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SPECIAL STUDY PHASE 1

CHILD ABUSE

Nama Mahasiswa : JAGTISH RAJENDRAN


Nim

: 0902005200

Semester/ Class

: II/B

Supervisor

: Dr. I G A ENDAH ARJANA, Sp KJ (K)

FAKULTAS KEDOKTERAN
UNIVERSITAS UDAYANA
2010

ACKNOWLEDGEMENT

First of all, I would like to show my gratitude to the Lord because with his blessings I
have managed to complete my special study task entitled Child Abuse.
The objective of this special study is to fulfil the requirements of our Special Study Block
of this second semester and its impossible to be done without the help of many parties. I would
like to thank the special study board for coming up with this idea as it really helps students like
me deepen our knowledge in the topic of interest.
With pleasure, I, Jagtish Rajendran, would like to convey my heartiest thank you to Dr.
I G Ayu Endah Arjana, Sp KJ (K). the supervisor for my special study topic, and not to be
forgotten my beloved friends whose encouragement, guidance and support from the initial to the
final level enabled me to develop an understanding of the topic and successfully complete my
paper work. I would like to convey a special gratitude to Dr. Wayan Westa, Sp KJ (K) for
sparing his time despite his tight schedule to evaluate my presentation of special study.
I would like to apologise if there is any weakness that could be found in my report and I
would be glad to get feedbacks from the readers as it would help me in improvising myself in
time to come. Last but not least I hope that my writing would be beneficial to the readers as how
it was for me.
THANK YOU!

Denpasar, July 2009


By,

........................................
Jagtish Rajendran
Nim:
0902005200

No

Contents

Pages

Acknowledgement

Index

II

1.

Introduction

2.

Definition

3.

Epidemiology
3.1 Socio Demographic Factors

3.2 Prevalence

3.3 Perpetrators

3.4 Localization

4.

Etiology

5.

Signs & Symptoms

6.

Diagnostic Instrument

7.

Treatment & Management

10-11

8.

Diagnosis Criteria

12-13

9.

Prognosis

14

10.

Differential Diagnosis

15

11.

Summary

12.

Suggestions

18

References

19-20

Appendix
Log Book : Daily Activities Report

8-9

16-17

1. INTRODUCTION
Child abuse is seen to be one of the leading causes to all injury-related mortality in
infants and children. The chance of an abused child being abuse again is approximately 50
percent, and increases the rate of mortality if the abuse is not caught and stopped and first
presentation. [8] Child abuse acts like a virus - it attacks the host organism and alters it physically.
It self-replicates. "Infection" creates a downward spiral through generations, where every victim
of child abuse is capable of infecting more and more victims. Children who survive abuse to
adulthood in turn are more likely to abuse their own children. [3]
Child abuse is not just an individual or familial problem. Child abuse bursts out of the
family and infects our society with callousness and cynicism, anger and violence, and crime,
drugs and disease. Victims of child abuse have a life-long effect and the effect on our society is
pervasive. Yet, it is found difficult to measure the prevalence rate of abuse in our society, and no
trial or attempts have been taken so far which have overcome the basic difficulties of
underreporting. Child abuse has an negative impact on children which could result in behavioral,
cognitive, emotional, and developmental difficulties. Looking into it from a; life course
perspective, it has been recognized that these difficulties can extend into adulthood.

[10]

Therefore, the responsibility lies with the physicians to recognize and treat these cases at
first presentation to prevent significant morbidity and mortality. On the hopeful side, the private
sector and volunteer organizations have taken the leadership role in healing our society of the
effects of abuse. There are many organizations, staffed by volunteers and funded through
donations, which are doing good work to prevent and fix the problem. [3]
Child abuse has 4 major categories all by itself which are neglect, physical abuse,
emotional abuse and sexual abuse. [3][11] This study will entirely focus on physical child abuse.

2. DEFINITION

Child physical abuse is the intentional infliction of injury on a child. In most cases, the
person causing the abuse is a family member or caregiver. Examples of Physical Abuse
include beating with a belt, shoe, or other object; biting a child; breaking a child's arm,
leg, or other bones; burning a child with matches or cigarettes; hitting a child; kicking
a child; not letting a child eat, drink, or use the bathroom; pulling a child's hair out;
punching a child; scalding a child with water that is too hot; shaking, shoving, or
slapping a child.

Kaplan & Sadocks Synopsis of Psychiatry defines physical child abuse as any act which
results in a non-accidental physical injury such as beating, kicking, punching, biting, burning and
poisoning. Some physical abuse is results of unreasonably severe corporal punishment or
unjustifiable punishment. Physical abuse can be organized by damage to the site of injury: skin
and surface tissue, the head, internal organs, and skeletal. [4]

Arnon Bentovim defines physical abuse as those acts of commission or by omission by


a care-giver which cause actual physical harm, or have the potential for harm. Physical
abuse also includes the induction of illness states through the administration of
medication or noxious substances. [3]

The National Center on Child Abuse and Neglect defines child physical abuse as: "The
physical injury or maltreatment of a child under the age of eighteen by a person who is
responsible for the child's welfare under circumstances which indicate that the child's health or
welfare is harmed or threatened thereby
The federally funded Third National Incidence Study (NIS-3) defines physical abuse as a
form of maltreatment in which an injury is inflicted on the child by a caregiver via various non-

accidental means, including hitting with a hand, stick, strap, or other object; punching; kicking;
shaking; throwing; burning; stabbing; or choking to the extent that demonstrable harm results. [18]

3. EPIDEMIOLOGY
Each year, the Childrens Bureau, an agency within the Department of Health and Human
Services collects data on child maltreatment. The results are published in an annual document
called Child Maltreatment. [4] Children of all ages, genders, ethnicities, and socioeconomic group
undergo physical abuse. Individual and community variations in what is considered abuse,
inadequate knowledge and training among professional in the recognition of abusive injuries,
unwillingness to report suspected abuse and professional bias are the several reasons which
causes physical abuse remains as an underreported problem. [10]
3.1 SOCIO DEMOGRAPHIC FACTORS
Sex
A history of child physical abuse was reported more often by males than females. Severe
physical abuse was reported by similar proportions of males and females. Physical abuse occurs
more often in families with four or more children. [10]
Age
The age group from 0 to 3 years had the highest victimization rate. This is a examination rate of
the age distribution of abuse victims. 67% of abused children are less than 1 year old and 80%
are less than 3 years old. The rate of victimization declined as the age of the victims increase. For
example, the rate of infants (0 to 3 years of age) was 16 per 1000 whereas the rate for
adolescents (16 to17 years) was 6 per 1000. [4]
Culture
In many countries child abuse and neglect were often ignored or denied as a result of
people's acceptance of violence in a given culture or due to their belief that the culture must

focus on preserving the family. Some cultures simply denied that child neglect or abuse
occurred. For example, in Malaysia the problem of abuse was at one time believed to be a
problem only for Western cultures. [17]
It is important to offer information and empathetic understanding to the parent, when you
recognize signs of bruising or other injury due to a culture-based practice. For example,
ecchymosis, the purple or black-and-blue area resulting from a bruise is a sign of bruising which
is related to culture based practices. Ecchymosis can be the results of cupping, pinching or
spooning. Folk remedies may use substances such as arsenic, lead, urine, feces, and slime mold.
Practices that may be interpreted as abuse include co-sleeping, comfort nursing of older children,
early marriage, physical punishment, and refusal of treatment for reasons of religious belief. [17]
3.2 PREVALENCE
The prevalence of physical abuse is a question that can be answered in some countries but not
others. For example, in countries such as United States, Australia, Malaysia, and Ireland this type
of data is available. Other countries, such as Canada, are studying this question, whereas others,
such as Mexico and Romania, are working towards to detect children in needs. It is evident that
there are differences with regard to the prevalence of physical abuse in each country with where
the numbers are available. [16]
For instance, in Australia, 28 percent reports physical abuse. This is compared to the prevalence
reports in Ireland, where 11 percent were identified as physical abuse. In the United States, the
Child Protective Services (CPS) state physical abuse in 25 percent of cases.

[16]

In the United

States, 152250 children and adolescents were reported as victims of physical abuse in the year
2004. One-tenth of all substantiated cases of child abuse in the U.S. are from California. [11]
3.3 PERPETRATORS
Researchers have identified a number of factors associated with the physical abuse of a child,
such as the characteristics of individuals who abuse and the characteristics of families in which
child abuse occurs. [4] Non-family members commit less than 10 percent of physical child abuse.
Obviously, in countries such as Sri Lanka where enforcement into the military and child
prostitution are greater problems, the non-family abuse rate may be higher. In addition, only 3

percent of child maltreatment occurs at day care facilities or other institutions. This rate may be
higher in countries such as Romania and Russia where institutional abuse of children has been
identified as a serious problem. [16]
In general, there are a number of individual perpetrator differences that predict abuse. For
instance, individuals who were abused as children are believed to be more at risk to become
abusers as adults. Physical abuse is also more likely to occur in family situations in which
parental knowledge of parenting skills is inadequate, when high levels of stress are present, when
parents are very young, when parental expectations are too high regarding a child's behaviors,
when substance abuse is present, and when adults in the family have low levels of empathy
towards a child. Abuse is found more often in families with female children and in families with
four or more children. Finally factors such as economic distress, lack of social support, and
cultural or religious values have been linked to incidences of physical abuse in most countries
that have addressed this problem. [3]
3.4 LOCALIZATION
Severe physical abuse cause changes in the childs developing brain that persists into adulthood.
[4]

Adult survivors of abuse are more likely to have abnormalities of their EEG that indicate

limbic irritability. MRI scan are more likely to show abnormalities which indicates reduced size
of the adult hippocampus which are pronounced more on the left side of the brain. Reduced size
of the corpus callosum manifest deficient integration between the left and right side of
hemispheres. These neurobiological effects of child maltreatment probably mediate the
behavioral and psychological symptoms that follow abuse such as increased aggressiveness,
heightened autonomic arousal, depression and memory problems. [11]

4. ETIOLOGY
Physical abuse is caused by a persons inability to control their anger or frustration. This
loss of control is usually caused by factors that have nothing to do with the child, such as job or
personal stresses, loneliness, depression, lack of a support system, psychiatric disorders, or
substance abuse. Poverty and psychosocial stress especially financial stress highly associated
with child abuse. Child maltreatment is strongly correlated with less parental education,
underemployment, poor housing welfare reliance and single parenting. A child that is difficult
because of a behavioral disorder, prematurity, mental retardation or physical disability may also
be a target for abuse if the parent is not equipped to handle these types of challenges. Child abuse
is common in multiproblem families with domestic violence, social isolation, parental mental
illness and parental substance abuse especially alcoholism. [4]
Many of those who commit physical abuse have been abused themselves as children. As
a result, they often do not realize that abuse is not appropriate discipline. Those who commit
physical abuse also frequently have poor impulse control, which prevents them from thinking
about what happens as a result of their actions. [8]
A rare type of physical abuse occurs in Munchausen by proxy syndrome, a disorder in
which a caregiver, usually a parent, either makes the child appear to be sick by altering medical
records or test results, or actually makes the child sick. The parent does this because he or she
has an abnormal need for attention and enjoys the type of relationship developed with the child
because of the illness. [6]

5. SIGNS & SYMPTOMS


The symptoms of physical abuse include signs of injury, such as unexplained bruises,
burns, scrapes, or broken bones.

[15]

Children will also have fading bruises or other marks

noticeable after an absence from school. Children might seem frightened of the parents and
protest or cries when it is time to go home. An abused childs behavior may change, making the
child withdrawn and distrustful, although most children will deny that anything is wrong. [4]
Prolonged shaking of a child under the age of one causes a condition called shaken baby
syndrome, which results in brain injury and often death. Skull fractures are also common in
physically abused children. Over the long run, abused children are more likely to use drugs,
become sexually promiscuous, have low self esteem, exhibit extremely passive or aggressive
behavior, have difficulty with interpersonal relationships, perform poorly in school, have
frequent nightmares, and experience depression that can lead to attempted suicide. Children who
are physically abused often become abusive parents. [6]
The physician should consider the possibility of physical abuse when the parent or other
adult caregiver offers conflicting, unconvincing, or no explanation for the childs injury and
describes the child as evil, or in some other very negative way. Actions like uses of harsh
physical discipline with the child and a history of abuse as a child should also be taken into
consideration. [1] [2]

6. DIAGNOSTIC INSTRUMENTS
Diagnostic instrument is used for physical abuse evaluation. The home assessment
provides an evidence-based approach to the evaluation of the parenting environment, provided
for the child by the principal caretaker. The evaluation of family provides a broad based
approach to carrying out an extensive assessment of the family context.

[3][5]

Questionnaires such

as The Family Pack of Questionnaires and Scales, The Recent Life Events Questionnaires, The
Home Condition Assessment, The Parenting Daily Hassle Scales, The Family Activity Scale,
The Home Inventory, The Family Assessment and also The Adult Wellbeing Scale are used as
diagnostic instruments. (Refer to Appendix 2)
Other instruments are available for more individual assessment both in childhood and in
adolescence to reinforce basic clinical approaches to interviewing. Retinal hemorrhages in
children younger than 2 years are detected using dilated, indirect ophthalmoscopy performed by
an ophthalmologist. For children less than 2 years of age with any suspicious old or new fracture
are recommended for a skeletal survey. Head CT detects subarachnoid, subdural or
intraparenchymal injury. [1]
Laboratory test are also carried out to diagnose the physical abuse. For instance, cases
with genitor urinary or abdominal trauma, complete blood count, hepatic trasnsminase, lipase,
fecal occult blood test, urinalysis, partial thromboplastin time, prothrombin time, and urine
toxicology and amylase evaluation are carried out to ensure no underlying blood disorder.
Moreover, when bleeding disorder is concern hematologic disorder are tested via CBC count,
INR, bleeding time, platelets, prothrombin time and partial prothrombin time. If additional
testing is needed, it will be indicated after the initial screening test. Above mentioned, are those
strongly recommended for most patients. [1]
On the other hand, diagnoses that are optional are history; examination or laboratory
results that suggest abdominal trauma, an abdominal CT should be done. Furthermore, if a bite is
present, a dentist consultation would be recommended as dentists can determine the cause. Bone

scan are normally done to find any occult fractures up to two weeks after injury and if CT of the
head is inconclusive, then a magnetic resource imaging of the head is carried out. [1] [11]

7. TREATMENT AND MANAGEMENT

The cooperation from many different professions as well as knowledge of the


locally/regional available child protection resources and personnel is required for child
protection. Establishment of child protective committee is well advised in all hospitals. All
potential responses should be taken into account, ranging from conversation with the custodial
parents, relatives and other persons from the childs social circle is whenever the suspicion of
child abuse arises. Once physical abuse towards a child is suspected, the physician required by
the law to report it to the authorities such as Child Protection Office or police in case of severe
physical abuse. [6]
Forensic medical consultation is recommended accompanied with appropriate
documentation, so that evidence can be presented in judicial settings such as civil, family or
criminal court. By this way, the physician need have no fear of legal consequences resulting
from breaching of medical confidentiality. The physician can request for guidance on how to
proceed with the case and information on types of help that the law provides in physical abuse
cases by describing the case anonymously to the Child Protective Service or family court. This
procedure should also be documented. [6]
A multidisciplinary approach, or child protection team which consist of evaluating
physician, a childrens physician or children forensic specialist, social work services, nursing
staff, mental health professional and law enforcement is required to ensure adequate evaluation,
treatment and follow-up of potentially abused child. The immediate strategic intervention is to
make sure the child safety, which can be ensured by removing the child from abusive
environment. [8]
A multi modal treatment plan can be initiated utilizing components of anxiety
management, psychoeducation, cognitive behavioral interventions, and exposure related to the
feared experiences, once a literal safe place is located for physically abused children. Children
may require monitoring and support for long periods of time after the abuse has ended, given the
multiple long term effects of maltreatment.

[4]

Counseling, including play therapy, is also

necessary for abused children over age 2. The child will need help dealing with the fear and pain

of abuse caused by adults, who should be trusted figures. Failing to get this help can lead to
significant psychological problems, such as post traumatic stress disorder (PTSD). [15]
Cognitive behavioral treatment involving all family members individually or family
therapy has shown to be more effective than routine community management. Family therapy
approach led to children giving positive feedback that their parents have become less violent
towards them. Both of these approaches reduce children aggressive behavior, transmission of an
aggressive style from parent to child and family conflict. [3]
Physician should ensure that child receives the necessary follow-up services. Child
primary care physician should be notified and Child Protective Service would ensure that the
family complies with the plan of care. This service should address the psychological effects of
abuse on the young child, sibling, and the non-offending caregiver and not only include the
referrals to medical providers. Adult-partner violence usually co-occurs with child abuse, it is
strongly suggested that several family members undergo medical and mental health assistance if
required. [11]

8. DIAGNOSIS CRITERIA

It is important to assess the whole child and all the injuries present. A child with two
suggestive injuries is more likely to have been abused than if there is only one injury. What we
do at present is to put an informal probability on each injury and make a combined assessment of
the likelihood of abuse. It would be an advance if we could put actual figures to these
probabilities and then combine them. [7]
The most common reason for referral to child protection teams and for medical
assessment for child abuse is bruising. The overall assessment of the child is an informal
combination of probabilities of abuse or accident with respect to all the bruises a child has. The
likelihood of physical abuse increases with the number of bruises present. Several factors help us
decide on the probability of abuse. These are the age and development of the child, the site of the
bruising, and the pattern of the bruise. [12]
A major cause of death and handicap in babies is due to subdural hemorrhage. It has been
known for many years that this problem is often caused by shaking abuse. It is essential to
investigate all cases of subdural hemorrhage in infancy, as follows with ophthalmoscopy by an
ophthalmologist, a full multidisciplinary social assessment, a coagulation screen, a skeletal
survey supplemented by a bonescan or a repeat survey at 10 days, and computed tomography or
magnetic resonance imaging. [11]
Fractures are a serious causation of child physical abuse. Considerable force is required
to cause a fracture and they cause a lot of pain. In considering the diagnosis of non-accidental
fractures, we need to consider the age of the child, exclusion of medical disease and the type and
site of the fracture. [11]
In diagnosing a fracture or fractures as being due to abuse, it is essential to exclude
medical conditions that could be predisposing causes of a fracture. Of these conditions the most
important is osteogenesis imperfect. However, metabolic bone disease in neonates, copper
deficiency, osteomyelitis, rickets, osteoporosis, leukaemia, and disseminated neuroblastoma can
all cause fracture and should be excluded. [11]

With burns and scalds, the differentiation between accident, neglect, and deliberate abuse
is not easy. The doctor has to assess the history\and the findings and attempt to ascertain whether
they are likely to be compatible. For instance, injuries on both front and back are unlikely to
result from a child spilling a hot drink. Abdominal injuries are a rare but definite feature of abuse
in childhood. [11]
Craniofacial, head, face, and neck injuries occur in more than half of the cases of child
abuse. Careful intraoral and perioral examination is necessary in all cases of suspected abuse.
Some authorities believe that the oral cavity may be a central focus for physical abuse because of
its significance in communication and nutrition. The injuries most commonly are inflicted with
blunt trauma with an instrument, eating utensils, hands, or fingers or by scalding liquids or
caustic substances. [1][7]
Good notes and accurate examination are important as with any other type of medical
work. These notes could be used as evidence for courts. The purpose of the examination should
be clear to make a diagnosis of definite or possible abuse. It is not to make a decision about what
happens to the child: in the short term that is the social services responsibility, in medium term
that of the case conference, and in the long term that of the courts. The perpetrator will be
identified by the police and this is not the purpose of examination. The examination and history
should be done in a non-judgemental manner and in a calm medical context. Topographical chart
is used to enter all accurately measured injuries. Investigation of abuse consist of careful
examination of the child, the color of each contusion observed and documentation of bruising
with use of body charts depicting size in two planes, A photographic record should be obtained
wherever possible and especially if there may be a prosecution. [7] [12]

9. PROGNOSIS
The elements of prognosis include the extensiveness of traumatic damage caused to the
childs emotional and physical and emotional health and the level of abuse perpetrated. It also

consist of level of parental skill and the adequate level of the care that the child will need the
specific therapeutic work. Other than that, the degree of responsibility for the condition of the
child taken by the parents and the capacity to provide the care of child needs. Moreover, the level
of parental psychopathology and the motivation the parent should have to reverse the personal
attributes which leads to abusive actions are part of prognosis element. Besides, the general
attitude of the parents to the authorities is important in prognosis, to know whether there is a
prospect of cooperation or denial. Settings needed for therapeutic work, whether outpatient day
or residential basis is also an element of prognosis. [3]
A hopeful prognosis demands the parents take sufficient responsibility for abusive
actions where appropriate. For instance, a non-abusive protects their child from physical abuse
from their abusive partner and above their relationship with their inmate. Parents who have been
abusive should be willingly cooperate with child care professional and accept the need for
change even if it is the motivation to keep the children within the family rather than them being
removed. Development of reasonable attachment and relationship between parents and children
is required to provide adequate care for the particular child. The prognosis will be hopeless if
none of these criteria are met. Children who were severely traumatized have the probability to be
re-traumatized when through contacts with abusive parents. [3]
The child's physical recovery depends on the severity of the injuries. Psychological
recovery depends on the results of therapy, and whether the child can develop trusting
relationships with adult caregivers. The authorities will determine whether the abuser gets
psychiatric help, such as parenting training and impulse/anger management training. Child
protection agencies generally make every effort to reunite families when possible. [13]

10. DIFFERENTIAL DIAGNOSIS


Although the diagnosis of physical abuse is direct but there can several difficulties. A
deep understanding of the effect of abusive situations is required for proper diagnosis of physical

abuse. This understanding will also enable the physician to differentiate between those injuries in
the modus operandi of childrens activities, e.g. fights, falls, sporting activities of children and
accidents and those injuries caused by striking, shaking and hitting. Particular pattern of injuries
and bruising of different stages and ages in children, which are characteristic of physical abuse in
a particular location, accompanied with bite marks, burn with consistent physical injury and
finger marks is set as concern in differential diagnosis. Physical appearance is the main key to
what has occurred to the child, given that childrens response is silence and parental denial. The
risk taking of a hyperactive child can lead to injury which has to be differentiated form abusive
actions. [3]
Injury such as bruises can be mistakenly diagnosed as accidental or non-accidental
bruise: dermatologic disorder; hematologic disorder; genetic disorders e.g. Ehlers-Danlos
Syndrome; Mongolian spots or Henoch-Scholein purpura. Differential diagnosis for burns could
be cultural practices, dermatitis, accidental burn, inflicted burn, Steven Johnsosn Syndrome or
skin infection. Fractures can be incorrectly diagnosed as accidental or intentional fracture,
congenital syphilis, birth trauma, osteogenesis imperfect, leukemia, rickets, scurvy,
osteomyelitis, or physiologic changes. There could be faulty diagnosis of head trauma as
accidental or inflicted trauma, hemorrhagic disease, infection, birth trauma, metabolic disease
e.g, glutaricaciduria, type1; or intracranial vascular anomalies.

[8]

Presentation of forceful

complaints that child is suffering from episodes of fits, abdominal pain or hyperactive behavior
without physical evidence could cause highly complex diagnosis of factitious illness by proxy or
munchausen syndrome by proxy. [3]
Diagnosis requires a high level of meticulous observation as well as investigation of
possibility without prematurely revealing concern. A parent who has induced an illness will opt
to go to another hospital. Establishing possible secondary gain for a parent having a sick child
and psychiatrist observation of a child could be done using a careful multi-disciplinary work. [4]
11. SUMMARY
One of the leading causes to all injury-related mortality in infants and children is said to
be child abuse. There are 4 major categories in child abuse all by itself which are neglect,

physical abuse, emotional abuse and sexual abuse. Child physical abuse is the intentional
infliction of injury on a child. In most cases, the person causing the abuse is a family member or
caregiver. Each year, data on child maltreatment is collected by the Childrens Bureau, an
agency within the Department of Health and Human Services. Children of all ages, genders,
ethnicities, and socioeconomic group undergo physical abuse. Male and female children
experience similar rates of severe physical abuse. The age group from 0 to 3 years had the
highest victimization rate. In many countries child abuse were often ignored or denied as a result
of people's acceptance of violence in a given culture. The data on prevalence of physical abuse is
available only in some countries but not others. Characteristics of individuals who abuse and the
characteristics of families in which child abuse occurs are the factors associated with physical
child abuse. Severe physical abuse cause changes in the childs developing brain that persists
into adulthood. Physical abuse is caused by a persons inability to control their anger or
frustration due to poverty, depression, personal stresses, psychosocial stress, loneliness, lack of a
support system, psychiatric disorders, or substance abuse. The symptoms of physical abuse
include signs of injury, such as unexplained bruises, burns, scrapes, or broken bones. Instruments
such as questionnaires, laboratory results, CT scan, MRI scan, opthalmolscopy, skeletal survey
and bone scan is used as diagnostic instrument to diagnose physical child abuse. A
multidisciplinary approach, or child protection team which consist of evaluating physician, a
childrens physician or children forensic specialist, social work services, nursing staff, mental
health professional and law enforcement is required to ensure adequate evaluation, treatment
and follow-up of potentially abused child. Failing to get this help can lead to significant
psychological problems, such as post traumatic stress disorder (PTSD). A child with two
suggestive injuries is more likely to have been abused than if there is only one injury. Good notes
and accurate examination are important as with any other type of medical work to be used as
evidence for courts. Topographical chart is used to record down all accurately measured injuries
and photographic record should be obtained wherever possible and especially if there may be a
prosecution. A hopeful prognosis demands the parents take sufficient responsibility for abusive
actions where appropriate. The prognosis will be hopeless if none of the required criteria are met.
A deep understanding of the effect of abusive situations is required for proper diagnosis of
physical abuse. This understanding will also enable the physician to differentiate between those
injuries in the modus operandi of childrens activities and injuries caused by physical abuse.

Physician should ensure that child receives the necessary follow-up services. Child primary care
physician should be notified and Child Protective Service would ensure that the family complies
with the plan of care. Cognitive behavioral treatment involving all family members individually
or family therapy has shown to be more effective than routine community management.
Establishment of child protective committee is well advised in all hospitals.

12. SUGGESTIONS

Early identification and treatment of childhood physical abuse is important to stop the
pain and reduce the likelihood of long-term psychological effects. People who suspect that a
child is physically abused should call the police or report these suspicions to their local child

protective services agency. Parents should be extremely cautious before leaving their children
alone in the care of anyone until they are sure the caregiver is trustworthy and caring. [14]
The child abuse is a crime and perpetrators should be treated as criminals and should not
be given any mercy unless mental disorder is authentically proved. The first, primary and
predominant priority in cases of child abuse is protection of the child because he is the direct
victim of the crime and may also be wounded and in some cases these wounds could be fatal and
result in the death of the victim. [15]
All issues of family unit treatment must be resolved in favor of the child's emotional,
psychological, and physical safety because if these problems are not resolve yet than they will
generate profound effects on the future of the child and he or she may react violently in the form
of suicide. A social worker charged with protection of the child and simultaneous rehabilitation
of the offender is a professional schizophrenic. [3]
Professionals must begin to distinguish between abusers and who simply never learned to
be parents and those who exploit a power relationship with their own children for personal
sexual gratification and/or profit, just because these people doesnt keep their responsibilities
despite being an indulgent father or mother they abuse and destroy their children for their own
pleasure.

[15]

Child abuse has profound consequences for its victims. And untreated child abuse

has a predicable range of fallout including delinquency, drug abuse, suicide, and mental illness.
Identification, treatment, and follow up of cases of child abuse cannot be limited to a single
agency. All agencies, from day care centers to schools to social services to probation to mental
health, must participate jointly in a consortium model to provide services. [1] [4]

REFERENCES

1.

American Academy of Pediatrics, Diagnostic Imaging of Child Abuse, Section on


Radiology, Pediatrics 2009;123;1430-1435

2.

Amy EB, Melissa LA, Frederick PR, Elizabeth AC, Paul AF, David C, Robert JR, Robert
ST, Health Care Utilization and Costs Associated with Childhood Abuse, January 2008,
23(3):294299.

3.

Arnon Bentovim, Physical and sexual Abuse, A Clinicians Handbook of Child and
Adolescent Psychiatry, 2005, pg 655-694

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