Universiti Kebangsaan Malaysia National University of Malaysia

Dr Norazlin Kamal Nor SCAN team coordinator UKMMC Child Development Centre Department of Paediatrics Faculty of Medicine Universiti Kebangsaan Malaysia
Family Medicine Scientific Conference 2013: Symposium 9- Making Our Children Safe July 2013

Varies according to time, place, culture

IACAPAP ebook WHO (World Health Organisation)

CHILD ABUSE or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation resulting in actual or potential harm to the childs health, survival, development or dignity
(International Association of Child and Adolescent Psychiatrists and Allied Professionals)

Salient points: ill treatment of child-as opposed to nurturing has the potential to cause harm to the childincluding threats to harm as well as neglect usually involves parents or other people in the context of a relationship of responsibility, trust or power

 In 1960s, paediatrician Dr Henry Kempe saw a large

number of children presenting with fractures for which an accidental cause didnt seem plausible X-rays revealed old breaks and abnormal skeletal changes In 1962, he described The battered child syndrome which led to the identification and recognition of child abuse Sexual abuse acknowledged only a decade later Emotional child abuse recognized only in 1990s

The CRC states that children everywhere are entitled to basic human rights which include the right to: Survival Develop to the fullest Protection from harmful influences, abuse and exploitation Participate fully in the family, cultural and social life Child abuse and neglect violates these rights

Physical abuse
-Physical harm or injury

Neglect
-Failure to provide for a child's basic needs

-Failure to provide a supportive environment

Emotional abuse

-involvement in sexual activity a child is unable to give informed consent to and is not developmentally prepared for

Sexual abuse

Exploitation
-Use of child in work or activities for the benefit of others

Neglect

Physical Abuse

failure to provide for a childs basic needs: punching, beating, kicking, biting, food, shelter, care, healthcare burning, shaking, stabbing, choking, or otherwise harming a child

Exploitation
child labour

Emotional Abuse
constant criticism, threats, rejection as well as withholding love, support, or guidance

Sexual Abuse
Physical and non-physical eg. fondling a childs genitals, penetration, incest, rape, sodomy, indecent exposure

 There is a lack of reliable global estimates of the

prevalence of child maltreatment, especially for lowand middle-income countries

Globally 40 million children are estimated to suffer

abuse each year (WHO, 2001)

There is potentially a large pool of undetected

maltreatment which may not have been recognized to be due to abuse

 About 25% to 50% of all children report having been

physically abused. Many are also the victims of emotional abuse or neglect, and what is reported may only be the tip of the iceberg
Neglect is the commonest form of maltreatment

reported
Research shows that 20% of women and 5%- 10% of

men report having been sexually abused as children

(Finkelhor, 1994)

250 million child labourers in developing countries aged 5 to 14 yrs

One million children are introduced into commercial sexual exploitation worldwide
(Casa Alianza, 2001)

(Human Rights Watch, 2001)

15 million children in India are bonded labourers, working to pay off family debts

(WHO Factsheet on Child Maltreatment in 2010)

3000 2000 1000 0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Data courtesy of Malaysian Social Welfare Department

500 450

400 350 300 250 200 150 100 50 0 Boys Girls Total 2000 2001 2002 2003

Rates of child maltreatment according to type of abuse

IACAPAP ebook

Proportion of child abuse by type in Malaysia

Proportion of child abuse by type: world data

Child Family Society

Younger age

Constitutional vulnerabilities e.g. Cerebral Palsy, Mental Retardation, prematurity etc.

Difficult temperament
Gender female higher risk for sexual abuse, male higher risk for physical abuse

Chronic illnesses

I.

Sociodemographic profile II.

Physical factors

Low socioecononomic status, poverty, unstable housing Low educational attainment, unemployment Single parenthood, young parental age

Chronic physical illness & disabilities

III. Psychosocial factors

Parents with mental health problems (eg. depression) & poor coping skills Poor social support from spouse, families Marital disharmony eg domestic violence Parents who were themselves abused as children

I. Socio-cultural Cultural practices that condone abuse II. Legal aspects Policies or lack of policies leading to child exploitation III. Disasters Natural eg tsunami Man-made disasters eg wars

History History inconsistent with injury and may vary with different historians and with each telling Untreated or late presentation for treatment of illness or injury Recurrent injuries Parents with history of drug abuse, alcoholism, domestic violence Child left without adequate supervision or abandoned without caretaker at home

Examination findings Injuries inconsistent with childs stage of development. Ex: bruises on shins are common in toddlers learning to walk, but are exceptional in non-mobile baby Observation of behaviour and interaction Inappropriate reaction of parents or caregiver who are vague, elusive, unconcerned or excessively distressed or aggressive Child fearful of going home Lack of attachment between carer and child Highly critical and negative parental attitudes to child

Signs of child physical abuse

Definition Physical abuse involves physical harm or injury to the child It may be the result of deliberate attempt to hurt child or severe, inappropriate methods of disciplining child Signs Any injury which cannot be explained; recurrent injuries Unusual injuries in atypical sites eg. ear pinna or with distinct marks or patterns, eg. cigarette burn marks Injuries inconsistent with a childs developmental age, eg. head injury in a child not yet mobilizing

 Subdural haematoma & retinal haemorrhages

which are unexplained or inconsistent with the reported injury. Eg. shaken baby syndrome Adult human bite marks, cigarette burns, lash marks Bruising with finger tip marks Torn frenulum

 Bruises

Present in 90% of physically

---

abused children Time taken for a bruise to appear depends on depth of injury Colour of bruises change with time, allowing timing of bruising to be estimated May need to exclude bleeding disorder eg ITP. Investigations: FBC, Coagulation profile

PATTERNS OF INJURIES IN NAI

Belt mark

Hand print bruise

Grab mark

Slap mark

Accidental injuries

Non-accidental injuries

Multiple bruises of varying ages in varying shapes and positions

Impression of fingers of a hand: slap mark

Linear mark below right ear : cane/ whip injury

Impression of marks of teeth: human bite mark

Fractures
Fractures in absence of major

trauma, birth injury or underlying bone disease Suspicious findings in a baby too young to walk or crawl Multiple fractures in different stages of healing particularly worrying Unexplained rib fracturesespecially if in a young childshould raise suspicion of abuse

Posterior rib fractures

Metaphyseal fractures

Accidental Injuries

Non-Accidental Injuries

Usually fracture occur age >5 years old

Usually fracture occur age <3 years old

Only single or two fractures

Multiple fractures at different sites and ages

Site & type: Clavicular fractures Long bone shaft fracture Linear skull fractures

Site & type: Metaphyseal fractures Posterior rib fractures Complex skull fracture

 No specific site but most commonly found on the

back of hand, buttocks, feet and genitalia

Types of burns:

Immersion
Geographic Splash

Cigarette burn

Immersion burn

Iron mark

Geographical burn: In a distinct pattern Eg: circular cigarette burns, steam iron burns. Immersion burn: Sharply demarcated lines on hands and feet (stocking-glove distribution), buttock and perineum Uniform depth

 Trauma that occurs when an infant is shaken

violently, and can also be associated with impact injuries, blunt force trauma and hypoxicischaemic injury Clinical constellation of findings: subdural haematoma retinal haemorrhages skeletal fractures (eg metaphyseal) posterior rib fractures Diffuse, serious brain injuries may occur Most often seen in children < 2 years of age

Retinal hemorrhage

Subdural hemorrhage

Signs of child emotional abuse

 Restriction of movement

Habitual scapegoating
Denigration Discriminating against or

Threatening Frightening Blaming Humiliating

ridiculing Other non-physical forms of rejection or hostile treatment.

 Headaches or stomach aches with no medical

cause Change in behaviour Increased tantrums Abnormal fears, eg. increased nightmares Low self-esteem, self-blame, over-reaction to mistakes Attempts to run away Depression Drug or alcohol addiction Suicide attempt

The involvement of a child in sexual activity that she does not fully comprehend is unable to give informed consent to is not developmentally prepared for And violates the laws or social taboos of society.

(WHO, 1999)

 An underdiagnosed type of child abuse Victims: often a girl, can be of

background Abusers: usually known to the child and not uncommonly male members of the household Sexual Activities or behaviourswide variation of activities considered to be child sexual abuse May occur with or without physical contact Physical: fondling, molesting; penetrative sexual activities including rape and sodomy Non-physical: voyeurism, flashing, exposing or involving children in any form of pornographic material, making sexual comments

any age or social

 Sexual abuse is unfortunately not uncommon

among youths Any involvement of a minor in sexual behaviour is statutory rape, even with the consent of the minor The age of consent in Malaysia is 16 years No cut-off age of alleged male perpetrator Reporting of such cases to the authorities are mandatory

 Injury to genital areas: pain or bleeding

Physical symptoms: abdominal pain, urinary tract infection,

sexually transmitted disease, pregnancy Extremely sexualized behaviour inappropriate for the childs age or fear of sex Nightmares, unusual fears,depression, attempts to run away, school refusal Eating disorders, drug or alcohol addiction Bed-wetting and thumb-sucking in older children, also low self-esteem and withdrawal behaviours

 Persistent failure to meet a childs basic physical

and psychological needs resulting in serious impairment of his health or development Basic needs include: Health Education Emotional development Nutrition Shelter Safe living conditions
(WHO, 1999)

Clinical presentation includes: Physical symptoms Developmental delay Illness and disease Psychological damage

Contributing factors: Domestic violence Substance abuse Mental health issues Parents who were themselves neglected

 An Act to consolidate and amend the laws related to :

care, protection and rehabilitation of children provide for matters connected therewith and incidental there to Abuse, neglect, abandonment or exposing a child to physical and/or emotional injuries is punishable under this law Sets up Child Protection Teams to coordinate locally based services to families and children in need of protection.

If believes on reasonable grounds that a child s/he is examining or treating is physically or emotionally injured as a result of being illtreated, neglected, abandoned or exposed, or is sexually abused, Shall immediately inform a Protector.

Liable to a fine not exceeding five thousand ringgit or to imprisonment for a term not exceeding two years or to both if fails to inform a Protector

May take the abused child into temporary custody until it is assumed by a Protector or police officer.

 the Director General the Deputy Director General a Divisional Director of Social Welfare, Department of

Social Welfare
the State Director of Social Welfare of each of the States any Social Welfare Officer appointed under section 8

 The SCAN team is a multidisciplinary team made up

of professionals involved in managing children with suspected child abuse and neglect Team members include physicians (paediatricians, Child Psychiatrists, other medical specialities eg O&G, forensic), social welfare officer, police, NGO Purpose: To assess, coordinate and formulate a plan for the management of children presenting to hospital with injuries, symptoms or conditions suspected to be due to abuse or neglect of the child

 There is a need to be constantly aware of the possibility of abuse or neglect, or the risks of this in children The assessment of risk, and interventions to protect children, require a multidisciplinary and multi-agency approach In general, the duty to patients, including that of confidentiality, is overridden by the duty to protect children

http://iacapap.org/iacapap-textbook-of-child-and-adolescentmental-health