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Suffer The Little Children

Child Abuse

Physical  abuse 

Physical child abuse (ie, nonaccidental injury that a child sustains at the hands of his or her caregiver) can result in skeletal injury, burns, bruising (see the image below), and central nervous system injury from head trauma. To determine whether a child’s injury was likely to have been inflicted rather than accidental, the clinician must establish the full extent of the injury and must understand the child’s developmental level and abilities.

Expert panel issues new skeletal survey guidelines for toddler fractures

A multispecialty panel of experts released new skeletal survey guidelines to help guide assessment of whether fractures in children under 2 years of age are due to abuse or accidents. Recommendations include the following:

Skeletal survey should be performed in children with fractures resulting from abuse, domestic violence, or being hit by a toy or other object.

  • Skeletal survey should be performed in children with rib fractures and in those without a history of fracture from trauma, except in ambulatory children 12 months of age or older with a toddler fracture or buckle fracture of the radius/ulna or tibia/fibula.

  • If no abuse is suspected, skeletal survey should not be performed in cases of distal spiral fracture of the tibia/fibula in children 12-23 months old with a history of falling while running/walking, or in cases of distal radial/ulna buckle fracture in ambulatory children 12-23 months old with a history of falling onto an outstretched hand.

  • Skeletal survey should be performed in most children under 12 months of age.

Signs and symptoms

Physical indicators that should raise suspicion for maltreatment include the following:

  • Injury pattern inconsistent with the history provided

  • Multiple injuries/multiple types of injuries

  • Injuries at various stages of healing

  • Poor hygiene

  • Presence of pathognomonic injuries, including loop marks; forced immersion burn pattern; and classic abusive head trauma findings of subdural hematoma, retina hemorrhage, and skeletal injuries

Bruising over bony prominences is common in childhood, but patterns of bruising that raise the concern of possible abuse include the following:

  • Involvement of multiple areas of the body beyond bony prominences

  • Bruising of ears, facial cheeks, buttocks, palms, soles, neck, genitals

  • Bruises at many stages of healing

  • Bruises in nonambulatory child

  • Patterned markings resembling objects, grab marks, slap marks, human bites, and loop marks

  • Oral injury, lingular or labial frenula tears

Skeletal injuries in children younger than 2 years may not be obvious; therefore, a skeletal survey screening is recommended. Many fracture types can be accidental or inflicted. Fractures that raise a high degree of suspicion for inflicted injury include the following:

  • Any fracture in a nonambulatory infant without clear accidental and consistent mechanism

  • Metaphyseal fractures

  • Multiple, bilateral, differently aged posterior rib fractures

  • Multiple and complex skull fractures if only simple impact history

  • Spinous process fractures

  • Scapular fractures

Burn patterns that may suggest physical maltreatment include the following:

  • Patterned contact burns in clear shape of hot object (eg, fork, clothing iron, curling iron, cigarette lighter)

  • Classic forced immersion burn pattern with sharp stocking-and-glove demarcation and sparing of flexed protected areas

  • Splash/spill burn patterns not consistent with history or developmental level

  • Cigarette burns

  • Bilateral or mirror image burns

  • Localized burns to genitals, buttocks, and perineum (especially at toilet-training stage)

  • Evidence for excessive delay in seeking treatment, and the presence of other forms of injury

History and the physical examination findings determine which laboratory and diagnostic imaging studies are performed. Screening tools for suspected disorders or injuries are as follows:

  • Bleeding problem: A basic bleeding evaluation (platelets, prothrombin time [PT], activated partial thromboplastin time

  • Genetic bone disease or mineralization defect: Calcium, magnesium, phosphorus, and vitamin D levels; review of radiographs with a pediatric radiologist; genetic consultation, if available, may be warranted

  • Toxin or drug ingestion: toxicology screening

Child abuse: A survivor’s story

By Angela Goodwin-Slater

My childhood is filled with many memories. There were the normal memories of playing with my brother and friends, going to the movies, and hanging out at the mall. Most of my memories were of a loud angry household. My most vivid childhood memories were of my mother screaming at me, calling me names, and putting me down. Occasionally, she would spank us. When she did, she would be so angry that she would lose control. When she would get angry with me, she would yell and call me names, purposely being hurtful. 

 

My  first such  memory  was  when I was 5 years old. We were getting ready for church and I   

was unable to find one of my shoes. When I told my mother, she yelled and screamed that I had misplaced the shoe on purpose so that I wouldn’t have to go to church. On the way to church, she continued by telling me that I was the devil and I had nothing but evil in me. In the fourth grade, I went to a new school. For the first four or five months, I was picked on and bullied. When I told my mother, her first response was to ask me what I had done to make them pick on me. It was about this time that I began to believe that I was less than, not as good as, other kids. I carried that feeling into adulthood, and still fight with it today. 

One day during the summer before seventh grade I was working on a puzzle when a friend called, I asked my mother to ask her if I could call her back later because I was almost finished. She did as I asked, but after she hung up the phone she flew into a rage and told me that I was a bitch and that I would never have any friends. I still carry that with me. As a teenager, I was given the offer to train for the U.S. Swimming Team for the 1988 Olympics. I was excited. This was my dream. My mother declined the offer. When I asked her why, she said she didn’t have time to waste with that. These events were not as rare as it would appear. My mother would often yell, scream and put me down. By my early to mid-teens, it was routine. It was part of my day. The only upside to my mother’s rages was that she wouldn’t speak to me for a few days afterward. The silence was calming. I enjoyed it while I could. 

Having said all of that, I loved my mother, and I know she loved me. She made many sacrifices so that my brother and I could have some of the things we wanted, and go on vacations. We would look through all of the catalogs that we got in the mail and pretend that we were shopping at the mall. The problem came when she got angry. She responded to me the way her grandmother responded to her. I have always been disappointed that she never tried to be better than that. I did drugs and drank during junior high and high school. I stopped doing drugs during my late teens, but I started drinking rather heavily.

When I was about 20 years old I began to see a therapist, and eventually a psychiatrist. I have been in and out of therapy and on and off of medication for the last 25 years. I am currently in therapy, and very happy with my therapist. I am also taking antidepressants and anti-anxiety medication. Every day is a struggle with self-esteem. Every day I fight to believe I’m not the person my mother said I was. The biggest struggle is to build up my children’s self-esteem while working on my own. As a parent, I try very hard not to yell, scream and be mean like my mother was. When I get upset with my children, I focus on what they did wrong. I never tell them what horrible people they are, because they aren’t.  I realize that I get angry, too angry, and I’m the one that needs a time out. I don’t spank my kids.  Not because I believe it’s wrong, because I don’t. But because I’m afraid that I will lose control like my mother did. 

Now, as an adult, this daughter wants to do better, and she doesn’t want to cause harm to her own children. She recognizes her flaws and difficult upbringing and is struggling not to repeat the cycle of abuse in her family. How can we help her now as a mother? She needs to understand that:

 

  • Violence is contagious and can be learned. But violence can also be prevented. What parents do to their children or in front of them serves as lessons and models for the children’s behaviors. 

  • Parents are first teachers and can model and teach positive behaviors. Parents that provide a safe, nurturing, healthy and stable environment for their children help prevent violence and abuse in their families. 

  • Spanking is not an effective way of parenting and teaching good behaviors because it focuses on negative behaviors that have already occurred. It also teaches that it is ok to hurt someone you are supposed to love and protect. 

  • Parenting styles have consequences for children’s emotions and behaviors. Those who use spanking to discipline may lead their children to have low self-esteem, depression, toxic stress and trauma that can lead to risky behaviors such as drug and alcohol abuse. 

  • Parents need to be patient. Children are learning as they grow: what children can understand, feel and do changes with age and developmental stage. If you know what to expect, you will be less frustrated with a child’s behaviors and less aggressive. 

  • We can learn anger management by practicing: Using the rethink/ideal card will help her understand what caused the anger and the body’s reactions, how to express emotions with words using “I” statements, and strategies to resolve problems and conflicts in positive ways. 

  • We have different emotions for different situations. It is important to recognize what situations are generating specific emotions. Many times we are frustrated or tired, not angry, but we use violence. Using the ACT Program “Wheel of Feelings" will help differentiate emotions. 

  • When deciding to go to psychotherapy it is important to check if the provider adopts an evidence-based trauma focused treatment.

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