CHILD ABUSE Divina Francia A. De Guzman- - PowerPoint Presentation

1. CHILD ABUSEDivina Francia A. De Guzman-Talosig, MD

2. ChildRefers o person below eighteen (18) years of age orThose over but are unable to fully take care of themselves or protect themselves from abuse, neglect, cruelty, exploitation or discrimination because of a physical or mental disability or conditionNavarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.Republic Act No. 7610. Special Protection of Children Against Abuse, Exploitation and Discrimination Act.

3. Child Abuserefers to the maltreatment, whether habitual or not, of the child which includes any of the following: Psychological and physical abuse, neglect, cruelty, sexual abuse and emotional maltreatment; Any act by deeds or words which debases, degrades or demeans the intrinsic worth and dignity of a child as a human being; Unreasonable deprivation of his basic needs for survival, such as food and shelter; or Failure to immediately give medical treatment to an injured child resulting in serious impairment of his growth and development or in his permanent incapacity or deathRepublic Act No. 7610. Special Protection of Children Against Abuse, Exploitation and Discrimination Act.

4. History takingcomprises 90% of the diagnosisfollows the sequence of events as they happenedobtained in a developmentally appropriate, non-leading and non-suggestive mannerconfidential and part of the medical recordsnot a forensic interviewformulate a diagnosis as to the physical and mental health of the childlook for possible evidence of abuseobserve confidentiality at all timesProtocol for Case Management of Child Victims of Abuse, Neglect, and ExploitationChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016

5. Components of HistoryPatient’s profileObservations on behavioral and physical appearance of the patientHistoryChief complaintDisclosureIncidentAlleged PerpetratorActs DescribedPast and Comorbid AbusePast Medical HistoryChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016

6. Physical ExaminationPurpose:to assess the patient for acute or chronic injuries to treat and prevent sexually transmitted infectionsChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016

7. Components of Physical examinationGeneral survey and nutritional statusMental statusOrientation to time, place and personConsciousness, demeanorDevelopmental assessmentMental health assessmentChild’s behaviorExtragenital examinationAnogenital examinationTanner StagingExternal genitaliaUrethral and perihymenal areaHymenPerineumVaginal dischargeInternal and speculum examinationAnal examinationChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016

8. Case 1Nanay Flora had a grandson named Mac-mac. He was a son of a respected general, Ricardo Dalisay. Nanay Flora was very strict. She wanted Mac-mac to become a soldier and follow the steps of his dad. However Mac-mac wanted to pursue hairdressing. With Nanay Flora’s frustrations, she called Mac-mac “salot”. Even when talking with her grandson’s teachers or friends, she referred Mac-mac as “salot”. Mac-mac then committed suicide. What was the type of abuse present? A. Educational neglect B. Emotional abuse C. Physical abuse D. Sexual abuse

9. EMOTIONAL ABUSE

10. Definitionaka psychological maltreatment, mental violence, verbal abusemost common form of child maltreatmentmost unreported and unrecognizedPsychological maltreatment: “repeated pattern of caregiver behavior or extreme incident/s that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another’s needs (APSAC, 1995)Navarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.

11. Mental violence: described as psychological maltreatment, mental abuse, verbal abuse and emotional abuse or neglect and this can include:All forms of persistent harmful interactions with the child, for example, conveying to children that they are worthless, unloved, unwanted, endangered or only of value in meeting another’s needsScaring, terrorizing and threatening; exploiting and corrupting; spurning and rejecting; isolating, ignoring and favoritism;Denying emotional responsiveness; neglecting mental health, medical education and needs;Insults, name-calling, humiliation, belittling, ridiculing and hurting a child’s feeling;Exposure to domestic violence;Placement in solitary confinement, isolation or humiliating or degrading conditions or detention; andPsychological bullying and hazing by adults or other children, including via information and communication technologies such as mobile phones and the internet (known as “cyberbullying”)UN General Comment No. 13 on UN Convention on the Rights of the Child (CRC) Article No. 19

12. ManagementImproved parenting skillsParental self-careSocial supportInterventions appropriate for recognized risk factors such as:Mental health problemsSubstance abuseDevelopmental disordersMonitoringNavarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.

13. CASE 2Daniela, a very rich and ambitious woman, was occupied in planning revenge to Romina. Daniela was constantly out meeting gunmen. When at home, she was at her room devising plots. Marga, her daughter, was not able to finish grade 12. With Marga’s determination to finish her studies, she worked in a club as a waitress. One night, she was raped and murdered by Daniela’s gunman. What was/were the abuse/s committed by Daniela? A. Educational neglect B. Sexual abuse C. Physical abuse D. Both A and B

14. Child Neglect

15. DEFINITION“… the inattention or omission on the part of the caregiver to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter safe living conditions, in the context of resources reasonable available to the family or caretakers; and causes, or has a high probability of raising harm to the child’s health or physical, mental, spiritual, moral, or social development. This includes the failure to properly supervise and protect children from harm as much as is feasible.” Kleigman, R., et al. 2016. Nelson Textbook of Pediatrics 20th ed.Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-based

16. Failure to meet children’s physical and psychological needs, protect them from danger, or obtain medical, birth registration or other services when those responsible for children’s care have the means, knowledge and access to services to do so.Includes: physical neglect, psychological or emotional neglect, neglect of children’s physical or mental health, educational neglect and abandonmentUN General Comment No. 13 on UN Convention on the Rights of the Child (CRC) Article No. 19

17. Chronic child neglectA parent or caregiver’s ongoing, serious pattern of deprivation of a child’s basic physical, developmental, and/or emotional needs for healthy growth and development Indicators:One or more needs basic to a child’s healthy development are not metThe neglect happens on a recurring or enduring basisThe neglect is perpetrated by a parent or a caregiverChronic Child Neglect. 2019. https://www.childwelfare.gov

18. When the CHILD…frequently absents from school begs or steals food or money consistently dirty and has severe body odoruses alcohol or other drugs states that there is no one at home to provide careuntreated illnesses and physical injuries When the CAREGIVER…feels overwhelmed addressing a range of challengesappears to be indifferent to the child seems apathetic or depressed behaves irrationally or in a bizarre mannerActs of Omission: An Overview of Child Neglect. 2018. https://www.childwelfare.govSmith M, Robinson L, Segal J. 2019. Child Abuse and NeglectRECOGNITION

19. ManagementEARLY HELPProvide concrete services firstChild care; Health care and public benefits; Food and clothing; Transportation; Housing and utilities; Attention to past trauma affecting the parent’s lifeEnsure safetyMULTIDISCIPLINARY PRACTICESFAMILY SUPPORT APPROACHESTraining in parenting / Parenting classesHome visitationEnhancement of parenting skillsRaising the parent’s level of copingEmotional supportActs of Omission: An Overview of Child Neglect. 2018. https://www.childwelfare.gov

20. Case 3Connor, grade 2 student, was very talkative in a class. One day, he was laughing very hard while playing a joke to his seatmate. Miss Lupita, his teacher, hit his mouth with a stick. Connor cried hard.Connor’s mother filed a complaint to school. However, Miss Lupita said that she was only disciplining the loud student. 1. Was there an abuse present? 2. If yes, what was the type of abuse?

21. Physical Abuse

22. DEFINITIONWHOIntentional use of physical force against a child that results in, or has a high likelihood of, resulting in harm to the child’s health, survival, development, or dignityIncludes hitting, beating, kicking, shaking, biting, strangling, scalding, burning, poisoning, and suffocatingNavarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.

23. Discipline or Abuse?Corporal PunishmentAn act or acts which involve PHYSICAL FORCE and HUMILIATING OR DEGRADING ACTS imposed upon a child as punishment for an alleged or actual offense inflicted by an adult or another child, who has been given or has assumed AUTHORITY or RESPONSIBILITY for punishment or disciplinePositive DisciplineNon-violent, solution-focused, respectful and based on child development principles approach to enabling children learn or develop appropriate thinking and behaviorDepartment of Social Welfare and Development AO No.7, Series of 2015. DSWD Child Protection Policy in the Workplace.

24. Corporal PunishmentBlows including beating, kicking, slapping, lashing or any part of a child’s body, with or without use of instrument such as cane, broom, stick, whip or beltPulling hair, shaking, twisting joints, cutting or piercing skin, dragging or throwing a childForcing a child through the use of power, authority of threats to perform physically painful or damaging acts such as holding a weight or weights for an extended period, kneeling on stones, salt or pebblesRefusal to provide the child’s physical needsTying up of a childDepartment of Social Welfare and Development AO No.7, Series of 2015. DSWD Child Protection Policy in the Workplace.

25. Imprisoning of a childUse or exposure to substance that can cause discomfort or threaten the child’s health including fore, ice, water, smoke, pepper, alcohol, dangerous chemicals such as bleach or insecticides, excrement or urineVerbal abuse or assaults including intimidation or threat or bodily harm, swearing or cursing, ridiculing or denigrating the childMaking the child look or feel foolish in front of one’s peers or the public such as shaving hair or other analogous acts Department of Social Welfare and Development AO No.7, Series of 2015. DSWD Child Protection Policy in the Workplace.

26. Case 4Mic-mic, 4-month old girl, was brought to PER due to seizures. According to the Mic-mic’s father, he left her daughter on the bed, but later found her cyanotic at the floor. There were no other persons at the house that time. He immediately brought the patient to PER. At the PER, the ROD noticed right periorbital bruise. What diagnostic test/s should be requested? A. CBC B. Cranial CT scan C. Skeletal survey D. A and B only E. All of the above

27. Red Flags of Physical AbuseThe child fell from a low height less than 4 feet.The child feel and struck head on the floor or furniture, or a hard object fell on the child.Unexpectedly found dead.The child choked; was shaken to dislodge object.The child turned blue; was shaken to reviveThe sudden seizuresResuscitation efforts caused injuriesThe caretaker tripped and slipped while carrying the childA sibling did itThe child left alone for a short time in a dangerous situationThe child fell down the stairsChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-basedBIOMECHANICSThose who don’t cruise, don’t bruise.

28. FRACTURESChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Kliegman, R., et al. 2016. Nelson Textbook of Pediatrics 20th ed.

29. BRUISING and lacerationsAccidental bruising patternAbusive bruising patternChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-basedPatterns of bruising that are suggestive of physical child abuse include:Bruising in babies and young children who are not independently mobileBruises that are seen away from bony prominencesBruises to the face, back, abdomen, arms, buttocks, ears and handsMultiple bruises in clustersMultiple bruises of uniform shapeBruises that carry the imprint of implement usedBruises indicating a ligature (wrists, ankles)

30. Fingertip BruisePetechial BruisePatterned (Imprint) BruiseChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016

31. BITE MARKSAdult BiteChild BiteCanine to canineTo second molarInvolves 1 archBoth archesIntercanine distance:3 – 4.5cmIntercanine distance:<2.5 cmHuman BiteCanine BiteCompress fleshTear fleshAbrasion, contusion or lacerationPunctures, laceration, avulsion4 incisors and smaller canines6 incisors and 2 very large caninesChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-basedBite Mark

32. BurnsPatterns of burns that are suggestive of physical child abuse include:Scalding immersion burns: no splash marks, clear tide levels, and well-demarcated outline of the contacted surface; stocking or glove-pattern burnDoughnut pattern: burns localized to the perineum buttocks with central sparing of buttocksSkinfold sparingSymmetrical distributionBurns consistent with the mechanism of injuryChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-based

33. Abusive head traumacaused by direct impact, asphyxia, or shakingmay lack external signs of injury, even with serious intracranial traumaSigns and symptoms (nonspecific): lethargy, vomiting (without diarrhea), changing neurologic status or seizures, and comaClinical features: severe acute encephalopathy, extracranial features (70%), retinal hemorrhages (65-90%)Kliegman, R., et al. 2016. Nelson Textbook of Pediatrics 20th ed.Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-based

34. DIAGNOSTICSTests for hematologic disordersCT ScanSkeletal surveyAppendicular skeleton: Humeri (AP); Forearms (AP); Hands (PA); Femurs (AP); Lower legs (AP); Feet (AP)Axial skeleton: Thorax (AP, lateral, right and left obliques), to include ribs, thoracic and upper lumbar spine; Pelvis (AP), to include the mid lumbar spine; Lumbosacral spine (lateral); Cervical spine (lateral); Skull (frontal and lateral)Child Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-basedKliegman, R., et al. 2016. Nelson Textbook of Pediatrics 20th ed.

35. Case 5Camila, 15-year old Grade 6 student, was brought by her father to the Bagong barangay health center because of dysuria. The pedia resident interviewed the patient first. She noticed that the patient was anxious. On probing, Camila disclosed that her twin brother Camilo was touching her breast and genital area when they were left alone in their house. Camila also said that, according to her brother, it was to show their love as twins. What is the type of abuse present? A. Educational neglect B. Emotional abuse C. Physical abuse D. Sexual abuse

36. Sexual Abuse

37. DefinitionWHO (2006)Activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other personNavarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.

38. Factors to Consider in Performing an Immediate ExaminationHistory of abusive incident within 72 hoursGenital trauma heals rapidly and may heal completely thus there are less chances of identifying injuries among children examined 72hrs after the incidentHistory of acute genital, anal or extragenital trauma particularly bleeding or injuryHistory of bleeding or pain, such as dysuria, increases the chances of identifying injuries when the child is examinedChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-based

39. Pregnancy evaluation and preventionEmergency contraception may be given to female adolescents who are seen within 72 hours to 120 hours of the most recent sexual contactChild Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-based

40. Diagnosis and management and/or prevention of sexually transmitted infections (STIs)Indication:The child has or has had symptoms or signs of an STD or of an infection that can be sexually transmitted, even in the absence of suspicion of sexual abuse. A suspected assailant is known to have an STD or to be at high risk for STDs (e.g., has multiple sex partners or a history of STDs).A sibling or another child or adult in the household or child’s immediate environment has an STD.The patient or parent requests testing.Evidence of genital, oral, or anal penetration or ejaculation is present.Child Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016Navarro, X., et al. 2014. Fundamentals of Pediatrics Competency-based

41. Safety issuesAlternative placement must be done if it is dangerous for the child to go home because of the perpetrator’s access to the child.Suicide riskIf the child is suicidal, the child must not be sent home without being seen by a psychiatrist.Child Maltreatment Medico-legal Terminology and Interpretation of Medical Findings: A Consensus of Medical and Legal Child Protection Practitioners in the Philippines 4th ed. 2016

42. Risk Factors

43. Child’s characteristicsAge (younger than 4 years old)SexSpecial characteristics: low birth weight, prematurity, behavioral problems, or physical or mental handicaps; children with special needsWorld Report on Violence and Health. Child abuse and neglect by parents and other caregivers.Navarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.

44. Caregiver and family characteristicsDomestic violenceAlcohol and drug abuseUntreated mental illnessLack of parenting skillsStress and lack of supportLarger family sizeMultiple birthsHaving several siblings in the familySmith M, Robinson L, Segal J. 2019. Child Abuse and Neglect.Damashek A, et al. 2013. Fatal child maltreatment: characteristics of deaths from physical abuse versus neglect. Child Abuse & Neglect. 37: 735–744.Yamaoka Y, et al. 2015. Child deaths with persistent neglected experiences from medico-legal documents in Japan. Pediatrics International. 57: 373–380.Navarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.

45. Community factorsPovertySocial capital: degree of cohesion and solidarity that exists within communitiesSocietal factors: includes culture, policies, social welfare system, preventive health care, and justice systemWorld Report on Violence and Health. Child abuse and neglect by parents and other caregivers.

46. Effects Of child abuse

47. School ImpactDevelopmental disabilities Lack of success in school School absenteeism and dropouts2019 Prevention Resource Guide. https://www.childwelfare.gov/topics/preventing/

48. Intellectual ProfileStanford-Binet Intelligence Scales 5th Edition (SB5) IQ scores were found to be significantly lower than the minimum average scores on the testVerbal IQ (VIQ) scores were likewise found to be significantly lower than Nonverbal IQ (NVIQ) scores; Lower scores in Knowledge (KN)Working Memory (WM) accompanied by Fluid Reasoning (FR) were likewise lower than Visual Spatial Processing (VS) and Quantitative Reasoning (QR)Regarding types of abuse, those who have experiences of neglect significantly have lower scores in all SB5 Factor Indices, compared to physical and sexual abuseBengwasan, P. 2018. The intellectual profile of abused and neglected children in the Philippines: An analysis of SB5 IQ scores of sexually abused, physically abused and neglected children. Child Abuse & Neglect. 81: 389–395.

49. Medical ImpactPhysical health outcomesTeen pregnancyDepression and suicide attemptsChronic illnesses, including heart disease, cancer, and lung diseaseNavarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.2019 Prevention Resource Guide. https://www.childwelfare.gov/topics/preventing/

50. Social ImpactSubstance useCrime (aggression and delinquency in adolescence)High costs to child welfare systems, juvenile courts, and schoolsChronic Child Neglect. 2019. https://www.childwelfare.gov2019 Prevention Resource Guide. https://www.childwelfare.gov/topics/preventing/

51. Reporting

52. The Mandatory ReportersThe following are mandated to make a report, either orally or in writing, to DSWD/LSWDO within forty-eight (48) hours, the examination and/or treatment of a child who appears to have suffered from abuse:Head of any public or private hospital, medical clinic and similar institutions, and Attending physician and nurseFailure to report a child abuse case shall be punishable with a fine of not more than two thousand pesos (P2,000.00) or as may be determined in the future by a court with jurisdictionProtocol for Case Management of Child Victims of Abuse, Neglect, and Exploitationhttps://doj.gov.ph/child-protection-program.htmlNavarro, X., et al. 2014. Fundamentals of Pediatrics: Competency-based.

53. Others who may reportThe following government workers have the duty to report all incidents of possible child abuse:Teachers and administrators in public schoolsProbation officersGovernment lawyersLaw enforcement officersBarangay officialsCorrections officersOther government officials and employees whose work involves dealing with childrenProtocol for Case Management of Child Victims of Abuse, Neglect, and Exploitation https://doj.gov.ph/child-protection-program.html

54. Any person who, acting in good faith, reports a child abuse case shall be FREE from any civil or administrative liabilityAs much as possible, the persons who report should give their names and contact details for further contacts, if necessaryTheir protection and anonymity shall be assuredThe person who reports need not be the complainant but has knowledge of the incidentProtocol for Case Management of Child Victims of Abuse, Neglect, and Exploitation https://doj.gov.ph/child-protection-program.html

55. The child victim may or may not be with the person reporting the incidentAny person who reports MUST provide basic information on the child victim (name, age, address or whereabouts of child, the reasons that child may be at risk or in an abusive or exploitative situation) and the alleged perpetratorany relevant information to suspect that a child is being abused or exploited shall suffice to initiate any action and investigationProtocol for Case Management of Child Victims of Abuse, Neglect, and Exploitation https://doj.gov.ph/child-protection-program.html

56. Where to reportDepartment of Social Welfare and Development (DSWD) Commission on Human RightsLocal Social Welfare and Development Office (LSWDO) of the municipality, city, or provincePhilippine National PoliceNational Bureau of InvestigationOther law enforcement agenciesPunong barangay or tribal leaderBarangay kagawadAny member of the Barangay Council for the Protection of Children (BCPC)Barangay help desk person or Violence Against Women (VAW) help desk officerProtocol for Case Management of Child Victims of Abuse, Neglect, and Exploitation https://doj.gov.ph/child-protection-program.html

57. Who can be the ComplainantOffended partyParent or legal guardianAscendant or collateral relative of the child within the third degree of consanguinityDuly authorized officer or social worker of the DSWD or LSWDOOfficer, social worker, or representative of a licensed childcaring institutionPunong barangayAt least three (3) concerned responsible citizens of the community where the abuse took place who have personal knowledge of the offense committedProtocol for Case Management of Child Victims of Abuse, Neglect, and Exploitation https://doj.gov.ph/child-protection-program.html

58. referrals

59. ReferralsMulti-sectoral National and local government agenciesDepartment of Social Welfare and Development (DSWD)Council for the Welfare of Children (CWC) Committee for the Special Protection of Children (CSPC) Barangay Community CouncilsNon-government and faith-based organizationsCivic and private sectors Protocol for Case Management of Child Victims of Abuse, Neglect, and Exploitation https://doj.gov.ph/child-protection-program.htmlRoche S. 2017. Child Protection and Maltreatment in the Philippines: A Systematic Review of the Literature. Asia & the Pacific Policy Studies. 4(1): 104–128.

60. Multi-disciplinaryPoliceProsecutorJudgeLawyerSocial workerMedical doctorPsychiatristPsychologistBarangay officialsProtocol for Case Management of Child Victims of Abuse, Neglect, and Exploitation https://doj.gov.ph/child-protection-program.html

61. “Our passion is our strength.”- Billie Joe Armstrong -