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Tufts OpenCourseware
Author: Robert Reece

I. Lecture Outline

A. Definition of Child Abuse

Physical or mental injury, sexual abuse, negligent treatment, or maltreatment of a child under 18 by a person who is responsible for the child’s welfare under circumstances which indicate that the child’s health or welfare is harmed.

B. Types of Maltreatment

  1. 63%: Neglect – most common cause of death in children 0-3 (36%)
  2. 19%: Physical abuse
  3. 10%: Sexual abuse
  4. 5%: Emotional abuse/neglect
  5. 11%: Other

C. Incidence

  1. Over 900,000 substantiated cases in 2003.
  2. Over 1500 autopsy-proven fatalities due to maltreatment
  3. Less than1% from daycare or foster care
  4. Most often 0-3 years old
  5. Many cases are not reported
  6. Often associated with domestic violence and/or alcohol/substance abuse

D. Characteristics of Abuser

  1. 60% of perpetrators are FEMALE
  2. Substance abuse, poverty, poor impulse control
  3. Physical and sexual abusers are usually MALE

E. Accident or Abuse?

  1. Plausibility of history
  2. Changing of history; inconsistencies; concept of discrepant history
  3. Certain lesions are characteristic of inflicted injury
    1. Bruises on dorsal surface of body
    2. Bruises on face, ears, buttocks, genitalia, neck
    3. Classic metaphyseal lesions of long bones
    4. Posterior rib fractures
    5. Multiple fractures, varying stages of healing
    6. Classic triad of shaken baby syndrome: subdural and or subarachnoid hemorrhage, retinal hemorrhages, brain swelling
    7. Fractures in infants under 6 months of age
  4. Delay in seeking medical care, demeanor of caretakers, developmental stage of child doesn’t match history, eye witnesses, STDs in young children, belt/buckle marks, fractures from twisting arms/pulling child up by the arms, internal abdominal injuries, high risk environment

F. Shaken Baby Syndrome (SBS)

  1. Most are less than1 year old
  2. Baby is shaken 10-20 times to stop infant from crying
  3. Often the mom’s boyfriend is the perpetrator
  4. Mortality rate 20-25%
  5. Clinical triad in SBS
    1. subdural hemorrhage/hematoma – rupture of bridging vein; subarachnoid hemorrhage can also be observed.
    2. unique retinal hemorrhages – multiple hemorrhages involving several layers of the retina, all the way out to the ora serrata
    3. cerebral edema
  6. The brain injury is what counts, not the bleeding
    1. Infant’s brain has gelatinous consistency: high H2O, unmyelinated neurons
    2. Sensitive to injury Neuronal death
    3. Bridging vein rupture Brain strikes skull Diffuse neuronal trauma Hypoxia during shaking and brain stem damage Release of toxic chemicals from dying neurons

G. Skeletal Injuries

  1. Long bone diaphyseal spiral fractures due to torsional forces can be the result of accidental trauma or abuse
  2. Posterior rib fractures, classic metaphyseal lesions, fractures in very young children, fractures associated with other abusive injuries- highly suggestive of abuse

II. Sample Test Questions

  1. Which of the following injuries in a 4 year old is most likely to be the result of abuse?
    1. cut chin
    2. bilateral bruises on the knees
    3. scraped forehead
    4. Bruises on the face
  2. What is NOT a feature of Shaken Baby Syndrome?
    1. retinal hemorrhages
    2. occurrence in infant less than 1 year old
    3. associated with a high mortality rate
    4. Torn frenulum
  3. Which of the following fractures is not highly specific for physical abuse?
    1. posterior rib fractures
    2. classic metaphyseal fractures of the long bones
    3. linear skull fracture
    4. vertebral fractures
  4. Which of the following can be seen as sequelae of childhood maltreatment? (Circle as many as apply)
    1. neurological disorders
    2. cognitive-behavioral disorders
    3. structural changes in the brain
    4. adult medical conditions
    5. post traumatic stress disorder
  5. A 4-year-old girl tells the physician that her mother’s boyfriend asked her to touch his penis. Physical examination of the child is unremarkable. The next thing that the physician should do is to
    1. contact the state child-protective service agency
    2. contact the child’s biological father
    3. speak to the boyfriend about the child’s remark
    4. contact a child psychiatrist to determine if the child is telling the truth
    5. question the child at length to determine if she is telling the truth
  6. Which of the following injuries in a 4-year-old child is most likely to be the result of abuse?
    1. cut chin
    2. bilateral bruises on the knees
    3. scraped forehead
    4. cut elbow
    5. ruptured spleen

1 - Answer: D - The other injuries are likely to be obtained from normal play.

2 - Answer: D - Torn frenulum is an abusive injury, but is not often associated with sbs

3 - Answer: C - Linear skull fractures are very common accidental injuries.

4 - Answer: All of the above

5 - Answer: A

6 - Answer: E