsible adult-• Inflicts non accidental physical
injury• Creates risk of physical injury• Creates risk of emotional health• Commits or allows a sexual offense
against child• Has potential for abuse
Substance Abuse
Maltreated or Neglected Child
Child <18 years old Whose responsible adult:• Fails to provide the minimum
degree of basic needs.• Example:
Inadequate food, shelter or Abandoned child.
Emotionally Neglected Child
Child <18 years old • Failure to meet the child’s needs for
affection, attention and nurturing.• Failure to Thrive (FTT)
< 10th % in height and weight with no organic cause.
• Verbal abuse- “You’re stupid”• Kids can be aggressive and • impulsive, or have feeding
disorders
Abusive Adult
• May have been abused or neglected as a child.
• A MAJOR RISK FACTOR
• Learn aggression is appropriate.
• Difficulty controlling impulses and forming attachments
Substances Abuser
• Primary concern is habit • Little or no concern for
children.• Drug use decreases inhibitions
and impulse control• Increase in illegal activity
– Stealing or Prostitution – Involve children in prostitution
and pornography.
Social Isolation
• Lack of emotional support.
• Low self esteem.
• Moves residence frequently.
• Distrust others
Life Crisis• Multiple stressors/inadequate
coping mechanisms.• Single parents
– ↑↑ Responsibility for sole parent.
• Teenage pregnancy • “Babies having babies”
– Parents immature and fewer resources.
Homelessness
Knowledge Deficit
• View child as miniature adults.• Absence of Child Nurturing Experience• Parent had no loving relationship
– Expects baby to provide love.
• Violence and corporal punishment is accepted as discipline.
• Parents view child as bad or evil.
Unrealistic Expectations
• Limited knowledge – Unrealistic expectations of
appropriate developmental milestones
• Preemies and disabled children are @ high risk for abuse – Secondary to high tech constant
care.
Signs of Physical Abuse
Bruises- • Various stages of healing.• Bilateral and generalized. • Unilateral are usually with accidents.• Clustered patterns reflect objects
used:– Belt, hand, spoon, wire
• Face, mouth, lips, torso, back, palms, buttocks, thighs, soles of feet
Lacerations
• Mouth, lips, gums- oral sex
• Laceration of frenulum could be from forcing bottle in mouth or penis.
• External genitalia, penis, vagina, anus
Burns• Cigarettes
– circular and evenly shaped.
• Hot water submersion – “Sock like or Glove like” burn
•No splash marks.
• Stun gun– circular and uniform 0.5cm.
Fractures• Multiple fractures in various
stages of healing. • Spiral fracture = Red Flag!
• Old rib fractures/skull fractures.
• Dislocation of shoulder/elbow.
Head Injuries
• Hair pulling-bald patches.
Shaken Baby Syndrome• Whiplash from shaking• Subdural hematoma• Meningeal tear• Retinal hemorrhage• Seizures • Death
Poisoning
• Intentional giving harmful substances: Crack, cocaine, MDMA or alcohol.• Unintentional – Free Access (Neglect)
Munchausen Syndrome by Proxy• Parent fabricates illness of child• Gains attention & viewed as concerned• Signs of illness only occur when parent
• in room.
Sexual Abuse
2008 • 80,000 episodes/year (under reported)• Incest Molestation Rape• Child Pornography Child Prostitution
• Higher incidence with females • High risk with father, family member or
male friend • Rare for a stranger
Physical Signs of Sexual Abuse
• Sore throats• Vaginal infections• Bruises on hard/soft palate• Incontinence• Pain itching genital area• Torn stained bloody underwear• Loss in rectal tone Non-intact hymen in females
Behavioral Signs of Sexual Abuse
• Reluctant to change in gym class• Self mutilation• Excessive masturbation in young child• Withdrawal• Promiscuous behavior.• Alcohol/drug use• Eating disorders• Suicide Attempts Regressive behaviors Severe mood swings
Nursing Interventions
Provide privacy• Separate from parents• Maintain safe environment
• Monitor Verbal & Non-Verbal Cues!• Identify child’s words for genitals• Provide opportunity to talk• Abuse is not their fault• Reinforce that telling someone was right thing to do
Report ProcedureReport Phone # • 1-800-635-1522 (State Central Register) • 1-800-342-3720 (CPS hotline)
Immediately notify charge nurse/supervisor or can report independently.
• First oral report • Submit written report DSS-2221A in 48 H. • (Nursing supervisor or MD does this with
local CPS.) Report is admissible in court
DSS-2221A Report
• RN is mandated reporter.
• Class A Misdemeanor Failure to report suspected child
abuse/maltreatment
• Make report clear, objective and accurate.
History of Injury
• Date, time and place• Sequence of events• Describe parent and child
interactions – Are they appropriate?– Who does child reach out to?
• Presence of witnesses.• Interview with child and parent
individually.– Congruent reports?
Physical Examination
• SANE (Sexual Assault Nurse Examiner)
• Anatomical location of injury
• Size, shape and color of distinguishing marks.
• Pain or bone tenderness and ROM.
• State of health and hygiene Appears malnourished/unkempt
Documentation• Pictures
– Date, time, pt name, med record #. – X-rays
• Clothes– Note if torn, body fluids or bloody– Do not remove from the child if
possible
• Lab reports• Chain of custody must be• maintained.
Actions taken• What was done?
– If child admitted to hospital and CPS notified and will be involved.
• Where was child placed? – Relative’s home or foster care.
• Who was notified? – Name of case worker and case
number to be placed on chart.
• CPS must complete investigation
• in 60 days.
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