Child abuse and maltreatment

Dr Samaneh Farnia

Child and adolescent psychiatrist

Mazandaran Univrsity of Medical Sciences

• The best available data suggest that approximately 30% of child and adolescent psychiatric outpatients , and as many as 55% of child and adolescent psychiatric inpatients have a lifetime history of abuse or neglect

A history of abuse is a highly significant risk factor for the development of

• Psychiatric disorders, Affective dysregulation, aggressive behavior, insecure attachment, academic under-achievement

• Medical health problems

Child abuse

Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.

four major types of maltreatment:

• Physical abuse,

• sexual abuse,

• psychological maltreatment,

• neglect

CDC reports:

• Emotional abuse 12%

• Physical abuse 9%

• Neglect 3%

• Sexual abuse 1% ( 10 -25 % of girls)

آمار اورژانس اجتماعی

هشت درصد از مداخلات : کشوراورژانس اجتماعی رئیس کهاورژانس اجتماعی مربوط به کودک آزاری است

،کودک آزاری مربوط به غفلت و بی توجهیدرصد آن 50•

درصد از نوع آزار عاطفی و روانی، 30•

وآزار جسمی درصد 16تا 15•

جنسی استآزار درصد 4تا 3•

آمار اورژانس اجتماعی

پدر، درصد کودک آزاری توسط 57•

مادر، درصد از سوی 26•

درصد از سوی خواهر و برادر و 1.3•

درصد توسط نامادری و ناپدری و 9تا 8•

غریبهدرصد از سوی افراد 1.5•

.انجام شده است

Homicide

• During 1st week : exclusively by mothers

• 1st week to 13 y : mothers = fathers

• 13 y to 15 y : fathers 63%

• 16 y to 19 y : fathers 80%

Risk factors

• Parental mental illness or substance abuse

• Lack of social support

• Poverty

• Minority ethnicity

• 4 or more children in a family

• Young parental age

• Parental hx of abuse

• Stressful events and violence

Risk factors

• The most common age of initial sexual abuse is 8-11 y.

• Sexual abuse in all SES

• Known perpetrators more common than extra-familial source

• Physical abuse and neglect in lower SES

• Child: prematurity, ID, physical handicaps

Clinical presentation

Caregiver• Lack of reasonable explanation for the injury• Excessive or inadequate level of concern• Delay in seeking medical attentionChild • Unusually fearful and distrustful• Afraid to go home• Sleep difficulties• Substance abuse• Hypersexual behavior

Medical finding

• Cutaneous injuries, bruises, lacerations in the shape of an object or in special areas e.g. upper arms, medial thighs

Medical finding

• Head injuries , ICH, retinal hemorrhage, bilateral ocular injury, traumatic hair loss with scalp hematoma

Medical finding

• Stocking –glove distribution burns, perineum burn, multiple burn in various stage of healing, recognizable shape

Medical finding

• Skeletal injuries, posterior rib fx, multiple fx in various stage of healing, metaphyseal fx in long bones of infants, spiral fx, subperiostealhemorrhage, epiphyseal separation,…

Medical finding

• Ear injuries, twisting injuries of the lobe,…

• Abdominal injuries, hepatic hematoma, laceration, …

• Chest injuries, pulmonary contusion’ pneumothorax, pleural effusion

Medical finding of sexual abuse

• Vague somatic complaints (abd. pain, headaches)

• Secondary enuresis and encopresis

• Redness or irritation, laceration, scarring, bruising of anogenital, anal dilatation

• Repeated UTI and or hematuria

• Anal fissures or blood in the stool

Intervention

• History taking before P/E

• Use of sedation for collection of forensic samples if the child is unable to cooperate

• Offer reassurance about healing and recovery

• A careful history and comprehensive physical exam

• A minimum number of times, smallest number of clinicians

• Exam should not cause additional emotional trauma

Intervention

• Radiologic documentation of skeletal injuries (in child less than 2 y but not helpful in children older than 5 y)

• Brain or head injuries (CT scan)

Impact of abuse

• Timing/ duration/ frequency and specific characteristic of abuse

• Child’s resilience and vulnerability

• Poor outcome : longer duration, use of force, penetration in sexual abuse, perpetrator close or related to child

Impact of abuse

• Overstimulation of HPA , elevated cortisol level

• Altered brain homeostasis, limbic and hippocampal damagememory deficit and emotion dysregulation

• Dissociative mechanism first protective then maladaptive

Impact of abuse

• Hyperarousal, vigilance, irritability, aggression, sleep difficulties

• Attachment dysregulation

• Substance abuse and self injurious behavior

• Attentional problems

• Depression and suicide

• Dissociative and psychotic disorders

• Anxiety and PTSD

• Multiple somatic and health problems

Impact of abuse

Substance use, self medication

• Alcohol serves to reduce anxiety

• Opiates trigger soothing dissociation

• Stimulants activate mesolimbic dopaminergic rewards area in children deprived of true rewards in their lives

- Physical abuse enact, more support, less PTSD

- Sexual abuse secrecy and shamemore PTSD

Prevention

• Home based models

• School based models

• Identifying high risk groups

• Provide an accepting relationship

• Increase family’s competence

• Decrease social isolation

• Parenting groups

Child and parent treatment

• Protect the child

• Strengthen the family

• Supportive and problem oriented approaches

• Family based therapy

• TF-CBT

• Play therapy

• Clonidine

Clonidine (an α-2-agonist) to decrease NE release(0.003-0.010 mg/kg)Initial dose of 0.05 mg of clonidine for patients between 4 and 17 years of age, about half an hour before bedtime and increased by 0.05 mg increments to a maximum of 0.4 mg

Clonidine should be tapered gradually when it is discontinued, even if it is used only at night for insomnia.

Given that many children and adolescents with PTSD have comorbid depressive and anxiety disorders, SSRIs are recommended in the treatment of these coexisting disorders.

Initial dose children adolescents

Citalopram 10 20-40 20-40

Escitalopram 5-10 10-20 10-20

Fluoxetine 10 20 20-40

Fluvoxamine 25 50-200 50-200

Sertraline 12.5 - 25 50-200 50-200

Paroxetine 10 10-30 20-40

References

• Dulcan’s texbook of child and adolescent psychitry , 2016

• Green’s child and adolescent clinical psychopharmacology, 2019

• Kaplan_&_Sadock’s_Comprehensive textbook of psychiatry , 2017, Wolters Kluwer.