All ethnic and religious groupings. Serious abuse only is more common in children from socioeconomic groups D & E (IV & V). The categories of Abuse are Physical, Sexual, Emotional, and Neglect.
Risk factors:
In the UK:
Some early warning signs are:
Any injury has the potential for being non-accidental, but there are certain characteristics that should rouse suspicion.
Accidental bruising tends to be on bony prominences (eg shins, knees) and on the front of the body. Exceptions are the scalp, the centre of the occiput, and in walking children, the lower back.
Bruising is seen in coagulopathies and platelet disorders, of which there are many, some extremely rare. But note family history (incl menorrhagia, consanguinity), history of severe bleeding post dental extraction or surgery, epistaxis, bleeding from cord at birth, injection haematomas. The distribution of bruises is also different. If in doubt, do a basic screen including vWF and consult a haematologist. There are also things that can look like bruises:
A bruise cannot accurately be aged from clinical assessment in vivo or on a photograph. Plenty of data to show high degrees of natural variation and poor inter/intra-observer correlation.
Bruising as an indicator of child abuse, Sabine Maguire, Paeds Child Health 2008;18(12):545.
Animal bites tend to puncture, cut and tear. Human bites tend to bruise, are crescent-shaped, and often do not break the skin. Impossible to relate clinically to a particular attacker - needs forensic dentistry +/- DNA.
Skull fractures due to abuse are not easily differentiated from those due to accidental trauma - both tend to be parietal and linear. The significance of complex types eg depressed fractures varies between studies.
A tendency to fractures is seen in osteomalacia, in Osteogenesis imperfecta, Jobs syndrome (plus eczema, dysmorphism, high IgE).
Review, Arch Dis Child 2005;90:182-186
Do skeletal survey and if under 2yrs CT head. Some fractures are seen on bone scan that are not apparent on X-ray and vice versa so complementary - but no normative data for DEXA scan in children.
In infants, ophthalmology review and MRI are needed.
General advice:
Professional witnesses are called to act as witnesses of fact where they are involved in the care of the child or as independent expert witnesses because of their particular and individual knowledge or skills. The competences needed to do court work in family proceedings, are set out in the Chief Medical Officer's report Bearing Good Witness.
Four factors most consistently identified as predicting future maltreatment:
Children maltreated previously were approximately six times more likely to experience recurrent maltreatment than children who had not previously been maltreated. The risk of recurrence was highest in the period soon after the index episode of maltreatment (within 30 days), and diminished thereafter. Archives of Disease in Childhood 2006;91:744-752
Combination of diffuse axonal injury (stretching/shearing) and hypoxic-ischaemic damage from apnoea (after damage to respiratory centres). Most children with subdural haematoma will have other evidence of non accidental injury so the diagnosis is not in doubt, but otherwise it is not clear whether the bleeding is secondary to disrupted veins or leaking from hypoxic cells - potentially subdural could be the result of apnoea alone. It is not clear just how much force is needed to cause this chain of events, but it does not occur in the course of normal play or childcare activities. It follows that it is never acceptable to shake an infant.
Literature:
Glutaric aciduria: enzyme defect preventing metabolism of lysine and tryptophan. Manifest as macrocephaly at birth, then encephalopathy, spasms, muscle weakness. Can present with subdural/retinal haemorrhages! Manage with protein restriction, lysine/tryptophan free formula, carnitine replacement.
Differential diagnosis: Glutaric aciduria, galactosaemia, encephalitis, clotting disorders can give subdurals plus retinal haems.
Outcome - 25% die, 50% profound disability.For subdurals, do CT first then MRI (detects different ages of subdural, and shows parenchymal damage) within 7/7, then repeat @14/7.
Consists of rejection, isolation, terror or corruption. Manifests as clingy with relentless attention seeking, hyperactivity, sudden speech disorder, behaviour change or developmental delay. Indicators of neglect are poor personal hygiene and clothing, frequent accidental injuries, untreated medical problems.
"Acceptable" sexual experimentation? eg age difference, power balance, display/contact vs penetration.
Warning signs are secondary enuresis (or daytime soiling/wetting), sudden behaviour changes (eg deterioration in school performance, regression, self-mutilation/attempted suicide), developmental delay, imitation, self harm, sexualized behaviour.
Is an urgent examination needed, with a view to getting specimens? A forensic exam involves 2 doctors and videocolposcopy. May confuse picture if delayed (eg hymenal damage) but may allay child's anxiety about "things below being damaged". Single doctor exam is appropriate if no allegations. Don't ask child questions (could be considered leading, could be traumatic). Note state of clothes, nails etc. Video colposcopy needs consent. Coughing during exam may reveal FB.
Chain of evidence for samples is essential, ie named individual responsible for sample at all times. 2 person exam is to witness clinical findings, not to interpret. Refer National guideline on the management of suspected sexually transmitted infections in children and young people (Sex Trans Inf 2002;78:313?90). If in doubt, consider empirical treatment of vulvovaginitis with mebendazole for child and family. Do MSU!
It is the consultant's responsibility to give opinion - so should always see together with SpR or at very least confirm findings, esp if possibility of court procedures.
Every Judicial Enquiry into the violent death of a child as a result of abuse or neglect has highlighted repeated system failures:
Lord Laming's Climbie Inquiry added: nobody noticed when things were not being done. Referral of a child at risk of significant harm is an emergency and should be done immediately. Any verbal referral to Social Services should be followed up within 48 hours by a written notification form. Social services in turn should feedback action taken within 72 hours. The General Medical Council states clearly that the need to protect a child overrides the duty of confidentiality to that child in respect of sharing information with other professionals. Where appropriate you should inform those with parental responsibility about the disclosure.
Area Child Protection Committee coordinates Child Protection activity incl Child Protection Register, guidelines for practitioners, education and training in child protection, audit and review of procedures and cases.
Different from an agency check, where there is just sharing of information to establish whether there are other grounds for concern.
After referral, social work should decide on whether there should be:
If immediate risk, then involve police in case emergency powers needed to remove child. Otherwise social work can contact Women & Children Unit. Also consider other children who may be vulnerable in same household.
Planning meeting = case discussion. Senior colleagues-in Police, SW, Health. By phone acceptable in emergency. Rarely, joint investigation will have to go ahead before the case discussion. Consists of:
Medical examination should be done in all children where abuse is suspected. Any allegation of child sexual abuse merits full attention, and 2 doctors are required - to document findings, rather than to interpret them. Aims are:
Types of medical examination:
Police surgeon can do assessment if child is 13yr or over. GPs can also take referrals for medical examination during working hours, and may be best placed where social work are undertaking an investigation alone. Out of hours there is a child protection consultant on call for alleged sexual abuse, otherwise the case should be discussed with the receiving medical registrar. Where an Emergency Protection Order has been applied for, a consultant should provide a medical report within 4 hours. The Order does not carry with it the authority to examine or treat - emergency treatment may be given, of course - so consent law applies as above.
Joint investigation - between social work, police and health services. Prevent the child being interviewed or examined unnecessarily. Parents should be kept informed of all investigations, unless this is felt to place children at further risk or to impede the investigation.
Agreed timescale, care plan to address areas of need and identify a package of supports, format for monitoring progress.
Where compulsory measures are thought necessary to protect a child (incl from self destructive behaviour), referral should be made to the Children's Reporter and thence the Children's Panel. Standard of proof here is the balance of probabilities rather than establishing fact. However, the child nd family must accept the grounds for referral stated by the Reporter, otherwise the case will be referred to the Sheriff.
A means of learning lessons from the death or serious injury of a child by abuse or neglect. They are not an Inquiry, nor is their purpose to allocate blame or to identify underperforming professionals (they are anonymised). You should therefore co-operate with requests for information, even where the child?s family does not consent, or if it is not practicable to ask for their consent. Case notes may be secured by the PCT or by the Police. It is wise to take copies for the purposes of continuing medical care. Get advice from your Medical Defence Societies. The Named or Designated Doctor or Nurse for Child Protection (identified by each Health Authority) will compiles a report, which is submitted to the overall Review Chair.
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