INTRODUCTION

According to UNICEF violence against children can be "physical and mental abuse and
injury, neglect or negligent treatment, exploitation and sexual abuse. Violence may take place
in homes, schools, orphanages, residential care facilities, on the streets, in the workplace, in
prisons and in places of detention." Such violence can affect the normal development of a
child impairing their mental, physical and social being. In extreme cases abuse of a child can
result in death.

Child abuse is a state of emotional, physical, economic and sexual maltreatment meted out to
a person below the age of eighteen and is a globally prevalent phenomenon. However, in
India, as in many other countries, there has been no understanding of the extent, magnitude
and trends of the problem. The growing complexities of life and the dramatic changes
brought about by socio-economic transitions in India have played a major role in increasing
the vulnerability of children to various and newer forms of abuse.

WHAT IS CHILD ABUSE?

Child abuse is

Verbally abusing a child

Teasing a child unnecessarily
Exposing child to pornographic acts or literature
Touching a child where he/she does not want to be touched
Forcing a child to touch you
Breaking down the self-confidence of a child
Hitting or hurting a child often to relieve your own frustration
Manipulating a child
Not taking care of a child, for example: unclean, unclothed, unfed child
Using child as a servant
Not listening to a child
Neglecting emotional needs of a child
Hitting and ridiculing a child at school
Neglecting a child’s medical needs
Neglecting a child’s educational needs
Leaving a child without supervision

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DEFINITION
Child abuse refers to the intended, unintended and perceived maltreatment, whether habitual
or not, of the child, including any of the following:
 Psychological and physical abuse, neglect, cruelty, sexual and emotional
maltreatment.
 Any act, deed or word which debases, degrades or demeans the intrinsic worth and
dignity of a child as a human being.
 Unreasonable deprivation of his/her basic needs for survival such as food and shelter;
or failure to give timely medical treatment to an injured child resulting in serious
impairment of his/her growth and development or in his/her permanent incapacity or
death.

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DEMOGRAPHICS
Worldwide:

 W.H.O. estimates that 150 million girls and 73 million boys under 18 have been
subjected to forced sexual intercourse or other forms of sexual violence.
 In 2002 a Global School-Based Student Health Survey found that 20% and 65% of
school going children reported having been verbally and physically bullied in the last
30 days.
 ILO estimates show there were 218 million child laborers in 2004, out of which 126
million were engaged in hazardous work.
 UNICEF estimated 3 million girls and women in sub-Saharan Africa, Egypt and
Sudan are subjected to female genital mutilation every year.

India:

According to Ministry of Child and Women development, Government of India survey in

2007:

 53% of children, both boys and girls are victims of abuse

 2 out of 3 children are physically abused
 8 cases of abuse are reported everyday
 88% of perpetrators were parents of the reported physical abuse cases

FACTORS AFFECTING CHILD ABUSE

Parental

Factors Environmental

Child

Parental factors:

Parent has already abused a child

Pregnancy was not wanted
Young, unsupported mother often with low education.
Parents have unrealistic expectations of the child and lack parenting knowledge
Parent is isolated and has few support
Low self-esteem of parent
Parent has a mental illness or is abusing drugs or alcohol

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Environmental factors:

Overcrowding in the house

Poverty or lack of opportunity to improve the family’s resources
Family violence is present
A non-biological adult living in the house
Family is experiencing multiple stresses

Child factors:

Baby is sickly, or unwanted

Child has a physical or developmental disability
Child is the product of an abusive relationship
Lack of attachment between child and parent

FORMS OF ABUSE
There are many forms of child abuse and they vary according to cultural and geographical
settings. The four prominent forms of child abuse are

FORMS OF CHILD
ABUSE

Physical Emotional Sexual Neglect

PHYSICAL ABUSE
Even if the caregiver didn’t mean to cause injury, when the child is injured it is abuse.
Physical discipline from a parent that does not injure or impair a child is not considered
abuse; however non-violent alternatives are always available.

Definition:
The deliberate infliction of injuries on a child, usually by the child's caregiver is termed
physical abuse. This may include hitting, slapping, kicking, beating or otherwise harming a
child.

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Signs of physical abuse:
Physical Signs of physical Abuse

 Unexplained bruises and welts

- At various stages of healing
- Can reflect shape of objects used
- Often on face, torso, buttocks, back, thigh
 Unexplained burns
- Often on palms, soles, buttocks and back
- Often has distinct shapes with no splash marks
 Unexplained fractures and dislocations
 Other unexplained injuries, human bite marks or pinch marks
 Loss of hair?bald patches
 Injuries on 2 or more planes of the child’s body

Behavioral Signs of Physical Abuse

Physically abused children find it difficult relating to their peers and the adults around them.
They are also vulnerable to "emotional storms", or instances of overwhelming emotional
responses to everyday situations. These "storms" can take the form of profound grief, fear, or
rage.

 Apprehension when other children cry

 Inconsistent versions about occurrence of injuries
 Little respect for others
 Difficulty in getting along with others

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  Aggressiveness; hurting others
 Nightmares, insomnia
 Often late or absent from school
 Seems afraid of parents or other adults
 Arriving early for school; reluctant to go home afterwards

Possible Signs of Physical Abusers

 Showing little or no interest in the child’s well-being

 Blaming the child for injuries.
 Indicates child is not trustworthy, a liar, evil, a troublemaker
 Taking child to different physicians or hospitals for each injury
 Delays or prevents medical care for child
 Were abused themselves or raised in homes where excessive punishment was used
 History of alcohol or drug abuse

EMOTIONAL ABUSE

Definition
It is maltreatment which results in impaired psychological growth and development.

- Also known as verbal abuse, mental abuse, and psychological maltreatment

- Includes acts or the failure to act by parents, caretakers, peers and others that have
caused or could cause serious behavioral, cognitive, emotional, or mental
distress/trauma.
- Injury from emotional abuse can be just as serious and lasting as that from physical
abuse, but it is much more difficult to identify.

Types of Emotional Abuse

TYPES

Rejecting Isolating

Ignoring Corrupting

Exploiting Terrorizing

Witnessing
family violence

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1. Rejecting: Putting down a child or youth’s worth or putting down their needs
- constant criticism
- name-calling
- telling child he/she is ugly
- yelling or swearing at the child
- frequent belittling-use of labels such as “stupid”, “idiot”
- constant demeaning jokes
- verbal humiliation
- constant teasing about child’s body type and/or weight
- expressing regret the child wasn’t born the opposite sex
- refusing hugs and loving gestures
- physical abandonment
- excluding child from family activities
- treating an adolescent like she/he is a child
- expelling child from family
- not allowing youth to make own reasonable choices

2. Isolating: Keeping a child away from family and friends

- leaving child in room unattended for long periods
- keeping child away from family
- not allowing child to have friends
- not permitting child interaction with other children
- keeping child away from other caregiver if separated
- rewarding child for withdrawing from social contact
- ensuring child looks and acts differently than peers
- isolating child in closet
- insisting on excessive studying and/or chores
- preventing youth participating in activities outside the home
- punishing youth for engaging in normal social experiences

3. Ignoring: Failing to give any response to or interact with a child or youth at all
- no response to infant’s spontaneous social behaviours

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 - not accepting the child as an offspring
- denying required health care
- denying required dental care
- failure to engage child in day to day activities
- failure to protect child
- not paying attention to significant events in child’s life
- Lack of attention to schooling, etc.
- refusing to discuss youth’s activities and interests
- planning activities/vacations without adolescent

4. Corrupting: Encouraging a child or youth to do things that are illegal or harmful to

themselves
- rewarding child for bullying and harassing behaviour
- teaching racism and ethnic biases
- encouraging violence in sporting activities
- inappropriate reinforcement of sexual activity
- rewarding child for lying and stealing
- rewarding child for substance abuse and sexual activity
- supplying child with drugs, alcohol and other illegal substances
- promoting illegal activities such as selling drugs
- teaching and promoting prostitution

5. Exploiting: Giving a child or youth responsibilities that are far greater than a child/youth
that age can handle
- infants expected not to cry
- anger when infant fails to meet a developmental stage
- child expected to be ‘caregiver’ to the parent
- young child expected to take care of younger siblings
- blaming child or youth for misbehaviour of siblings
- unreasonable responsibilities for jobs around the house
- expecting youth to support family financially
- encouraging participation in pornography

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 - sexually abusing child or youth
- requiring child or youth to participate in sexual exploitation

6. Terrorizing: Causing a child or youth to be terrified by the constant use of threats and /or
intimidating behaviour. This includes witnessing, which is when a child or youth observes
violence, hears violence, or knows that violence is taking place in the home.
- with infants and children, excessive teasing
- yelling and scaring
- unpredictable and extreme responses to child’s behaviour
- extreme verbal threats
- raging, alternating with periods of artificial warmth
- threatening abandonment
- beating family members in front of or in ear range of child
- threatening to destroy a favourite object
- threatening to harm a beloved pet
- forcing child to watch inhumane acts against animals
- inconsistent demands on the child
- displaying inconsistent emotions
- changing the ‘rules of the game’
- threatening that the child is adopted and doesn’t belong
- ridiculing youth in public
- threats to reveal intensely embarrassing traits to peers
- threatening to kick adolescent out of the house

7. Witnessing Family Violence: When children and youth are exposed to family violence
frequently
- Children and youth who witness family violence experience all six types of
emotional abuse.

 When children and youth are exposed to family violence they frequently:
 fear the parent/caregiver's reactions, and are placed in a constant state of
anticipating the adult's moods

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  watch over siblings in order to protect them
 suffer from sleeplessness
 watch assaults on family members
 are forced to lie about the events going on in their home
 may be injured while trying to protect siblings and/or the battered caregiver

 According to The Family Violence Prevention Project, 1990, these children and youth
who are exposed to these types of emotional abuse learn that:
 violence is an acceptable form of conflict resolution
 violence has a place in the family dynamic
 if violence is reported, there are few, if any, consequences
 appropriate roles within the family include inequality of power and decision-
making
 violence equals stress management
 victims of violence should tolerate and accept responsibility for others' violent
behaviour

Causes of emotional abuse

 Parents have negative attitudes towards children

- They associate their own negative feelings with the child's difficult behaviour
 Poor parenting methods.
 Parental mental health problems
 Domestic violence
 Drug and alcohol misuse
 Being abused or having been in care as children

Physical and Behavioral indicators of emotional abuse

Physical indicators Behavioral indicators

 Eating disorders  Habit disorders such as biting, rocking,
 Sleep disturbances head banging, or thumb sucking
 Inappropriate wetting or soiling  Poor peer relationships
 Speech disorders or stuttering  Behavioral extremes
 Failure to thrive  Sad appearance

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 Developmental lags  Apathy
 Asthma, severe allergies or ulcers  Lack of responsiveness
 Chronic academic underachievement
 Self-destructive behavior, oblivious to the
hazards or risks
 Irrational and persistent fears, dreads or
hatreds
 Poor self-esteem
 Repeats negative comments

SEXUAL ABUSE

Definition
Sexual abuse is when an older child, a youth or an adult uses a child or youth for his or her
own sexual gratification.

Includes, but is not limited to:

 Rape
 Incest (Incest with children is when the child is sexually violated by a parent, parent
figure, older sibling, other relative, or other significant person in the child's family
life.)
 Indecent acts/ proposals
 Allowing, permitting, or encouraging a child to engage in prostitution or pornography

Categories of Sexual Abuse

There are two categories of sexual abuse:

Non-contact
Contact

A. Non-Contact:
It includes
* forced to watch sexual acts
* forced to listen to sexual talk, including comments, tapes, and obscene phone calls
* forced to indulge in sexually explicit material such as videos, DVDs, magazines,
photographs, etc.; can be in-person, on the computer via e-mails, and otherwise
through the Internet

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 * forced to look at sexual parts of the body--includes buttocks, anus, genital area
(vulva, vagina, penis, scrotum), breasts, and mouth
* An adult exposing genitals to a child
* sexually intrusive questions or comments; can be verbal, on the computer, or in
notes

B. Contact:

It includes

* Being touched and fondled in sexual areas, including kissing. Touching and fondling
of the genitals is the most common form of substantiated abuse cases.
* Forcing a child or youth to touch another person's sexual areas
* Forced oral sex: oral sex is when the mouth comes in contact with the penis, the
vagina or the anus; many children believe that oral sex is "talking dirty" or just a
"kiss".
* Forced intercourse: can be vaginally, anally or orally; penetration must occur;
penetration can be with body parts and/or objects (the most common body parts used
are the fingers, tongue and penis).

Physical and Behavioral signs of sexual abuse

Physical signs Behavioral signs

 redness, rashes, and/or bleeding to oral,  Withdrawal, Fantasy or Infantile behavior
genital and/or anal areas  Bizarre, Sophisticated, or Unusual Sexual
 bruises on breasts, buttocks, lower Behavior or Knowledge
abdomen, thighs, genital/rectal areas  Excessive masturbation in young children
 complaints of pain or itching in genital or  Poor Peer Relationships
anal areas  Delinquency or Run Away
 difficulty walking or sitting  Reports of Sexual Abuse by Caretaker
 unusual or offensive body odours  Unwilling to Change for Gym or
 difficulty in bladder or bowel control participate in PE
 constipation
 pain or discomfort on urination
 blood in urine
 abnormal dilation of vaginal or rectal
openings
 foreign bodies in vaginal, rectal or

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 urethral openings
 sexually transmitted diseases found
vaginally, rectally or orally
 yeast or bacterial infections
 frequent sore throats; difficulty
swallowing; choking
 ear infections/problems
 sudden weight gain or extreme weight
loss
 severe psychosomatic complaints such as
stomachaches and headaches

NEGLECT

Definition:
Neglect can be defined as the persistent failure to meet a child’s physical and/ or
psychological needs, likely to result in significant harm to a child’s health and development.

This includes the failure of protecting the child from a harmful situation or
environment when feasible.

Basic needs of human:

A. Physical Needs
B. Psychological/Emotional Needs

Physical Needs

1. Food

Though there is room for what we call junk food in a child's diet, overall, food has to be
nutritious and should follow basic nutritional guidelines: fruit, vegetables, proteins, grains
and cereals. Adequate quantity of food is just as important as quality. Poor nutrition is one of
the top signs of child neglect.

With poverty, food is often the first of the basic human needs that is neglected. Does this
mean there is neglect if proper nutrition is not provided when a family is stricken with
poverty? If neglect by definition is a choice as identified earlier in this page, then the answer
to this question must be a resounding 'no'.

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But the answer isn't as simple as that. And even if the answer is no, the child or children are
not getting proper nutrition, regardless of the cause.

2. Clothing

Clothing must be clean and appropriate for the weather: warm coat and boots for winter, and
adequate clothing to protect from other outdoor elements. This is one of the signs of child
neglect that is most often noticed.

3. Shelter

The criteria for appropriate shelter are that it be warm, dry, clean and safe. Housing can be an
apartment, basement suite, house, or any lodgings that fit the above guidelines. Inappropriate
housing is another of the most determinable signs of child neglect.

4. Safe Environment

A safe environment encompasses all aspects of safety in, around and outside of the home
(like safe driving when in the car), and takes into account the age of the child or children.
This not only means keeping the child safe from harsh outdoor elements, the removal of
dangerous surroundings, and the incorporation of safety rules, it also includes ensuring that
young children are not left unattended around hot stoves, ovens, furnaces, hot water, etc.

5. Supervision

Supervision is generally not thought of when considering the basic human needs. It is often
one of the signs of child neglect that is determined only after a child is injured in some way.

For small children, supervision means not leaving them unattended. Supervision is required
daily and during potentially dangerous activities such as swimming and driving.

With adolescents, supervision means asking where the youth is going, who he/she is going
with, what time he/she will be back, and imposing curfews. Again, I'm stating the obvious
when I say a caregiver needs to know where their children or youth are at all times, otherwise
child neglect is present.

6. Good Hygiene

Good hygiene is as simple as making sure the child is bathed regularly and that their hair is
clean. In terms of signs of child neglect, your sense of smell is the best indicator here.

7. Medical and Dental Care

Medical care means getting a child to the doctor in a timely manner when the child is not
feeling well, the child is in pain, has a fever, and/or the child is vomiting.

Dental care requires that a caregiver provide a toothbrush, toothpaste and dental floss for the
child to keep their teeth clean. If a child has a toothache, the caregiver must get him/her in to

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see a dentist. Rotting teeth, coupled with ongoing bad breath is one of the signs of child
neglect.

8. Physical Touch: Hugs and Kisses

Here we are with hugs and kisses listed again, this time as a physical need. The act of
touching is a primary need for children, for human beings in general. This primary need was
tragically demonstrated during war time when orphaned babies, too many for the scant
reserve of nursing staff to hold, rock or even touch, except for occasional diaper changes,
died as a result of lack of human contact.

9. Adequate Rest

Adequate rest is paramount for children and youth to function properly. This is not just
curfews for youth, but with a small child it means she/he needs to be in bed early to ensure
the child gets enough sleep. Also, a mattress, clean sheets and an appropriately warm blanket
are necessary to provide a setting for the child to get adequate rest. If a child is constantly too
tired to perform day to day activities, or if the child is frequently dozing off, these may be
signs of child neglect.

10. Exercise and Fresh Air

Exercise and fresh air are two of the basic human needs that Canadian schools have taken
into account with our mandated physical education program. While there is no predetermined
number of hours set as the minimum required, experts advise that children should receive at
least 3 hours of exercise per week, and 1 hour of fresh air daily.

Emotional Needs

1. Caring and Love

Though it seems obvious, it's important enough to say anyway: A caregiver would show
caring and love with hugs and kisses, compliments, spending time with the child. The child
needs to feel important. A caregiver could very well love the child, but if the child doesn't
feel loved, then neglect is probable.

2. Hugs and Kisses

Hugs and kisses are included several times within these examples, because hugs and kisses
encompass both the physical and emotional fundamentals of the basic human needs. Here it is
listed as an emotional need; children feel loved when there is human contact.

3. Respect

Most caregivers would agree that children should respect them and other adults. However,
many caregivers fail to realize that respect is a two-way street, and that children learn to
respect by being respected, not by being told to respect others. This is not to say that
discipline can't enter the picture; firmness and decisiveness is an integral part of parenting.

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Respecting a child comes in the form of listening to a child, speaking to the child in a way
that demonstrates respect for the emotional and physical well-being of the child. A child who
is constantly put down, degraded, and/or otherwise left feeling as though they don't matter is
a child suffering from neglect, a child not getting their basic human needs met.

4. Moral Guidance and Discipline

Moral guidance is teaching a child right from wrong. Discipline is following through to
ensure the child is learning the lesson.

5. Time Together

It means communicating and interacting with a child. With small children it can be getting
down on the floor with the child and playing and talking with them. With youth, going out to
watch the youth's soccer or football game(s), taking her/him to the mall for shopping, and
having dinner with the family are three examples of communicating with adolescents.

6. Encouragement, Reassurance, Praise, Support and Attention

A child needs to feel valued. Phrases such as "Well done!", "Good job!", etc. are clear
examples of encouragement, praise, support, and attention.

Reassurance is acts of making a child feel a sense of self-worth. This is particularly important
when a child/youth makes mistakes. If the child is berated for these mistakes, his/her self-
esteem is adversely affected. Low self-esteem is one of the signs of child neglect. Focusing
on the positive instead of dwelling on the negative is a powerful way to ensure a healthy self-
worth.

7. Listening Ears

Of the basic human needs, listening ears is as simple as it sounds: paying attention and
hearing what a child has to say, without judgment.

Education An education falls under basic needs because a child must learn to read, write, add,
subtract, multiply and divide in order to effectively contribute to society as an adult. An
education is mandatory in North America. It is the responsibility of parents or caregivers to
send their child to school

Forms of Neglect:
Neglect takes many forms and can be classified broadly as physical or emotional
maltreatment.

1. Physical neglect:
It involves the deprivation of necessities such as
* Food
* Clothing
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 * Shelter
* Supervision
* medical care
* education

2. Emotional neglect:
It generally refers to the failure to meet the child’s needs for attention, affection, and
emotional nurturance.

Indicators of neglect:
Physical indicators Behavioral indicators
 Height/weight significantly below age  Begs or steals food
level  Chronic hunger
 Inappropriate clothing for weather  Falls asleep in school
 Poor hygiene  Excessive absences and/or tardies
 Consistent lack of supervision  Dull, apathetic appearance
 Untreated illness or injury  Runs away from home
 Lack of safe, warm, sanitary shelter  Repeated acts of vandalism
 Lack of necessary medical and dental  Reports no caretaker in the home
care  Assumes adult responsibilities
 Poor social skills
 Language delays or disorders
 Depression

EFFECTS OF CHILD ABUSE

Child abuse has lifelong consequences on victims. With at least one in four children having
experienced some form of neglect or sexual, physical or emotional abuse. While physical
bruises fade over time, the wounds of abuse can last much longer if never addressed.

Here are some of the effects of child abuse:

1) Impaired brain development: The abused child may not properly develop cognitive
skills, which has long-term effects on academic abilities and mental health disorders.
2) Poor physical health: Adults who experienced childhood abuse are more likely to
experience health conditions such as heart disease, lung disease and diabetes. Abuse
has been linked to adolescent obesity as well.

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 3) Psychological issues: Depression, anxiety, low self-esteem, eating disorders,
personality disorders, post-traumatic stress disorder (PTSD), attachment disorders and
suicide attempts are all tied to childhood abuse.

4) Relationship issues: Abuse victims may struggle to trust others. Children may also
grow up to accept abuse as a normal part of relationships.

5) Substance abuse: Victims of childhood abuse are 1.5 times more likely to use drugs
than children who were not abused.

6) Behavioral issues: Adolescents and young adults are more likely to engage in
unprotected sex, skipping school, abusing drugs and other delinquent activities as a
consequence of abuse. Adults are 28 percent more likely to engage in criminal activity
if they experience childhood neglect and abuse.

7) Abusive to others: Children who were raised abused are more likely to continue the
cycle of abuse.

DIAGNOSIS OF CHILD ABUSE

The diagnosis and treatment of child abuse is complex, and require a multidisciplinary
approach to caring for the child involved, as well as the child's family. There is insufficient
evidence that any specific screening strategy or behavioral intervention produces better health
outcomes than clinician awareness and evaluation of potential signs of abuse.

The key steps that physicians can take to diagnose a case of abuse are:

* History
* Physical Examination
* Laboratory Studies
* Radiologic Studies
* Documentation

1. History

- History is taken from parents, caregivers, or other witnesses for a detailed

description of the circumstances surrounding a suspicious injury
- The history should be obtained in a thorough but non-accusatory manner

Comprehensive history components

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  Medical history, including prior injuries, trauma, hospitalizations, medical illnesses,
or congenital conditions
 Family history, particularly of bleeding disorders, bone disorders, or
metabolic/genetic conditions
 Pregnancy history, including whether the pregnancy was planned or unplanned
 Description of familial disciplinary patterns or practices
 Description of the child's temperament, especially whether he or she is typically
active, fussy, easygoing, etc.
 History of abuse toward the child, siblings, or parents
 Developmental history, including milestones, language, gross motor skills, and fine
motor skills
 History of substance abuse by parents, caregivers, or others in the home
 Recent social or financial stressors
 History of violent interactions among other family members

Historical components that suggest intentional trauma

 No explanation or vague explanation for a significant injury

 Significant delay in seeking medical attention
 An important detail of the history changes dramatically over time
 Explanation is inconsistent with the pattern, age, or severity of the injury
 History does not explain the injuries identified
 Explanation is inconsistent with the child's physical or developmental capabilities
 Different witnesses provide markedly different explanations for the injury

2. Physical Examination

In general, injuries to multiple areas, injuries in various stages of healing, and specific
patterns of injuries are suspicious for physical abuse. Accidental injuries often occur on bony
prominences, inflicted injuries tend to occur in protected areas, such as the neck, buttocks,
trunk, and upper arms.

Sites of accidental and non-accidental injuries

The figures below illustrated the sites of accidental and non-accidental injuries that aids in
identification of abuse

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The TEN-4 bruising clinical decision rule may be useful to identify children and infants who
should be evaluated for physical abuse. The TEN-4 rule states that bruising on the torso, ear,
or neck (TEN) in a child four years or younger, or bruising of any region in a child younger
than four months, requires further evaluation for abuse.

Physical Examination for Suspected Child Abuse

Examination Component Possible abnormal finding/Cause

1 General assessment of alertness, eye Intracranial hemorrhage, head injury

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 opening, and responsiveness
2 Height, weight, head circumference Failure to thrive, neglect, or growth failure
(compared with past measurements, if with concurrent physical abuse
possible)
3 Mouth and teeth examination Dental caries suggestive of neglect
4 Scalp examination Patchy hair loss caused by traumatic alopecia
or severe malnutrition
5 Funduscopic examination of the eyes Retinal hemorrhages
6 Skin examination for bruising or burns Multiple patterns of bruising suggestive of
abuse: bruise in child younger than four
months; bruise in torso, ear, and neck areas;
ear bruising (suggests “boxing ears”);
buttocks bruising; patterned bruises (hand,
cord, belt, object); bruises at different stages
of resolution; burn injuries
7 Palpation for tenderness, especially of Occult fracture
the neck, torso, and extremities
8 Deep tendon reflexes, muscle tone, or Spinal cord injury
responsiveness to tactile stimuli

3. Laboratory Studies

Laboratory studies are useful to identify disorders that might explain observed findings
(particularly coagulopathies), or occult or more severe injury not evident on examination.
Testing for sexually transmitted infection may be necessary if sexual abuse is suspected.

Laboratory Tests in Children with Suspected Abuse

Test Possible Abnormal Findings/Cause

1 Complete blood count, including Coagulopathy causing unexplained bruising
platelet count, coagulation times (e.g., or bleeding
prothrombin time, activated partial
thromboplastin time)
2 Fibrinogen, von Willebrand factor, Coagulopathy causing unexplained bruising
platelet aggregation studies, clotting or bleeding
factor assays
3 Hepatic transaminase, amylase, lipase Occult abdominal injury
levels
4 Toxicology screen Overdose or poisoning
5 Urinalysis, renal and electrolyte panel Occult back or kidney injury
6 Calcium, alkaline phosphatase, Malnutrition, bone mineralization disorders
phosphorus, albumin, parathyroid (e.g., rickets)
hormone levels

4. Radiologic Studies

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Physical abuse often results in skeletal injury. Radiographic imaging of children with
suspected physical abuse may consist of evaluation of localizing symptoms or physical
examination signs, as well as screening skeletal surveys.

Injuries detected on Radiographic imaging that are specific for Child Abuse

Highly specific Moderate specific Common but low specificity

 Metaphyseal lesions  Multiple fractures  Clavicular fractures
 Rib fractures  Fractures in different
 Sternal, scapular, and stages of healing
spinous process fractures  Epiphyseal separations
 Vertebral body fractures
 Digital fractures
 Complex skull fractures

5. Documentation

Documentation of the history, physical examination, diagnostic study results, clinical

impression, and diagnostic reasoning is vital not only for medical care, but also for legal
purposes. This includes photography of physical examination findings that raise concern for
abuse.

* Document the size of the injury by using an inch scale. Be sure that there is at least
one other close-up of the injury without the scale to demonstrate that the scale was not
covering evidence.
* Document pattern or circumferential injuries, such as burns and bite marks, using
photographs

MANAGEMENT
Child abuse is often an ongoing process. If the diagnosis of child abuse is being considered,
the parents and/or caregivers must be informed of all relevant investigations and referrals
being made.

1. Reporting to authorities (Documentation)

 Doctors are required to share information with other agencies, and with social
work and law enforcement bodies, to ensure that the child’s needs are met and he
or she is protected from harm.
 Doctors are required to provide written reports for use in multi-disciplinary
meetings, police investigations, and civil or criminal courts, and may be required
to appear as witnesses (of fact or as experts) in court.
 Accurate reporting also involves photographs of visible injuries and forensic
swabs (e.g., of bites).
2. Counselling

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  Counselling should be considered following full investigation and immediate
management of injuries.
 Cognitive behavioural therapy is increasingly used, but must be individualised.
 Family therapy is also indicated in certain situations to support other members of
the family.

3. Psychotherapy
Treatment can help both children and parents in abuse situations. The first priority is
ensuring the safety and protection for children who have been abused. Ongoing treatment
focuses on preventing future abuse and reducing the long-term psychological and
physical consequences of abuse.

Talking with a mental health professional can:

- Help a child who has been abused learn to trust again
- Teach a child about normal behavior and relationships
- Teach a child conflict management and boost self-esteem

Several different types of therapy may be effective, such as:

a) Trauma-focused cognitive behavioral therapy

This type of therapy helps a child who has been abused to better manage
distressing feelings and to deal with trauma-related memories. Eventually, the
supportive parent who has not abused the child and the child are seen together so
the child can tell the parent exactly what happened.
b) Child-parent psychotherapy
This treatment focuses on improving the parent-child relationship and on building
a stronger attachment between the two.

Psychotherapy also can help parents:

- Discover the roots of abuse
- Learn effective ways to cope with life's inevitable frustrations
- Learn healthy parenting strategies

4. Management of injuries/specialist consultation

 Individual injuries should be managed as appropriate, irrespective of whether they
are caused by abuse or accident.
 Where abuse is considered, the physician should ensure that an appropriate search
for additional or hidden injuries is also carried out.

HOW TO REACT IF A CHILD TELLS YOU ABOUT ABUSE:

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 Listen, do not interfere, assume or interrogate.
Reassure the child that he/she has done the right thing by telling you and that you are
glad they told you.
Make sure they understand it was not their fault.
Remain calm and accepting, don’t over react.
Do not promise not to tell.
Be honest and tell the child what to expect.
Reassure them you will do what needs to be done to make sure it doesn’t happen
again.
Determine the child’s needs for safety.

ROLE OF THE NURSE:

1. Physical Care

 Abuse victims often require physical nursing care. In the emergency room, this may
include cleaning wounds or applying a dressing.
 If injuries are severe, the patient may need surgery and nursing care during the
convalescent period.
 The nurse might provide medications for pain or help the patient learn to walk with
crutches.
 In addition, victims of abuse may need education for self-management if they have
injuries that will take some time to heal, such as broken bones.

2. Emotional Support

 The empathetic nurse can help provide emotional support by listening and allowing
patients to express whatever they feel.
 Children may respond to the gift of a stuffed toy to which they can confide all the bad
things that have happened to them.
 The older adult may be ashamed to admit that her children are abusing her.
 Nurses offer an opportunity to talk about feelings and may also be able to suggest a
referral to a counsellor who is experienced in dealing with abuse victims.
 The nurse may also be the first person to recognize symptoms of depression or
suicidal intent in an abuse victim

PREVENTION
 Recognizing the potential for child abuse and the seeking or offering of intervention,
counselling, and training in good parenting skills before battered child syndrome
occurs is the best way to prevent abuse.
 The use of educational programs to teach caregivers good parenting skills and to be
aware of abusive behaviors so that they seek help for abusive tendencies is critical to
stopping abuse.

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  Support from the extended family, friends, clergy, or other supportive persons or
groups may also be effective in preventing abuse.

Parental Concerns:

 Signs that physical abuse may occur include parental alcohol or substance abuse; high
stress factors in the family life; previous abuse of the child or the child's siblings;
history of mental or emotional problems in parents; parents abused as children;
absence of visible parental love or concern for the child; and neglect of the child's
hygiene.
 Parents who are in danger of abusing their children (for example, when they find
themselves becoming inappropriately or excessively angry in response to a child's
behavior) should seek professional counselling.
 Counselled through a parenting or caretaking crisis and offered guidance about how to
better handle the situation.

CONCLUSION

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Child abuse is a very serious concern. A child that’s being abused by its parents does not stop
loving its parents. It stops loving itself. We all share the responsibility of preventing child
abuse and provide a safe environment for the future of the World…..the CHILDREN.

JOURNAL ABSTRACT
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 An Experimental Study of Implicit Racial Bias in Recognition of Child Abuse

Mary Rojas , Ingrid Walker-Descartes , Danielle Laraque-Arena

Abstract

Objectives: We evaluated whether implicit racial bias influences pediatricians' suspicion of

child abuse.

Methods: Child abuse experts developed 9 injury vignettes. Pediatricians (N = 342) were
randomly assigned one of 2 versions to rate for suspicion of abuse, with the child's race in
each vignette varying between white and black. Data were collected online and anonymously.

Results: There were no statistically significant differences in suspicion for an abuse-related

injury based on the race of the child. We adjusted for pediatrician race/ethnicity, years since
graduation, location, and gender and did not find race effects.

Conclusions: We demonstrated an experimental approach to study the influence of implicit

racial bias on recognition of child abuse. Though we failed to find an effect, it is too early to
conclude that none exists. The relationship among human cognition, behavior, and healthcare
disparities is complex. Studies are needed that incorporate diverse approaches, clinical
contexts and scenarios, patient and physician characteristics, and validated measures if we are
to understand how it might be used to reduce healthcare disparities.

REFERENCE

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Book Reference

1. Norman S. Ellerstein, “Child Abuse and Neglect: A Medical Reference”, 1st edition,
1982, Wiley medical publication.
2. A Sudhakar, “Essentials of Pediatric Nursing”, 1st edition, 2017, Jaypee publications
3. A Padmaja, “Textbook of Child Health Nursing”, 1st edition, 2016, Jaypee Publications

Internet Reference

1. https://crossbarriers.org/child-abuse-in-india/
2. https://www.childhelp.org/child-abuse/
3. http://www.child-abuse-effects.com/types-of-emotional-abuse.html
4. https://www.child-abuse-effects.com/sexual-abuse.html
5. https://www.slideserve.com/cora/what-is-child-abuse
6. https://www.slideshare.net/Melz12/project-against-child-abuse-english-version2
7. https://www.slideshare.net/ZiaAlam/child-abuse-12212900
8. http://www.childlineindia.org.in/child-abuse-child-violence-india.html
9. https://www.aafp.org/afp/2013/1115/p669.html

Journal Reference

Rojas, M., Walker-Descartes, I., & Laraque-Arena, D. (2017). An Experimental Study of

Implicit Racial Bias in Recognition of Child Abuse. American journal of health behavior,
41(3), 358–367. https://doi.org/10.5993/AJHB.41.3.15

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