Peds Sherpath: Child Abuse and Neglect

Signs of child abuse: Speech and communication

Answering questions in words of one syllable or not at all; looking to others to respond first; seeking approval for answers; parent responds for the child

Signs of child abuse: Body image distortion

Being thin but describing self as fat

Signs of child abuse: Physical signs

Bruising (often first sign), skeletal muscle injury, burns

Family profile: Alcohol and drug use

Children whose parents overuse alcohol and other drugs are 3x more likely to be abused than other children from non-addicted families. Particular risk factors for child maltreatment include perpetrator alcohol or drug abuse, domestic abuse, and child disability.

Signs of child abuse: Posture and movements

Crouching in a corner; slow, concentrated movements

Neglect

Failure to properly care for the child eg: Withholding the child's basic needs of food, water, shelter, supervision

Medical neglect

Failure to provide medical care

Signs of child abuse: Facial characteristics and expressions

Fearful, anxious, tearful, sad, or angry expressions

Suggestive physical exam findings

Fractures in various stages of healing Injuries not typically found in children (e.g., long bone or rib fractures) Patterns of injury from specific objects (e.g., cigarette burns)

Signs of child abuse: Psychologic state

Frequently changing mood, demanding, bizarre, overly dramatic, or condescending, parents hovering over the child (refusing to leave)

Suggestive patient history

History inconsistent with physical findings Activity leading to trauma seems inconsistent with child's condition Delay in seeking treatment for injury Frequent emergency department visits

Signs of child abuse: Dress

Inappropriate for the weather; ragged or excessively dirty clothing

Physical Abuse

Intentional contact with the child that leads to pain and may lead to injury eg: Slapping, kicking, biting

Sexual abuse

Occurs when a child is inappropriately touched or made to perform sexual acts. Perpetrator is usually someone well-known to the child eg: parent, family member, family friend, babysitter, etc.

Sexual exploitation

Occurs when a child is made to perform sexual acts in exchange for money or other basic needs eg: pornography or prostitution

Family profile: Mental health issues

Perpetrators of sexual abuse are most often males who may have mental health issues; some were abused during childhood or adolescence.

Physical neglect

Withholding the child's basic needs

Risk factors for child maltreatment

child disability and/or a perpetrator who abuses drugs or alcohol

Emotional neglect

lack of emotional support

Abusive head trauma (AHT) aka shaken baby syndrome

-Caused by vigorous shaking of an infant held by the extremities, shoulders, or torso -Leads to whiplash-induced intracranial and retinal bleeding -Most common trigger is crying, esp if child is colicky -Typically no external signs of head trauma, skull fracture may be present -Should be considered in any infant with signs of increased ICP, retinal hemorrhage, seizures, subtle hydrocephalus, papilledema

Suspected abuse: communicating with the child

-Make eye contact with the child at eye level to establish trust -consult specialists or child abuse teams -anatomically correct dolls or art help children express what they cannot express in words -drawings may help identify abuse and assist in therapy

The nurse is caring for an infant with a suspicious injury. The mother of the infant is present in the room. Order the nursing interventions by priority with the highest priority placed first. 1. Ask the mother how the injury occurred in a nonjudgmental manner. 2. Inquire about family routine and who lives in the household. 3. Provide information about local parenting support groups. 4. Evaluate the verbal, physical, and visual contact between the child and mother.

1, 2, 4, 3 In a situation for suspected abuse, the nurse should first establish a relationship with the parent before inquiring about family dynamics to help ensure disclosure. Next the nurse should evaluate parenting skills, and finally refer the parents to a support group.

Bruises

Usually first and most common indicator of abuse but must be evaluated within the context of the child's developmental stage. Children who are being abused often have bruises in places where the child would not normally sustain this injury, such as on the back or back of legs. With sustained abuse, bruises are often in various stages of healing and may have a pattern of the instrument used to strike the child with.

During assessment of a 6-month-old infant, the nurse notes the child is in the 1st percentile for weight, has the psychosocial development of a 3-month-old infant and is wearing soiled clothing. Which type of child abuse would the nurse suspect? a. Sexual b. Neglect c. Physical d. Emotional

b. Neglect Neglect is characterized by failure to meet the child's basic needs, such as cleanliness and nutrition. This child's symptoms indicate neglect

The nurse is evaluating the understanding a hospitalized child with a history of abuse who is awaiting placement into a foster home. Which statement by the child would be a concern for the nurse and requires further follow-up? a. "If I am good, I can go back home." b. "I am afraid about going to my new home." c. "Talking about leaving mom makes me sad." d. "I want to stay in my room and play a game."

a. "If I am good, I can go back home." The child verbalizing that being good will allow the child to go back home is a concern because the child does not understand that they will not be returning to the home where they were abused. Furthermore, stating "If I am good" may indicate the child believes their behavior caused the abuse.

The nurse is caring for a 4-month-old infant who is admitted to the hospital for failure to thrive. Which other findings are consistent with child neglect? Select all that apply. a. Immunizations are not up to date. b. Area of crepitus on the upper left arm. c. Abdomen and lower back have bruising. d. Mother does not respond to infant's cries. e. Weight gain is below that expected for age.

a. Immunizations are not up to date. Lack of immunizations or immunizations not up to date is a finding consistent with neglect. d. Mother does not respond to infant's cries. Indifference in the parent-child interaction is a finding consistent with neglect. e. Weight gain is below that expected for age. Poor weight gain is a finding consistent with neglect.

Ongoing care: parental knowledge

- Can the parents describe normal child growth and development and developmental expectations? - Have the parents joined a support group?

Ongoing care: parenting skills

- Do the parents appropriately interact with the child through verbal, physical, and visual contact? - Have the parents described features of normal growth and development? - Do the parents make positive statements about the child? - Do the parents bring the child in for follow-up visits?

Ongoing care: decreased fears

- Does the child participate in play activities? - Has the child verbalized specific fears related to abuse and disclosure? - Has the child verbalized fears related to being removed from the family?

Ongoing care: free from injury

- Does the child remain free of inflicted injury? - Has the child been placed in a safe environment? - Has the child verbalized feelings regarding placement outside the home? - Has the family sought psychologic counseling?

Emotional abuse signs

-Delays in both physical and emotional development -Child behaves in ways that are too adult in relation to the child's age (eg. protective of others) or too immature for age -Child demonstrates repetitive habits eg. head-banging, rocking, biting, sucking -Parent-child relationship lacks warmth or attachments -Parents demonstrate overly critical approach

Characteristics of abusive family

-Isolation from community and social groups -Intense competition for emotional resources within the family, such as affection, attention, and nurturing -Little trust for outsiders and family members -Unpredictable and unstable family environment -Conflict resolution generally achieved through aggression or power struggle between family members -Communication often characterized by mixed or double messages, threats, or a focus on nonverbal communication -Family roles that are typically fixed and traditional with rigid rules -Frequent domination by a single family member (often a single parent's significant other) who maintains control through manipulation, intimidation, deceit, and aggression

Factitious Disorder By Proxy (aka Munchausen syndrome)

-The caretaker with Munchausen syndrome falsifies illness in the child through simulation or production of illness and then takes the child for medical care, claiming no knowledge of how the child became ill. -The most common reasons caretakers give for seeking medical treatment for the child are bleeding, seizures, apnea, diarrhea, vomiting, fever, and rash.

Assessment of abused child - interview

-take history -provide safe setting and/or comfort object -evaluate child's development against expected developmental milestones and observe role-model suitable interactions with the child -assess child's level of anxiety, ability to relate to examiner, emotional tone -assess family's interaction patterns, belief systems, social support systems -request information about bruises, injuries, and sexual abuse without emotion and with particular attention to the child's need for privacy and dignity -record child's comments verbatim; these may be needed later for legal proceedings -use appropriate assessment tool to identify behaviors typical of a sexually abused child -report any suspected abuse to the appropriate authorities. -recognize that the child may have low self-esteem; feel isolated from friends; demonstrate feelings of inadequacy, fear, and a possible desire to protect the perpetrator.

Family profile: Socioeconomic factors

Increased physical abuse is associated with periods of economic hardship or external stress.

Physical abuse signs

Physical:bruises in various stages of healing, bite marks, burns in unusual locations (back, palms), signs and symptoms of skeletal injury (multiple bone fractures, presence of spiral fractures. behavior: wariness or fear of adults, resist going home, Interviewing parents separately may reveal inconsistent story about how the child sustained injuries

Sexual Exploitation/Molestation

Sexual molestation is a form of physical abuse in which the child is touched sexually. Sexual exploitation consists of forcing children to exchange sex or sexual acts for drugs, food, shelter, protection, or other basic needs. eg: Involving children in pornography/prostitution

Emotional abuse

Subjecting a child to behavior that can lead to psychologic trauma eg: Harsh, abusive, violent speech

During assessment of a 7-month-old infant in the emergency department, the nurse notes papilledema, vomiting, and lethargy. The mother reports that the child has been colicky and that she brought the child in because of an altered mental status after the child had been left with a babysitter for 4 hours. Which type of abuse would the nurse suspect? a. Sexual abuse b. Emotional abuse c. Abusive head trauma d. Munchausen syndrome by proxy

c. Abusive head trauma The nurse would suspect abusive head trauma, specifically shaken baby syndrome, in a colicky child whose mental status suddenly changed after being left with a babysitter.

How can the experienced nurse best explain factitious disorder by proxy to a student nurse? a. "It occurs when the child has a psychiatric disorder." b. "It is the result of the parents covering up their child's illness." c. "It happens when the child fakes an illness to gain extra attention from parents and nurses." d. "It occurs when parents falsify illness in their child, yet there are no significant findings upon work-up."

d. "It occurs when parents falsify illness in their child, yet there are no significant findings upon work-up." Factitious disorder by proxy occurs when parents falsify illness in their child and claim they have no knowledge of how the illness occurred. Additionally, when the parent seeks medical care for their child, there are no significant findings on work-up. The parent does this to gain attention.

Family profile: Family characteristics

-Isolation from community and social groups -Intense competition for emotional resources within the family, such as affection, attention, and nurturing -Low levels of differentiation and trust among family members -Unpredictable and unstable family environment -Conflict resolution achieved through aggression and power struggle among family members -Family roles are typically fixed and traditional, with rigid rules, discipline, and expectations -Frequent domination by a single family member who maintains control through manipulation, intimidation, deceit, and aggression

Family profile: Family associations

-The typical perpetrator of physical abuse is a direct relative of the child (78% were parents), with mothers more often being perpetrators, compared with fathers. -In sexual abuse, the perpetrator is more likely to be a family friend or neighbor (60%), compared with a parent (3%).

Emotional abuse

-Yelling at the child -Mocking, insulting the child -Communicating threats -Isolating the child -Ignoring or excluding the child from group activities

Neglect signs

-inadequate weight gain for age -poor growth pattern -failure to thrive -inappropriate dress for weather -inadequate hygiene -child not sent to school -lack routine health care -parent appears indifferent or unaware of child's needs

Signs of child abuse: Grooming and personal hygiene

Dirty teeth; broken and dirty fingernails; matted and dirty hair

Major signs of Abusive head trauma (AHT)

If 3+ of the major signs are present in a child younger than 3yo, AHT should be suspected -Retinal hemorrhage -Skull fracture -Altered neurologic status -Apnea -Head or neck bruises -Subdural hematoma -Seizures -Increased ICP -Subtle hydrocephalus -Papilledema

Disclosure of abuse

The nurse, as a patient advocate, has a moral and legal duty to report any suspected child abuse -Report suspected child abuse to the appropriate authorities. -Nurses are mandatory reporters and not reporting suspected or confirmed child abuse is illegal. -Mandatory reporters are required to report the facts and circumstances that led them to suspect that a child has been abused or neglected. -Nurses can contact the local child protective service office or law enforcement. -Nurses do not have the burden of providing proof that abuse or neglect has occurred. -The nurse must document the facts surrounding the situation carefully and avoiding bias, as these may be used in legal proceedings. -Each state may have specific reporting policies the nurse should be aware of.

The school nurse is reviewing the personal and family history of several students. The nurse correctly identifies which student as having the greatest risk for child abuse? a. A child of a parent who socially drinks. b. A child of a divorced parent who remarried 4 months ago. c. A child whose parent is a recovered drug addict of 7 years. d. A child with Down syndrome who lives at home with other siblings.

d. A child with Down syndrome who lives at home with other siblings. A child with a disability is at a higher risk of child abuse than a nondisabled child. This child is considered at greatest risk for abuse.

The nurse is assessing a 6-year-old boy admitted to the hospital for a spiral fracture of the left arm. The mother reports he fell off the swing while outside. Which additional finding is suspicious for physical abuse? a. The child's clothes have dirt and grass stains. b. The child has a small abrasion on the injured arm. c. The child cries when the nurse touches the injured arm. d. The child clings to the nurse when his father enters the room.

d. The child clings to the nurse when his father enters the room. A child that clings to the nurse when his father enters the rooms is suspicious for physical abuse because the children who have been physically abused may exhibit fearfulness of adults.

The nurse is caring for a child with suspected physical abuse. Which statement regarding family history supports the likelihood of physical abuse having occurred? a. The mother mentions smoking cigarettes. b. The father tells the nurse he works full-time. c. The father reports a history of clinical depression. d. The mother reports a serious personal financial crisis.

d. The mother reports a serious personal financial crisis. Economic hardship and stress are associated with increased likelihood of the child experiencing abuse.

Sexual abuse signs

-difficulty walking or sitting -complaints of genital or urinary pain -withdrawn -bruising or laceration of perineal tissue -diagnosis of STD -nightmares -decreased appetite -sudden refusal to participate in physical activities -overt aggression or sexual language -parents overly protective, controlling, or seeking to isolate the child from others

Assessment of abused child - physical exam

-measure height and weight and compare to previous measurements - assess skin for impaired integrity or bruising, especially of the scalp, bottoms of the hands and feet, front and back of the truck, and genitalia

The nurse is assessing a 2-year-old child for signs of abuse. Which finding warrants further investigation by the nurse for possible abuse? a. The child sucks a thumb. b. The child wears a diaper. c. The child only says "baba" when speaking. d. The child cannot draw a person with six body parts.

c. The child only says "baba" when speaking. A 2-year-old should have a vocabulary of at least 50 words and be easy to understand (at least half of their verbalizations). This indicates there is a delay in the normal developmental progress and should be investigated further.

A nurse is reviewing the night-shift patient assignments on the pediatric unit. Which assessment finding is concerning for possible child abuse? a. A 10-month-old infant with scalp bruises b. A 9-month-old infant who sucks his thumb c. A 2-year-old child with a localized rash and fever d. A 3-year-old child who brings a blanket to the hospital

a. A 10-month-old infant with scalp bruises Bruising on the head is an assessment finding that is suggestive of child abuse

Which finding may be associated with child neglect? a. A child attends school dressed in dirty clothes. b. A 9-year-old child who sucks his thumb in class. c. A child upset because his parents denied him a new toy. d. A 4-month-old infant brought to the emergency department with a broken femur.

a. A child attends school dressed in dirty clothes. Dirty clothes, a sign of inadequate hygiene, may be a sign of child neglect.

The nurse is working in the emergency department when a disheveled 4-year-old patient is brought in with an injured arm that is likely fractured. Documentation reveals a prior visit for a fractured tibia and fibula. The child's parents report the injury occurred 3 days ago and are anxious to leave. Which findings would lead the nurse to initiate the abuse reporting protocol? Select all that apply. a. Arm fracture b. Parents anxious to leave c. Delay in seeking treatment d. Child's disheveled appearance e. The patient states that she feels isolated from her friends.

a. Arm fracture The patient's current fracture is a sign of physical abuse, since it is a repeat occurrence, indicating the need to initiate the abuse reporting protocol. c. Delay in seeking treatment The fact that the parents waited 3 days to seek treatment for the child's arm indicates neglect and the need to initiate the abuse reporting protocol. d. Child's disheveled appearance The child's disheveled appearance indicates neglect and the need to initiate the abuse reporting protocol. e. The patient states that she feels isolated from her friends. Feelings of being isolated from friends can be a sign that the child is living in an abusive household. (counted as correct in Sherpath, but does not apply to this question - should not be an answer)

The nurse is interviewing a mother and her 12-year-old child who report that the child has fallen for the fifth time in a month. Which observations would indicate to the nurse the possibility of child abuse?Select all that apply. a. Child refuses to speak to the nurse. b. Child clings to the mother during the interview. c. Parent answers all questions for the child during the interview. d. Parent refuses to leave the child's side during the examination. e. Child has deep purple bruises on the arms and graying bruises on the legs.

a. Child refuses to speak to the nurse. - Withdrawal can be an indicator of child abuse. c. Parent answers all questions for the child during the interview. - The nurse would suspect child abuse if the parent refuses to allow the child to speak during the interview and examination. d. Parent refuses to leave the child's side during the examination. - The nurse would suspect child abuse if the parent refuses to allow a brief, private examination of the child. e. Child has deep purple bruises on the arms and graying bruises on the legs. - Bruises in multiple stages of healing are signs of physical abuse.

A 4-year-old child is admitted to the emergency department (ED) with burns to the back of both hands, and the nurse suspects that the child has been abused. Which action should the nurse perform first? a. Examine the child while sitting on a chair b. Have the child role play the abuse with dolls c. Ask the child to draw a picture of what happened d. Ask the ED triage nurse to contact child protective services

a. Examine the child while sitting on a chair Sitting on a chair during the examination places the nurse at the child's eye level and can help establish the child's trust. This should be the nurse's first action with suspected abuse.

The nurse is treating a child and has determined that the child has been a victim of sexual abuse. Which person is most likely to be the abuser? a. A daycare worker b. Physical therapist c. The mother's boyfriend d. Neighborhood stranger

c. The mother's boyfriend A child abuser is most often a parent's significant other, and therefore the mother's boyfriend is most likely to be the abuser.

The nurse is caring for a 3-year-old child admitted for a fractured arm. Which findings would cause the nurse to suspect the child is being abused? Select all that apply. a. The child appears small for age. b. The child cries when the nurse enters the room. c. Radiograph that reveals a healing femur fracture. d. An assessment that reveals bruising on the forearm. e. The child refuses to talk about the injury with the nurse.

a. The child appears small for age. Children who are neglected and abused may not be receiving adequate nutritional intake and can appear smaller for their age. c. Radiograph that reveals a healing femur fracture. A radiograph that reveals a healing femur fracture, in addition to a newly fractured arm, depicts a child with fractures in different stages of healing; this is the most concerning finding in this situation. d. An assessment that reveals bruising on the forearm. Bruising on various parts of the body, at various stages of healing are a concern especially with the other history of injuries. Though bruising can be expected with accidental fractures, the nurse should evaluate the child for abuse in this situation.

A child presents to the emergency department with a fractured arm. During the assessment the child tells the nurse "daddy twisted my arm." Which is the nurse's best action? a. Assess the child's level of understanding b. Document the child's report in the record c. Ask the father if he twisted the child's arm d. Reassure the child that she/he will be protected

b. Document the child's report in the record The nurse's best action is to document the child's report verbatim in the record because this documentation may be needed later for legal proceedings.

The nurse is speaking to a health care provider who states, "Yes, this type of child abuse is the most common that we see." The nurse interprets that the health care provider is describing which type of child abuse? a. Sexual b. Neglect c. Physical d. Emotional

b. Neglect USDHHS research indicates that neglect is the most common type of child abuse recorded, followed by physical and sexual abuse.

A 7-month-old infant is brought to the emergency department with a femur fracture. The parents report that the child fell off a couch. Which form of abuse does the nurse suspect? a. Neglect b. Physical abuse c. Emotional abuse d. Munchausen syndrome by proxy

b. Physical abuse A lower extremity fracture in a nonambulatory child is a cause for further evaluation for signs of physical abuse.

A 9-month-old infant has been brought to the emergency department with a change in level of consciousness. The parent states, "My child has colic, which is why he won't wake up." Which form of abuse would the nurse suspect? a. Neglect b. Physical abuse c. Emotional abuse d. Munchausen syndrome by proxy

b. Physical abuse The child's signs and symptoms are indicative of physical abuse, specifically, abusive head trauma.

A nurse is caring for a teenage girl and suspects that she may be experiencing abuse at home. Which part of the patient's history would suggest the she may be a victim of abuse?Select all that apply. a. The patient sneaks out at night to visit friends. b. The patient states that she feels isolated from her friends. c. The patient belongs to a family of seven and acts out in school. d. The patient reports that she is expected to help care for younger siblings on weekends. e. The patient lives in a single-parent home and is required to live by very strict rules.

b. The patient states that she feels isolated from her friends. - Feelings of being isolated from friends can be a sign that the child is living in an abusive household. c. The patient belongs to a family of seven and acts out in school. - Children from large families are more susceptible to neglect. They may struggle for needed attention and may not get the love, nurturing, and support required for adequate emotional growth and development. e. The patient lives in a single-parent home and is required to live by very strict rules. - A child who lives in a home with unreasonable rules and strict family roles may be more susceptible to abuse.

The nurse is caring for several hospitalized children. Which patient is most likely to be experiencing Munchausen syndrome by proxy? a. A school-age child with vaginal discharge and a diagnosis of chlamydia. b. A preschool-age child with a low albumin level who is underweight for age. c. A school-age child admitted because of vomiting and dehydration for the sixth time this year. d. A preschool-age child with second-degree burns on both lower extremities and the buttocks.

c. A school-age child admitted because of vomiting and dehydration for the sixth time this year. Frequent hospitalizations for nonspecific symptoms are a sign of Munchausen syndrome by proxy.

The nurse is caring for a child who presents with multiple bruises in various stages of healing. Which action by the nurse is most appropriate? a. Question the child about any potential abuse. b. Ask the parents if the child has ever been abused. c. Allow the child to describe how the bruises occurred. d. Request the child undress to begin an immediate physical examination.

c. Allow the child to describe how the bruises occurred. The nurse's most appropriate action is to allow the child to describe how the bruises occurred to provide an accurate assessment.

A school nurse is speaking with a 10-year-old child who has been acting out in class. The child becomes tearful and says, "My dad's right. I can't do anything good." Which type of abuse might this child be experiencing? a. Neglect b. Physical abuse c. Emotional abuse d. Sexual exploitation

c. Emotional abuse Emotional abuse occurs when someone subjects a child to behavior that can cause psychologic trauma. Insulting the child is a form of emotional abuse.

The nurse notices burn marks on a child's arm. The child is also looking fearful and withdrawn. When the nurse asks him about the injuries, he hesitates and looks fearfully to his mother before answering. For which types of abuse should the nurse assess this patient? Select all that apply. a. Sexual b. Neglect c. Physical d. Emotional e. Munchausen syndrome by proxy

c. Physical Burns are a sign of physical abuse. d. Emotional A fearful expression is a sign of emotional abuse.

The nurse sees an 11-year-old female patient in the clinic who reports vaginal discharge. Which additional finding is the most likely indicator of sexual abuse? a. 3+ bacteria in urine b. Nausea and vomiting c. Positive test result for gonorrhea d. Frequent emergency department visits

c. Positive test result for gonorrhea A positive test result for a sexually transmitted infection is the most likely indicator of sexual abuse. This patient should be further evaluated for sexual abuse.

The nurse is providing information to new parents about infant abusive head trauma. Based on known causes of abusive head trauma, which information should the nurse provide to the parents to help prevent abusive head trauma in the infant? a. "Be careful when burping the infant on the back." b. "Do not leave the infant in the crib during the night." c. "Call the health care provider if the child has a seizure." d. "Place the infant in a safe place if you become frustrated by crying."

d. "Place the infant in a safe place if you become frustrated by crying." Because crying is most often the trigger of vigorous shaking of the infant, this is the best information the nurse can provide the parents to prevent abusive head trauma in the infant.

The nurse is caring for a 4-year-old child admitted to the pediatric unit. During the assessment, the nurse notes extensive bruising to the torso, but the assessment is otherwise normal. The parents report the child does not listen well and fell while riding a bicycle. Which nursing actions are most appropriate? Select all that apply. a. Inform the parents that the child should listen better. b. Question the parents about how long the child has had the bicycle. c. Remind the parents that 4-year-olds have trouble following directions. d. Ask the child about the injury when they are not in the parent's presence. e. Ask the parents which safety equipment the child wears while riding a bicycle.

d. Ask the child about the injury when they are not in the parent's presence. Providing a safe setting away from the parents is an appropriate action to assist in obtaining factual information from the child. e. Ask the parents which safety equipment the child wears while riding a bicycle. Evaluating which safety equipment was in place can assist the nurse in understanding if the injury findings are consistent with the bicycle fall. Additionally, the parent's response to this question may provide data on the likelihood that the 4-year-old actually rides a bicycle.