sosPsych/1-25-10

CHILD ABUSE
Dr. Japhet Gensaya Fernandez de Leon

CHILD ABUSE
Children <4 years old should not be separated from the parent in times of interview
Do not affirmate the mistake of the patient/teenager because he/she will not answer the questions anymore
Confidentiality

4 general principles
1. That all children should not be discriminated against, irrespective of race, color, sex, language, religion, disability, etc.
2. That children have a right to survival and development in all aspect of their lives, including physical, personal, social, emotional, cognitive,
cultural, etc.
3. That the best interests of the child must be a primary consideration in all decisions and actions affecting the child or children as a group
4. That children should be allowed to express their opinions, especially in matters concerning themselves

Republic Act 7610 defines child abuse

The maltreatment, whether habitual or not, the child and includes any of the following:
1. Psychological and physical abuse, neglect, cruelty, sexual abuse and emotional maltreatment
2. ---
3. Unreasonable deprivation
4. Failure to immediately give medical treatment to an injured child resulting to serious

Physical Abuse
Triptych of information
History given presenting injuries known biomechanics

Interview factors
Language level
Cognitive development
(Chronological) storytelling capacity
Reluctance to disclose

Guidelines for Interviewing Children

DO:
Make sure that the interviewer is someone the child trusts
Conduct the interview in private
Sit next to the child, not across a table or desk
Ask the child to clarify words/terms you do not understand
Be supportive, the child is likely to be frightened about telling family secrets
Stress that anything that happened was not the childs fault
Tell the child if any future action will be required
Be truthful; do not make promises that you cannot keep

DO NOT:
Allow the child to feel in trouble or at fault
Criticize the childs choice of words or language
Probe or press for answers that the child seems unwilling to give
Suggests answers to the child
Display shock or disapproval of the parents, the child, or the situation
Force the child to remove clothing
Conduct the interview with a group of interviewers
Leave the child alone with a stranger

RED FLAGS:
There is discrepancy between history given and injuries sustained
The oral history is incompatible with the childs development
The story changes or varies
There was unreasonable delay before seeking care
The parent or caretaker denies that there is an injury
The parent or caretaker seems hostile towards the child
BRUISING
Most common form of injury seen in physical abuse
Approximately age of Bruxism

Age Color
0-48 hours Red/purple, swollen and tender
2-3 days Purple, bluish
4-7 days Light green; yellow
>7 days Fading, pale

Burn assessment
Thickness, location, definition of burn likelihood of accident, temperature and time

Red Flags of Abusive Burns

Dorsum of hands, feet, Anogenital area
Repeated burns
Symmetric or patterned burns
Uniform thickness and clear border
Delay in seeking care

Fractures in children below 18 months of age

55-70% of all inflicted skeletal trauma is timed in children <1 year old
80% are above fractures
2% are accidental fractures

Fracture Specificity
Specific fractures:
Metaphyseal Epiphyseal (<3 years old)
Thoracic cage (posterior ribs)
Shoulder (scapula)
Clavicle (medial or lateral)
Vertebral body (from lateral compression)

Highly suggestive fractures:

Multiple, bilateral, symmetric
Repetitive, different ages
Complex skull fracture
With intracranial, visceral injury

Nonspecific fractures:
Diaphyseal (shaft of long bone)
Clavicular, midshaft
Skull, linear

Sexual Abuse
Involvement of dependent, developmentally immature children and adolescents in sexual activities that they dont fully comprehend, are
unable to give informed consent to and that violate the social taboos or family roles-Kempe, CH. 1978. Pediatrics
Injury is reported in reference to the face of the clock
Differentiate the different types of hymen
Remember that Tanner Stages (The higher the Tanner stage, the more elastic hymen and the less prone it is to injury)

Non-specific Genital Findings

Labial fusion (with a history of vulvar coitus)
Generalized erythema of the vestibule (with a history of fondling)
Vaginal discharge (depends on what kind of discharge)

Suspicious findings:
Narrow inferior hymen (<1 mm) confirmed in knee-chest
Notch in inferior hymen confirmed in Knee-chest
 Local erythema or abrasions within vestibule (no history)
Presence of STD

Clear indications of Abuse

Complete absence of hymen tissue down to the vaginal wall
Recent partial or complete transection or laceration of hymen or anus
Presence of sperm, gonorrhea, or syphilis

Child Abuse Accomodation Syndrome

SECRECY
Children are told to keep the abuse secret
Entire family may be torn apart if the child discloses the abuse

HELPLESSNESS
Children pretend to be asleep and switch off
Active resistance is changed to insecurity, victimization, and loss of psychological well being

ENTRAPMENT AND ACCOMODATION

Feeling of self blame and guilt
May lead to psychological disintergration, psychosis, personality disorder, etc.

Delayed Unconvincing Disclosure

Retraction of Statements

Crisis intervention
Long term
Short term

Issues in Crisis Intervention

Virginity
Sexual orientation
Fear of the perpetrator
Blaming the child
Anger and sadness

Long term Care management

People in need: child, family, perpetrator
Areas of service coordination: legal, psychological, socioeconomic

Short term effects upon the child

Emotional and behavioral
Education and learning
Social relationships

Long term effects lasting into Adulthood

Mental health problems
Sexual adjustments
Child rearing difficulties
Social dysfunction