Recognising and Managing Child Abuse in General Practice. Dr Ceiridwen Davies Consultant Paediatrician Child Abuse Team Red Cross Children s Hospital
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1 Recognising and Managing Child Abuse in General Practice Dr Ceiridwen Davies Consultant Paediatrician Child Abuse Team Red Cross Children s Hospital
2 Definition Outline Importance of Child Abuse Common presentations - Bruises - Fractures - Shaken Baby Syndrome - Burns - neglect - Suspicions of sexual assault Follow up Documentation and Criminal Justice system
3 What is child abuse? physical abuse emotional ill-treatment sexual abuse neglect negligent treatment and exploitation of children WHO Definition
4 Child Sexual Assault
5 Why is child abuse important? MORGAN COUNTY CHILD ADVOCACY CENTER INC
6 South African Law addresses it in the Children s Act 38 of 2005 (as amended by the Children s Amendment Act 41 of 2007) Section who on reasonable grounds concludes that a child has been abused in a manner causing physical injury, sexual abuse or deliberate neglect
7 blogs.telegraph.co.uk How do we make the diagnosis of child abuse and neglect?
8 Risk Factors Parent Characteristics Family Characteristics Child Characteristics Parent/child relationship Environmental
9 Indicators Positive disclosure History Suspicious behaviour Examination
10 Physical Abuse Bruises Fractures Inflicted Head Injury Photo Removed Burns General neglect Trauma unit,rxh
11 Bruising Photo Removed Photo Removed Trauma unit,rxh Trauma unit,rxh
12 Red Flags Injury not compatible with explanation - Mechanism - Amount of force - Age/developmental Photo Removed Injuries of different ages Unusual site of a bruise Patterned Bruise Trauma Unit,RXH
13 Photo removed Trauma unit, RXH Photo removed Sick Kids Hospital Trauma Unit, RXH
14 Sick Kids Hospital
15 Sick Kids hospital Sick kids Hospital
16 Trauma unit, RXH
17 Caution Sick kids Hospital pediatrics.about.com health.chla.org
18 Inflicted Fractures Trauma unit, RXH Trauma unit, RXH
19 Red Flags Injury not compatible with explanation - Mechanism - Amount of force - Age/development Recurrent incidents of trauma Sick kids Hospital Injuries of different ages Unusual fracture locations Trauma unit RXH
20 Sick kids Hospital
21 Sick kids Hospital
22 Metaphyseal fractures Sick Kids Hospital Diagnostic Imaging in Child Abuse,Non Accidental Trauma, by Simon Robben, Radiology Departement of the Maastricht University Hospital Diagnostic Imaging in Child Abuse,Non Accidental Trauma, by Simon Robben, Radiology Departement of the Maastricht University Hospital
23 Skull Fractures Sick Kids Hospital Trauma unit, RXH
24 Additional Imaging Sick Kids Hospital Subdural haemorrhage in right parasagittal Diagnostic Imaging in Child Abuse, Non Accidental Trauma by Simon Robben R front parietal subdural haematoma New subdural hematomas in the right frontal and posterior interhemispheric region.
25 Shaken Baby Syndrome Subdural Haemorrhages Rib fractures Metaphyseal fractures Retinal ahemorrhages Diagnostic Imaging in Child Abuse,Non Accidental Trauma by Simon Robben Radiology Departement of the Maastricht University Hospital
26 Ophthalmology Review Retinal Haemorrhages : often bilateral, multi-layered, extend to the periphery
27 Caution Caffey s Disease Menkes Disease Osteogenesis Imperfecta Diagnostic Imaging in Child Abuse,Non Accidental Trauma by Simon Robben Radiology Departement of the Maastricht University Hospital
28 Burns Scald injury : common accidental and non-accidental burn
29 Red Flags Age and development Burn characteristics Usually lower limbs Glove and stocking Clear demarcation Absence of splash marks Sometimes sparing is seen Burn patterns Cigarette Iron/radiator grid
30 Patterns Cupping burns Radiator burn Cigarette Burns
31 Neglect
32 Sexual Assault sandiegotherapistcounselor.com
33 How do we know if a child is being sexually assaulted?
34 How do we know if a child is being sexually assaulted? Positive Disclosure OR
35 Physical indicators Genital or anal bleeding Vulvitis or vaginal discharge Genital discomfort Associated signs of physical abuse Vaginal or anal tears Confirmed gonorrhea, syphilis & Trichomonas Presence of semen or pregnancy
36 Behavioral Indicators Sexualized play or sexually precocious excessive masturbation Insertion of foreign bodies Other : eg poor scholastic performance, overdosage or attempted suicide
37 The GP s Role Performing the Examination Completing the Documentation Providing initial treatment and follow up
38 The GP s Role Performing the Examination Completing the Documentation Providing initial treatment and follow up
39
40 The Influence of Hormones 2 year old Pre pubertal 12 year old
41 Different shapes of the Hymen Hymenal orifice: Normal limits HORIZONTAL - <5yrs = 5mm - >5yrs - add 1mm per year to age of 10yrs - >10yrs - maybe >15mm
42 Septated Hymen Crescentic Hymen Annular Hymen Images Thanks to Dr Cheema
43 Normal Variants MOUNDS ~ 30% rounded elevated tissue present NOTCHES common but rarely extends all the way to vaginal wall BEWARE between POSITION i.e. POSTERIOR MORE LIKELY TO BE ABNORMAL TAGS common Tissue extending >1mm over the edge most likely septal remnants CLEFT IN ANTERIOR 180º Usually at 11,12,3 or 9 o clock SUPPORT BANDS common at position
44 Female Genital Examination Frog leg position Knee chest position
45 Frog leg position Knee chest position Images thanks to Dr Mackerrow
46 Genital Documentation
47 Interpretation 1) Findings documented in newborns or commonly seen in non-abused children 2) Indeterminate findings These findings may support the child s clear disclosure of sexual abuse but without this should be interpreted with caution 3) Findings diagnostic of trauma and or sexual contact 4) Findings diagnostic of sexual contact Joyce Adams criterion 2007
48 Interpretation 1) Findings documented in newborns or commonly seen in non-abused children 2) Indeterminate findings These findings may support the child s clear disclosure of sexual abuse but without this should be interpreted with caution 3) Findings diagnostic of trauma and or sexual contact 4) Findings diagnostic of sexual contact Joyce Adams criterion 2007
49 Labial Fusion Vulvovaginitis Lichen sclerosis
50 Interpretation 1) Findings documented in newborns or commonly seen in non-abused children 2) Indeterminate findings These findings may support the child s clear disclosure of sexual abuse but without this should be interpreted with caution 3) Findings diagnostic of trauma and or sexual contact 4) Findings diagnostic of sexual contact Joyce Adams criterion 2007
51 Notches or clefts in the posterior half of the hymen extending nearly to the vaginal floor, confirmed in all positions Condylomata acuminata in a child older than two years who gives no history of sexual contact Immediate, marked anal dilatation Anal scarring Mounds at 3 o clock and 9 o clock
52 Interpretation 1) Findings documented in newborns or commonly seen in non-abused children 2) Indeterminate findings These findings may support the child s clear disclosure of sexual abuse but without this should be interpreted with caution 3) Findings diagnostic of trauma and or sexual contact 4) Findings diagnostic of sexual contact Joyce Adams criterion 2007
53 Acute trauma to ext genitalia/anal tissues Healing injuries including anal scarring Injuries indicative of blunt force penetrating injury - laceration of the hymen, - echymosis of the hymen, - perianal laceration deep to anal sphincter, - hymenal transection, - missing segment of hymenal tissue in inferior portion Presence of STI infection
54 Transection of The hymen At 9 o clock Labial minora abrasion Perineal laceration and transection of the hymen Images from trauma unit, RXH
55 Images thanks to Dr Cox RXH Grade 2 and 3 genital injuries
56 A normal examination does not exclude sexual assault especially when there is a positive disclosure
57 The GP s Role Performing the Examination Completing the Documentation Providing initial treatment and follow up
58 Initial Treatment Initiating PEP (AZT, 3TC and Kaletra) Pregnancy prophylaxis Bloods for HIV, VDRL docstoc.com Treatment of STD s
59 Follow-up 2 weeks, 1 month, 3 months and 6 month FBC at 2 weeks VDRL and HIV at 1 month PTSD symptoms Progress of Case Confirm safety plans stress-problems.com
60 Documentation Form 22: Reporting Of Abuse or Deliberate Neglect pdf Guidelines for the completions of the J88 form - KwaZulu- Natal...
61 Summary Child abuse is common Mandatory reporting Specifics related to physical abuse Red Flags Cautions Normal Female genital anatomy Introduced the Joyce Adams Criterion Perfect position Documentation
62
63 Children are the world's most valuable resource and its best hope for the future
64 innovationtools.com
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For further information, please contact BC Women s Sexual Assault Service at Thank-you.
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