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Family Violence

Health Promotion Disease Prevention

Instructor: Gregory M. Chase, MS Emergency Medicine, MSHED, PA-C, RN

Recognizing Child Abuse, Community Health Introductory Program: Principles of Instructional Design

Author: Gregory M. Chase, MS, MSHED, PA-C, RN.
Dr. David Sellen, PhD precepting

When you have concerns for a child's well-being, the indicators listed below may help guide you in your thought process. Many of these "symptoms" or "signs" could be caused by things other than abuse or neglect. Generally, these indicators do indicate that a child's safety may be at risk and, at the very least, the situation should be assessed by a professional able to determine the causes of these symptoms and offer the help and assistance necessary to reduce the risk to a child.

Signs of Physical Abuse

• Unexplained bruises and welts on the face, throat, upper arms, buttocks, thighs or lower back in unusual patterns or shapes which suggests the use of an instrument (belt buckle, electric cord) on an infant in various stages of healing regularly appear after absence, weekend, or vacation
• Unexplained burns cigarette burns, especially found on palms, soles of feet, abdomen, buttocks immersion burns producing "stocking" or "Glove" demarcations on hands and feet; "doughnut shaped" on buttocks or genital area
• rope burns
• infected burns indicating delay in treatment
burns in the shape of common household utensils or appliances

Behavioral Indicators
• behavioral extremes (withdrawal, aggression, regression, depression)
• inappropriate or excessive fear of parent or caretaker
• antisocial behavior such as substance abuse, truancy, running away fear of going home
• unbelievable or inconsistent explanation for injuries
• lies unusually still while surveying surroundings (for infants)
• unusual shyness, wariness of physical contact

Signs of Sexual Abuse

Physical Indicators

• torn, stained or bloody underclothes
• frequent, unexplained sore throats, yeast or urinary infections
• somatic complaints, including pain and irritation of the genitals
• sexually transmitted diseases
• bruises or bleeding from external genitalia, vagina or anal region
• pregnancy

Behavioral Indicators
• the victim's disclosure of sexual abuse
• regressive behaviors (thumb-sucking, bedwetting, fear of the dark)
• promiscuity or seductive behaviors
• disturbed sleep patterns (recurrent nightmares)
• unusual and age-inappropriate interest in sexual matters
• avoidance of undressing or wearing extra layers of clothes
• sudden decline in school performance, truancy
• difficulty in walking or sitting

Signs of Emotional Abuse

Physical Indicators
• eating disorders, including obesity or anorexia
• speech disorders (stuttering, stammering)
• developmental delays in the acquisition of speech or motor skills
• weight or height level substantially below norm
• flat or bald spots on head (infants)
• nervous disorders (rashes, hives, facial tics, stomach aches)

Behavioral Indicators

• habit disorders (biting, rocking, head-banging)
• cruel behavior, seeming to get pleasure from hurting children, adults or animals; seeming to get pleasure from being mistreated
• age-inappropriate behaviors (bedwetting, wetting, soiling)
• behavioral extremes; overly compliant-demanding; withdrawn-aggressive; listless-excitable

Signs of Neglect

Physical Indicators
• poor hygiene, including lice, scabies, severe or untreated diaper rash, bedsores, body odor
• squinting
• unsuitable clothing; missing key articles of clothing (underwear, socks shoes); overdressed or underdressed for climate conditions
• untreated injury or illness
• lack of immunizations
• indicators or prolonged exposure to elements (excessive sunburn, insect bites, colds)
• height and weight significantly below age level

Behavioral Indicators

• unusual school attendance
• chronic absenteeism
• chronic hunger, tiredness, or lethargy
• begging or collecting leftovers
• assuming adult responsibilities
• reporting no caretaker at home

How Can I Tell If A Child May Be Abused or Neglected?

It is not necessary that you decide if a child is abused or neglected. Child abuse and neglect are not always easy to identify. For example, bruises may or may not have been caused by abuse. A child coming to school with head lice or dirty clothes may or may not be due to neglect.

Yet, hundreds of people across the country are charged with the duty to be aware of the children they see and work with daily, and to report suspicions of child abuse, neglect, or dependency.

Key factors to identification of child abuse starts with experience. The future of a health care provider who has received professional training in child development will gain experience working with many children, will develop an innate sense of a child's well-being, will develop the ability and take on the responsibility to protect children from abuse and neglect.

Recognizing a child in need of protection goes beyond the legal definitions of abuse, neglect and dependency.
It is an accumulation of everything you know and sense about a child or a situation. Recognition does not always come about in a concrete way. It can be an inner voice that tells you that something is just not right. That's when a call is placed to Children's Services.

What Are the Legal Definitions of Child Abuse and Neglect?

The full legal definitions of abuse, neglect and dependency are rather lengthy. You can look up the entire text in the Ohio Revised Code sections referenced below. However, they can be summarized as follows:

Abused child (taken from O.R.C. 2151.031): Any child who is the victim of sexual activity, is endangered, or exhibits evidence of any injury or death inflicted other than by accidental means, or at variance with the history given of it, or because of acts or omissions of his parents, guardians, or custodian, suffers physical or mental injury that harms or threatens a child's health of welfare.

Neglected child (taken from O.R.C. 2151.03): Any child who is abandoned by his parents, guardian or custodian, lacks adequate parental care because of the faults of the parents, or whose parents neglect or refuse to provide him with proper or necessary sustenance, education, medical or surgical care, or any other care made necessary by his mental condition.

Dependent child (taken from O.R.C. 2151.04): Any child who is homeless, destitute or without adequate parental care through no fault of his parents, guardian or custodian; who lacks proper care or support by reason of the mental or physical condition of his environment, in such as to warrant the State, in the interest of the child, to assume his guardianship; or any child who is residing in a household in which a parent, guardian or custodian or other member of the household has committed an act that was the basis for an accusation that a sibling of the child, or another child who resides in the household is an abused, neglected or dependent child and, because of circumstances surrounding the abuse or neglect of the sibling and other conditions of the household, the child is in danger of being abused or neglected by that parent, guardian, custodian or other member of that household.

It is important that you understand the intention of the laws by defining child protection. The actions taken by County Children Services following the receipt of a referral is based on what the law provides to help the child and the family correct its problem.

Transgenerational (Child witnesses or indirect) domestic violence versus Direct Child Abuse

Intergenerational continuity of child physical abuse and children exposed to interparental violence, children who are witness to interparental violence (physical and or verbal), studies showed a significant association between exposure and childhood related behavioral problems. Furthermore, group comparison studies showed that witnesses had significantly worse outcomes relative to nonwitnesses and children from verbally aggressive homes, but witnesses' outcomes were not significantly different from those of physically abused children or physically abused witnesses.

Conclusion

The recognition of child abuse and neglect is an important step in the determination of domestic violence involving children. Victims may have experienced many kinds of injuries and harm that can sometimes be confused with a nonabusive injury. Forms of direct abuse include active and physical maltreatment; the general categories include phyical, sexual, and emotional maltreatment. Secondary abuse in the consequence of witnessing violence in the home.
There is no one profile that can be drawn to describ the victims of abuse. They are all ages, gender, and race; all are at risk, every race and gender is represented. While confusion exists on exact numbers of those maltreated, a conclusion can be drawn that abuse of all forms is high (vague), but none the less abuse is simply unacceptable within our society. Medical history and physical which includes a detailed injury inspection are part of the process in determining abuse. Age dating of bruises and pattern identification are tools to acess the condition of the child and provide the neccessary protecftion options. Multidisciplinary teams are important in providing insights into the injury and harm and for decisions on intervention.

It is common to dismiss or ignore concerns about juvenile violence. New events have forced health care professionals to look again at the consequences of abuse and neglect and its effects on adolescents. It is critical not to underestimate the devastating effects that family violence has on all children, adolescents included. Juvenile crime is a symptom of violence in the home.

Questions For Review

• Describe direct versus indirect child abuse, how do they differ, and how are they the same?
• What are the major forms of child abuse?
• What are the elements sexual abuse?
• What are the types of sexual abuse?
• What are the Legal Definitions of Child Abuse and Neglect?

Internet-Based Exercises

• Describe the signs and symptoms of "Shaken Baby Syndrome." What are the challenges prosecutors face when in the prosecution of such caases?
• Research here: http://www.preventfamilyviolence.com/statistics.html#what_is_child_abuse

References

Children as Victims. (2000). 1999 National Report Series. Office of Juvinile Justice Delinquency Program. NCJ. Washington, DC: U. S. Department of Justice. http://www.ojjdp.ncjrs.org/

Helfer, R., Kempe, R. (1988). The Battered Child, 4th ed. Chicago: University of Chicago Press.
Read more about Healthy Families America (HFA).
Research here: http://www.futureofchildren.org/information2826/information_show.htm?doc_id=70450