child abuse malaysian medical student 2012 13

Definition, Incidence Child Abuse In Malaysia And Its Complications

PREPARED BY MOHD HABROL AFZAM BIN ABD WAHAB

افزام حبرؤل محمدSTUDENT NO - 06-5-091

Definition • Child abuse is the bad

treatment of a child under the age of 18 by a parent, caretaker, someone living in their home or someone who works with or around children.

Reports of Child Abuse In Malaysia

Year Child abuse reports

2003 2,555

2004 3,101

2006 1,999

2007 2,279

2008 2,780Statistics from the Department of Social Welfare

The complications of Child Abuse Will Be Presented At The End Of Presentation.

Child Abuse (Classification)

Mohd Syafiq Bin Shahbudin06-06-102

Neonaticide

Definition: • It is killing of a premature or full term baby

within 24hours after birth. • This case rarely in developed country. It is done

usually by young single uneducated mother by act of commission or omission.

Cultural aspect: • The Chinese, as late as the 20th century,

dispatched newborn daughters because they were unable to transmit the family name.

Causes: 1) forbidden intercourse of unmarried young girl. 2) been raped and lead to unwanted child from

the assailant.

Infanticide

Definition: • It is killing of newly born, live born infant within 12

months after birth.

Etiology: • The mother with maternal psychosis (especially

puerperal depression) is almost always the perpetrator.

Euthanasia

Definition: • It is killing of a handicapped (physical, mental

or both) child usually under 3 years by a parent.

Perpretrator: • The mother is usually the maker.

Causes :

• low economic status of the parents that can’t afford to maintenance their handicapped child.

• no support from government and public to help unlucky parents like an association to assist parents by giving free consultation, equipments to facilitate handicapped child.

• poor mental state of the parents. • unfaithful parents.

Syndrome of repetitive physical child abuse

• It occurs more frequently in families of lower socioeconomic standard.

• The child is usually in the age group 6 weeks – 5 years and experiencing pleomorphic assaults often with increase in severity and frequency

Causes: 1) Great stress - Many people who commit physical abuse were

abused themselves as children. As a result, they often do not realize that abuse

is inapproriate discipline. 2) Poor impulse control - This will prevents them from thinking about the

result from their actions.

Statistic:

• The rate of child abuse is fairly high. The most common form is neglect

Classification of Child Abuse

By: Muhamad Ariff Bin Mohd Randzan

06-6-109

(5) Child neglect:It may take many forms: Physical neglect (food,

hygiene, clothes). Safety neglect. Medical neglect. Educational neglect. Emotional neglect.

(6) Murder-suicide: Often whole family is killed

usually in one accident.

(7) Murder-homicide: The great majority of victims

are girls after sexual assaults.

(8) Sexual abuse:1- Assaultive: producing injury or

severe emotional trauma.2- Non-assaultive: causing no or

little physical trauma & less emotional stress.

(9) Emotional abuse: It is persistent rejection or

coldness of parents or guardian toward a child which affect his behavior & development.

Thank You

RISK FACTORS OF CHILD ABUSE

Omar Mokhtar Bin Che Azani

06-6-67

Risk Factors Parental factors Family factors Child factors Environmental factors

Parental Factors

Personality characteristics and psychological well-being

History of childhood abuse Substance abuse Attitudes and knowledge Age (young parents 15-20 years)

Personality characteristics and psychological well-being

No consistent set of characteristics or personality traits has been associated with abusive parents.

Some characteristics frequently identified in those who are physically abusive or neglectful include:low self-esteem, poor impulse controldepressionanxietyantisocial behavior

History of childhood abuse A parent's childhood history plays a large part

in how he or she may behave as a parent. Individuals with poor parental role models or

those who did not have their own needs met may find it very difficult to meet the needs of their children.

There are individuals who have not been abused as children who become abusive, as well as individuals who have been abused as children and do not subsequently abuse their own children.

Substance abuse

Substance abuse can interfere with a parent's mental functioning, judgment, inhibitions, and protective capacity.

Attitudes and knowledge

Negative attitudes and attributions about a child's behavior and inaccurate knowledge about child development may play a contributing role in child maltreatment.

For example, some studies have found that mothers who physically abuse their children have both more negative and higher than normal expectations of their children, as well as less understanding of appropriate development of the children.

Age

Mothers who were younger at the birth of their child exhibited higher rates of child abuse than did older mothers.

Other contributing factors, such as lower economic status, lack of social support, and high stress levels may influence the link between younger childbirth—particularly teenage parenthood—and child abuse.

Family Factors

Family structure Marital conflict and domestic violence Stress Parent-child interaction

Family structure Children living with single parents may be at higher risk

of experiencing physical and sexual abuse and neglect than children living with two biological parents.

Single parent households are substantially more likely to have incomes below the poverty line.

Lower income, the increased stress associated with the sole burden of family responsibilities, and fewer supports are thought to contribute to the risk of single parents maltreating their children

In addition, studies have found that compared to similar non-neglecting families, neglectful families tend to have more children or greater numbers of people living in the household

Marital conflict and domestic violence 30 to 60 % of families where spouse abuse takes

place, child maltreatment also occurs. Children in violent homes may witness parental

violence, may be victims of physical abuse themselves, and may be neglected by parents who are focused on their partners or unresponsive to their children due to their own fears.

A child who witnesses parental violence is at risk for also being maltreated, but, even if the child is not maltreated, he or she may experience harmful emotional consequences from witnessing the parental violence.

Stress

Stress is also thought to play a significant role in family functioning.

Physical abuse has been associated with stressful life events, parenting stress, and emotional distress in various studies.

Parent-child interaction

Families involved in child abuse seldom recognize or reward their child's positive behaviors, while having strong responses to their child's negative behaviors.

Abusive parents have been found to be less supportive, affectionate, playful, and responsive with their children than parents who do not abuse their children.

Research on maltreating parents, particularly physically abusive mothers, found that these parents were more likely to use harsh discipline strategies and verbal aggression and less likely to use positive parenting strategies.

Child Factors

The abnormal or disable child The rejected child Other child characteristics

The abnormal or disable child Children with physical, cognitive, and emotional disabilities appear

to experience higher rates of maltreatment than the other children. In general, children who are perceived by their parents as

"different" or who have special needs including children with disabilities, as well as children with chronic illnesses or children with difficult temperaments may be at greater risk of abuse.

The demands of caring for these children may overwhelm their parents.

Disruptions may occur in the bonding or attachment processes, particularly if children are unresponsive to affection or if children are separated by frequent hospitalizations.

Children with disabilities also may be vulnerable to repeated abuse because they may not understand that the abusive behaviors are inappropriate, and they may be unable to escape or defend themselves in abusive situations.

The rejected child This child may be unwanted sex or

pregnancy. This unwanted child usually will be maltreat because the parent itself do not want to have that child.

For example, the mother who was raped tend to abuse her child to show her anger and revenge towards the rapist.

The study shows that parent who want the children will treat their child better than the parent who have the child from the unwanted sex or pregnancy.

Other child characteristics Some studies suggest that infants born

prematurely or with low birth-weight may be at increased risk for maltreatment

The relationship between low birth-weight and maltreatment may be attributable to higher maternal stress heightened by high caregiver demands, but it also may be related to poor parental education about low birth-weight, lack of accessible prenatal care, and other factors, such as substance abuse or domestic violence.

Child factors such as aggression, attention deficits, difficult temperaments, and behavior problems or the parental perceptions of such problems have been associated with increased risk for all types of child maltreatment.

These factors may contribute indirectly to child maltreatment when interacting with certain parental characteristics, such as poor coping skills, poor ability to empathize with the child, or difficulty controlling emotions.

In addition, these same child characteristics may be reinforced by the maltreatment.

Environmental Factors

Poverty and unemployment Social isolation and social support Violent communities

Poverty and unemployment Poverty and unemployment show strong associations

with child maltreatment, particularly neglect. Poverty particularly when interacting with other risk

factors such as depression, substance abuse, and social isolation can increase the likelihood of maltreatment.

Low income creates greater family stress, which, in turn, leads to higher chances of maltreatment.

Parents with low incomes, despite good intentions, may be unable to provide adequate care while raising children in high-risk neighborhoods with unsafe or crowded housing and inadequate daycare

Some other characteristics may make parents more likely to be both poor and abusive

For example, a parent may have a substance abuse problem that impedes the parent's ability to obtain and maintain a job, which also may contribute to abusive behavior

Poor families may experience maltreatment at rates similar to other families, but that maltreatment in poor families is more frequent

Social isolation and social support Some studies indicate that compared to

other parents, parents who maltreat their children report experiencing greater isolation, more loneliness, and less social support.

Social isolation may contribute to maltreatment because parents have less material and emotional support, do not have positive parenting role models.

Violent communities

Children living in dangerous neighborhoods have been found to be at higher risk than children from safer neighborhoods for severe neglect and physical abuse, as well as child sexual victimization.

THANK YOU FOR LISTENING

INVESTIGATIONS IN A CASE OFCHILD ABUSEAhmad Farhan Bin Mahabot06-6-9

MEDICAL HISTORY

Good rapport

General to specific

Open-ended Qs

Professional

Child alone

Confidentiality

Video/audiotapped

Conducting Interviews

MEDICAL HISTORY

Suggestive findings: A history that does not match the nature or

the severity of the injury Vague parental accounts or accounts that

change during the interview Accusations that the child injured

him/herself intentionally Delay in seeking help Child dressed inappropriately for the

situation

GENERAL SIGNS

Emotional abuse Excessively withdrawn and fearful Anxious about doing something wrong Extremes in behaviour Lack of attachment with the

parent/caregiver Acts inapproppriately adult or infantile

GENERAL SIGNS

Physical abuse Unexplained injuries e.g. bruises, burns or

cuts Certain pattern such marks from hand or

belt Always watchful or ‘on alert’ for bad things Wears inapproppriate clothing to cover

injuries Admitting to punishment that seems

excessive

GENERAL SIGNS

Child neglect Wears ill-fitting and filthy clothes Consistently bad hygiene Untreated ilness and physical injuries Left alone in unsafe environment Begs or steals food or money

GENERAL SIGNS

Sexual abuse Trouble walking or sitting Starting to wet at bed and having

nightmares Doesn’t want to change clothes in front of

others Lustful act and seductive behaviour Medical conditions like STDs or pregnancy

THANK YOU

PHYSICAL EXAMINATION & REGIONAL SIGNS of child abuse.

Prepared by:

NOOR AZILA BINTI ABDULLAH

06-6-21

PHYSICAL EXAMINATION

Detailed documentation of concerning findings :

1. BODY DIAGRAM & PHOTOGRAPH Nutritional neglect, Fail to meet expected growth

Photo of injuries

2. CLOTHING Signs of neglect (dirty, ill-fitting, stained, unwashed, bad

odour),

Wearing clothes inappropriate to the weather (to cover bruises)

3. REGIONAL EXAMINATION & SIGNSsearch for other signs that may indicate a non-traumatic cause of injury

REGIONAL SIGNS

HEAD

NECK

EYES

EAR

MOUTH & LIPS

CHEST

ABDOMEN

ABUSIVE HEAD INJURIES

This area is vulnerable to injury because of a child’s small stature.

It may be the closest body part to an adult’s hand or fist.

It is where the crying, back talk, bad language, etc. is emanating from.

WHY???

GENERAL SIGNS OF HEAD INJURY

Some children will present with clear signs of head injury. They will either be :

unconscious or

show signs of brain injury (such as fitting, paralysis or extreme irritability)

However, some children may present with less obvious signs, such as:

increased head circumference,

poor feeding,

excessive crying.

“SHAKEN BABY SYNDROME”(CAFFEY’S SYNDROME/ BATTERED CHILD SYNDROME)

• Excessive violent shaking or sudden impact to head

• Most commonly in children less than 2 years of age.

• Characterized by retinal, subdural and/or subarachnoid hemorrhages

• May present with coma or seizures without obvious evidence of scalp trauma

Intracranial haemorrhage occurs as a result of severe angular acceleration, deceleration & direct impact as the head strikes a solid object. 

The chest is compressed resulting in rib fractures. 

Arms & legs move about in a whiplash movement resulting in the typical 'corner' or 'bucket-handle'-fractures in the metaphyseal region.

LOCAL (PHYSICAL) SIGNS OF HEAD INJURIES

SCALP

FACE

EYE

EAR

MOUTH

NECK

SKULL FRACTURES

Skull fractures are common child abuse injuries, but they are also common in accidental trauma. 

Patterns of skull fracture that suggest child abuse are:

• Multiple 'eggshell' fractures

• Occipital impression fractures

• Fractures crossing sutures

LEFT: eggshell fractures in a child who died of cerebral injury after being thrown of a height

RIGHT: skull fracture crossing suture in abused child

Scalp Injuries

SCALP BRUISES/SCAR

SCALP LACERATION (CUT WOUND)

TRAUMATIC ALOPECIA

Face injuries

CUT WOUNDS & BRUISES

SLAPPING MARKS

BRUISES & PETECHIAE

Black eye (Raccoon eye)

Ear injuries

Post-auricular bruising

Subgaleal hematoma & Fingernail prints

Bite mark

Mouth injuries

Tongue laceration --note that this child had no teeth that could have caused this.

Brusing on soft palate from forced oral sex.

Fractured teeth as a result of a backhand blow to the face.

Trauma from a direct blow to the child's mouth.

Torn frenulum

Neck injuries

Burn on side of the neck

Strangulation mark

Choking mark

CHEST INJURIES

EXTERNAL INJURIES RIB FRACTURES

They are not evident on x-ray in the acute stage, as little displacement occurs. 

They are identified in the healing stage as a result of associated callus.

Old posterior rib fractures very indicative of non accidental trauma.

Skin of the chest showing “belt-marks” & bruises.

INTERNAL ORGAN INJURIES

Visceral injury is seen at autopsy of young infants, but it is rarely documented radiologically in living victims less than 1 year of age.

The mortality rate is 50% due to 'patients and doctors delay‘ -- children are brought to the hospital days after the injury, when perforation already has resulted in peritonitis and sepsis.

Common abdominal injuries in abused children are:

• liver laceration

• duodenal perforation/ hematoma

• pancreatic laceration.

VISCERAL INJURIES

Pancreatic laceration Liver laceration

VISCERAL INJURIES

A, A round, fading bruise over the right lower abdominal wall. Note the marked abdominal distention. B, At surgery she was found to have diffuse peritonitis, and two large rents were discovered in the jejunal mesentery. C, A long segment, found to be necrotic with a perforation, and adjacent bowel that appeared nonviable were resected.

THANK YOU!

Child abuse (cont.)

Student name : Mohammad Amin bin KhairudinStudent number : 06-5-86

Limbs :Bruises – around joints ( especially

wrist,forearm,upper arm,thighs and ankles ) from gripping in order to swing or shake the infant

Fractures – at any site in diaphysis , may be multiple

Spiral fractures – indicate twisting injuryTraction – Avulsion of parts of metaphysic

and slipped epiphysis Joint effusions

Bites : Abuser bites, self- inflicted bites and other

children bites must be distinguished.Favorite sites : Arms,back of

hands,cheeks,shoulders,buttocksShape : Two opposing semicircles

with abrasion,contusion,or bothSize : Dental arch size determines

whether it is done by adult,child,or animal

Bite mark example

Burns :1. Dry burns - Burns in unlikely sites e.g. buttocks and perineum.Children may be sat on hot plates,branded with irons or hot metals. - Cigarette burns on areas normally covered by clothing usually multiple and of different ages.2. Scalds - Over hot bath water - Deliberate pouring of hot water - Dipping in hot liquid

Poisoning : Occurs more commonly in baby sitters.The drugs used

more are antihistamines,cough mixtures and laxatives.

Scald example 1

Scald example 2

Radiological Examination In Child

AbuseBy Kamarul Azhar bin Mohamed

06-06-79

For children younger than 2 years suspected of having been physically abused, a skeletal survey is recommended to rule out skeletal injury.

To evaluate for missed physical abuse and unsuspected fractures

Provide the diagnosis of abuse in 50% of the children with positive skeletal survey results

Radiological examination

1.Long-bone injuries◦ Direct blow /shear force

2.Rib fractures◦ Compressive force

  3.Head injuries

◦ Forceful shaking

Common sites of skeletal injury

Fracture may cross the diaphysis in an oblique or transverse plane

Fracture may occur at metaphysis known as classic metaphyseal lesion(corner/bucket handle lesion)

1.X-ray

Highly specific and classic metaphyseal lesion (CML) occurs when a torsional force is applied to the immature primary spongiosa adjacent to a cartilaginous growth plate.

Fractures of the posterior rib, scapula, spinous process, and sternum(bones which are ordinarily difficult to break)

Fractures in different stages/ages of healing Fractures are usually multiple

Findings suspected of abuse

multiple bilateral rib fractures of different ages

Useful in patients with:◦ Head injury, especially with skull fractures◦ Acute neurological findings◦ Physical examination show retinal haemorrhage◦ Visceral injuries and retroperitoneum

haemorrhage

Common findings in cases of abuse:◦ Subdural especially interhemispheric and

subarachnoid hemorrhage◦ Duodenal and proximal jejunum injuries

2.Computed tomography scan (CT):

Subarachnoid hrg Subdural hrg

CT scanning of the thorax(lung injury) and abdomen(duodenal injury)

CT scanning of the liver injury

More sensitive to small subdural and subarachnoid haemorrhages, contusions of cortex and deep white matter lesions.

Used when CT findings is confusing such as:◦ for differentiating a hypoattenuating subdural

hematoma from cerebrospinal fluid (CSF)◦ detecting small and chronic extra-axial fluid

collections.

3.Magnetic resonance imaging(MRI):

Importances of MRIDetect most commonly

brain parenchymal injuries

shear injury

gray matter–white matter junction

corpus callosum

midbrain

edema contusion

No role in the evaluation of acute abusive injury.

May be used:◦ In unstable patients being examined in the

emergency department for initial screening for visceral injuries and free fluid.

Less sensitive than CT scanning  

4.Ultrasonography

assists in identifying new rib fractures and subtle long bone fractures not apparent on the skeletal survey especially at the costovertebral junction

5.Radionuclide bone scanning (Scintigraphy)

  Has high sensitivity and low specificity in

cases of child abuse. Correlation with x-ray is always necessary  

Complications Of Child Abuse

PREPARED BY MOHD HABROL AFZAM BIN ABD WAHAB

افزام حبرؤل محمدSTUDENT NO - 06-5-091

Child AbuseComplications Fine / Penalty

• Health and physical effects

• Intellectual and cognitive development

• Emotional, psychological, and behavioral consequences

• Punishable under the Child Act (2001) and the Penal Code (revised 1997).

• Offenders may be liable to a maximum fine of RM 50,000 ( about 100,000 EGP ) or up to 20 years imprisonment, or both depending on the offence.

• Offenders may also be punished with whipping in addition to the fine and/or imprisonment

Health and physical effects

• The immediate effects of bruises, burns, lacerations, and broken bones

• Longer-term effects of brain damage, hemorrhages, and permanent disabilities.

Intellectual and cognitive development

• Evidence of lowered intellectual and cognitive functioning in abused children as compared to children who had not been abused, and other studies find no differences.

• Research has consistently found that maltreatment increases the risk of lower academic achievement and problematic school performance. Abused and neglected children in these studies received lower grades and test scores than did no maltreated children.

Emotional, psychological, and behavioral consequences

• Emotional and psychological Consequenceso Low self-esteemo Depression and anxietyo Post-traumatic stress

disorder (PTSD)o Attachment difficultieso Eating disorderso Poor peer relationso Self-injurious behavior (e.g.,

suicide attempts)

.

Emotional, psychological, and behavioral consequences

Child Abuse (Prevention)

Mohd Syafiq Bin Shahbudin06-06-102

Prevention :

• Recognize the warning signs of abuse• Have alcohol or drug problems• Have a history of abuse or was abused as a

child• Have emotional problems or mental illness• Have high stress factors, including poverty• Not look after the child's hygiene or care• Not seem to love or have concern for the child

• Counseling or parenting classes may prevent abuse when any of these factors are present. Watchful guidance and support from the extended family, friends, clergy, or other supportive persons may prevent abuse or allow early intervention in cases of abuse.

References

• http://emedicine.medscape.com/article/407144-overview

• http://emedicine.medscape.com/article/915664-overview

• Lectures of forensic medicine textbook by staff members of department of forensic medicine and clinical toxicology, faculty of medicine, Alexandria University.

THANK YOU VERY MUCH