Child abuse

Ill-treatment is behavior towards a child who is outside the generally accepted norms and presents a significant risk of physical or emotional harm to the child. There are usually four types of abuse: physical abuse, sexual violence, emotional abuse (psychological abuse) and neglect. The causes of child abuse vary and are not fully understood. Violence and neglect to children are often accompanied by physical injuries, stunted growth and development, mental problems. The diagnosis is based on anamnesis and physical examination. The physician's tactics include identifying, fixing in the documents and treating any injuries and urgent physical and mental conditions, compulsory reporting to appropriate state authorities and sometimes hospitalization or other measures to ensure that the child is safe, such as giving the child to adoptive parents.

In 2002, 1.8 million cases of child abuse or neglect were reported in the United States, 896,000 cases were confirmed. Children of both sexes suffered with the same frequency.

In 2002, in the United States, approximately 1,400 children died due to ill-treatment, about 3/4 of them were under 4 years old. One third of the deaths were associated with disregard. Children from birth to three years are most often victims (16/1000 children). More than 1/2 of all reports to the Child Protection Service were made by specialists responsible for identifying and reporting cases of child abuse (for example, teachers, social workers, law enforcement officials, law enforcement agencies, child care providers, medical and psychoneurological staff institutions, guardianship officers).

Of the confirmed cases of child abuse in 2002 in the United States, 60.2% were due to neglect of the child (including medical); 18.6% - physical violence; 9.9% - sexual violence and 6.5% with emotional violence. In addition, 18.9% of children experienced other types of abuse, such as abandonment and congenital addiction. Many children suffered from several types of abuse at the same time. In confirmed cases of violence or neglect of children in more than 80%, ill-treatment was noted by the parents; in 58% of cases - on the part of women.

[1], [2],

Classification of child abuse

Different forms often coexist, overlapping in no small measure.

[3], [4],

Physical abuse of children

Physical violence is inflicting physical harm on the child or encouraging actions that present a high risk of harm. The child may be shaken, dropped, hit, bitten and burned (for example, with boiling water or a cigarette). Heavy corporal punishment is included in physical violence, but may be due to community characteristics. Violence is the most common cause of severe head injuries in children of the first years of life. Children of the first years of life often have abdominal injuries.

Children of the first years of life are most vulnerable (probably because they can not complain), then the frequency decreases in younger school age, and then rises again in adolescence.

Sexual abuse of children

Any action with a child that is aimed at the sexual satisfaction of an adult or a much older child is sexual abuse. Forms of sexual violence include sexual intercourse, i.e. Oral, anal or vaginal penetration; harassment, molestation, i.e. Genital contact without penetration; and non-specific forms that are not related to physical contact, including demonstrating to a child sexual material, forcing him to take part in sexual intercourse with another child or participating in the shooting of pornographic materials.

Sexual violence is not considered to be sexual games, when children of similar age (most often under 4 years of age each) without coercion are treated or touched each other in the area of the external genitalia.

Emotional Violence Against Children

Emotional violence is emotional harm through words or actions. Parents can scold children with screaming and screaming, scorn the child, belittling his abilities and achievements, intimidating and terrorizing him with threats, using for his own purposes or encouraging defiant or criminal behavior. Emotional violence can also occur if words or actions are ignored or interrupted, in effect being an emotional disregard (for example, ignoring or denying the child or isolating him from communicating with other children or adults).

[5], [6], [7],

Neglect of the child

Neglect of a child is not a guarantee of his basic physical, emotional, educational and medical needs. Neglect is different from violence by what usually happens without the intention to harm the child. Physical neglect includes not providing the child with the necessary food, clothing, shelter, supervision and protection against potential harm. Emotional neglect is not providing the child with affection and love or other kinds of emotional support. Educational neglect includes not enrolling a child in school, lack of supervision of school attendance or homework. Medical neglect is the lack of supervision of the child's proper preventive procedures, such as vaccination, or the necessary treatment for injuries or physical or mental illness.

Causes of child abuse

Violence. In general, violence can be a manifestation of loss of control over oneself from parents or other caregivers. There are several important factors.

Parents' features and traits of their character may be important. Parents themselves in their childhood could have lost their affection and warmth, were surrounded, did not contribute to an adequate formation of self-esteem or emotional maturation, and in most cases they themselves experienced some form of violence. Such parents can look at children as an unlimited and unconditional source of love and support, which they never received. As a result, they may have inadequate expectations of what their child can give them; they easily get frustrated and lose control; they may not be able to give the child something that they themselves have never experienced. Drugs or alcohol can provoke impulsive and uncontrolled behavior towards the child. Mental disorders in parents can increase the risk, in some cases, violence against the child occurs during the period when the parent is in psychosis.

Restless, demanding or hyperactive children, as well as children with disabilities due to physical or mental disorders, which are always more dependent, can provoke outbreaks of irritation and anger at parents. Sometimes strong emotional attachment does not develop between parents and a premature or sick child isolated from their parents in the first days of life, as well as with biologically unrelated children (for example, spouses of a previous marriage), which increases the likelihood of violence in the family.

Stressful situations can increase the likelihood of violence against a child, especially if emotional support from relatives, friends, neighbors or peers is not available.

Physical violence, emotional abuse and neglect are often associated with poverty and low socioeconomic status. However, all types of violence, including sexual violence, are found in all socioeconomic groups. The risk of sexual abuse is increased in children who are cared for by several people, or if a person with several sexual partners cares for the child.

Neglect. Neglect is often observed in poor families, when parents also have mental disorders (usually depression or schizophrenia), drug addiction or alcoholism, low intelligence. Leaving the family of a father who is unable or unwilling to take responsibility for the family to himself can provoke and intensify the child's neglect. Especially vulnerable to the risk of abandoning the child are children from mothers who use cocaine.

[8], [9], [10]

Symptoms of child abuse

Symptoms and signs depend on the nature and duration of child abuse.

Physical violence. Skin lesions occur frequently and may include palm prints or oval fingerprints due to slaps, rough grasping and shaking; long, ribbon-like ecchymosis due to belt strikes or narrow arcuate bruises due to strikes with a tight rope or cord; multiple small round burns from cigarettes; symmetrical burns of extremities or buttocks due to their deliberate immersion in hot water; traces of bites; thickened skin or scars in the corners of the mouth due to gagging the mouth. Naspid alopecia can be the result of hair pulling.

Fractures, often associated with physical abuse, include fractures of the ribs, spine, long bones and fingers in children who can not walk alone, as well as metaphyseal fractures. Confusion and focal neurological symptoms can develop if the CNS is damaged. Infants who have been rudely and vigorously shaken may be in a coma or stupor due to brain damage, while external signs of trauma may be absent (haemorrhages in the retina of the eyes are frequent exceptions). Traumatic damage to the internal organs of the thoracic or abdominal cavity can also occur without visible signs.

Children who are often subjected to violence are usually fearful and restless, they have a bad dream. They may look depressed or anxious.

Sexual violence. In most cases, children do not report freely that they are sexually abused, nor do they show any behavioral or physical signs of this. In some cases, sudden or extreme changes in behavior may occur. Aggression or distraction can develop, as well as phobias or sleep disorders. Some children who are sexually abused behave sexually inappropriately age. Physical signs of sexual abuse may include difficulties in walking or sitting; bruises, abrasions or tears around the genitals, rectum or mouth; separated from the vagina or itching or sexually transmitted diseases. If a child talks about sexual abuse, it usually happens late, sometimes in a few days, or even years. After a while (from a few days to 2 weeks), the genitals can return to normal sight or there may be healing, hardly noticeable changes in the hymen.

Emotional violence. In the first months of life, emotional abuse can dull emotional expressiveness and reduce interest in the environment. Emotional violence often leads to hypotrophy and is often mistakenly diagnosed as mental retardation or physical illness. Later, the development of social and verbal skills is often the result of inadequate stimulation and interaction with parents. Children who are emotionally abused may be insecure, anxious, distrustful, superficial in interpersonal relationships, passive and overly concerned with being able to please adults. Children who are subjected to scorn and ridicule by their parents often have low self-esteem. Children who are intimidated by their parents may look shy and withdrawn. Emotional impact on children usually becomes obvious at school age, when difficulties in forming relationships with peers and teachers develop. Often, emotional effects can be assessed only after the child is placed in another environment or the behavior of the parents changes to a more acceptable one. Children who are forced to act in their own interests can commit crimes or take drugs or alcohol.

Neglect. Poor nutrition, weakness, lack of hygiene or proper clothing and hypotrophy are frequent signs due to inadequate provision of food, clothing or shelter. There may come a stop in growth and death due to starvation or abandonment to the mercy of fate.

How to recognize child abuse?

Assessment of injuries and malnutrition is discussed elsewhere in the Guide. Detecting child abuse as a cause can be difficult, for this it is necessary to maintain a high level of alertness. Acute head trauma caused by one of the parents is often not diagnosed in complete families with an average income.

Sometimes direct questions can be answered. Children who have been ill-treated can describe the events and the person who committed them, but some children, especially with sexual violence, may be forced to promise to keep everything a secret, they may be frightened or so traumatized that they are extremely unwilling (and can even deny violence, if specifically asked about it). With the child should talk on one, quietly asking him unfinished questions; questions that need to be answered "yes" or "no" ("Did this your dad?", "Did he touch you here?"), can easily draw a distorted picture of events in young children.

The survey includes monitoring the relationship between the child subjected to violence and the persons, possibly responsible for it, at any opportunity. It should be as fully and accurately as possible to record all the results of the examination and anamnesis, including the recording of quotations directly from the story and a photograph of the lesions.

Physical violence. Both the anamnesis and the physical examination give the keys, allowing to suppose cruel treatment with the child. The signs suggesting violence against the child are the parents' reluctance or inability to explain the origin of the child's injuries; anamnesis that does not correspond to the nature of the lesions (for example, bruises on the back surface of the feet are associated with a fall), or an explicit stage of resolution (ie old lesions, interpreted by parents as fresh); anamnesis, which differs depending on the source of information; anamnesis of trauma that does not coincide with the development stage of the baby (for example, trauma caused by falling from the stairs, in a child too small to crawl); inadequate response of parents to the severity of the injury - either too anxious or, conversely, carefree; late recourse.

The main signs of violence in the survey are atypical injuries and injuries that do not combine with the anamnesis that leads the parents. Damage in children resulting from falls is usually single and located on the forehead, chin or in the mouth area or on the extensor surfaces of the extremities, especially elbows, knees, forearms, and lower legs. Bruising on the back, buttocks and back of the feet is extremely rare as a result of a fall. Fractures, with the exception of a fracture of the clavicle and a fracture of the radius in a typical place (Colles fracture), are less common during normal falls during a game or from a ladder. There are no fractures that would be pathognomonic with physical violence, but classic metaphyseal injuries, fractures of the ribs (especially the posterior and first ribs), dents or multiple fractures of the skull with an apparently minor injury, fracture of the scapula, sternal fractures and spinous processes should cause alertness.

Physical violence should be assumed if a serious injury is detected in a child who has not yet walked. It is necessary to examine the infants of the first months of life with minor injuries on the face. Children of the first months of life can look absolutely healthy or asleep, despite the significant brain trauma, for every listless, apathetic, drowsy child, one of the points of the differential diagnosis should be acute head trauma due to child abuse. Also suspicious is the presence of the child multiple lesions that are at different stages of healing; skin changes specific to certain types of injuries; and repeated injuries that involve violence or inadequate supervision of the child.

Hemorrhages in the retina are noted in 65-95% of children who have been roughly shaken, extremely rarely they occur with accidental head trauma. Also, bleeding in the retina may be present from the birth of the child and persist for 4 weeks.

Children under 2 years of age who have been physically abused need to examine the skeleton to identify signs of pre-existing bone damage [fractures in various healing stages or subarachnoid (protuberance) of long bones]. The examination is also sometimes carried out for children aged 2 to 5 years, in children older than 5 years, the survey is usually not effective. Standard examination includes a radiograph of the skull and thorax in a straight projection, the spine and long bones in the lateral projection, a pelvis in a straight projection and brushes in a straight and oblique projection. Diseases in which multiple fractures can occur are imperfect osteogenesis and congenital syphilis.

Sexual violence. Any sexually transmitted disease (STD) in a child under 12 years of age should be treated as a consequence of sexual violence until the opposite is proven. If a child is sexually abused, the behavior may initially be the only indication of an event (eg, anxiety, fear, insomnia). If suspected of sexual violence, you should examine the perioral and perianal areas, as well as the external genitalia, to identify signs of damage. If you suspect that the episode occurred recently, you need to take samples of hair and smears of biological fluids to obtain legal evidence. It is possible to use a light source with magnification and a camera to fix the lesions (for example, a specially equipped colposcope) in order to obtain official evidence.

Emotional violence and neglect. The survey focuses on the general appearance and behavior of the child in order to determine whether his development is violated or not. Teachers and social workers are often the first to detect disregard. The doctor may notice that the child is not on the reception or on the vaccination, unless they have been appointed recently. Medical neglect in children with severe life-threatening chronic diseases, such as respiratory distress syndrome or diabetes, may lead to a subsequent increase in the number of visits to the doctor and hospitalizations in emergency departments, as well as non-compliance with prescriptions for the treatment of the child.

Treatment of child abuse

The treatment is primarily aimed at resolving the priority health problems (including possible STDs) and ensuring the safety of the child. Ultimately, the treatment is aimed at normalizing long-term disrupted interpersonal interactions. Both violence and neglect should be approached with help rather than punitive measures.

Immediate safety of the child. Physicians and other professionals working in contact with children (for example, nurses, teachers, nursery staff, police) are required by law in all states to report cases of violence or suspicion of child abuse. Each state has its own laws. Also, the activity of other members of the society is encouraged to report on the facts of violence against children, which, however, is not mandatory. Anyone who reports violence and is justifiably and truthfully arguing, is protected from criminal and civil liability. A specialist who is obligated by law to report such cases and who has not done so may be subjected to criminal or civil (administrative) punishment. Violence reports are reported to the Child Protection Service or other relevant organizations. Employees of health care institutions may (but are not required to do so) notify their parents that they are informed by law of their suspicions and that they will contact, talk and probably visit at home. In some cases, the doctor may determine that informing parents before the assistance of the police or other services is available may pose a high risk of injury to the child. In these circumstances, it is possible to postpone informing parents or persons caring for the child.

Representatives of child protection organizations and social workers can help a doctor find out the likelihood of subsequent harm to the child and thus determine where it is best to be. Options include hospitalization for protection, the transfer of the child to relatives or temporary housing (sometimes the whole family moves from the home of the partner who terrorizes them), temporary placement in the foster family, and the return of the child to the home, provided adequate supervision is provided by the social services. The doctor plays a crucial role in working with community organizations, arguing and protecting the best and safest location of the child.

Observation. The source of primary health care is the basis. However, families of children undergoing ill-treatment often move, making it difficult to continuously monitor the child. Often parents do not come to the doctor at the appointed time; home visits by social workers or representatives of public organizations or nurses may be necessary to ensure the successful completion of all appointments.

A careful study of the family environment, previous contacts with social services, and the needs of parents is necessary. A social worker can conduct such research and help with conversations and work with family members. The social worker also provides tangible assistance to parents in receiving public assistance and registering a child in a preschool, as well as getting help with housework (which can lead parents out of stress by giving them a few hours a day to rest), and also coordinates the provision of psychological and psychiatric care for parents. Usually periodic or ongoing contacts with social services are needed.

In some places, assistance programs for parents are available, which hire trained professionals to work with parents who abuse children. Other types of support for parents - for example, support groups - are also very effective.

Sexual violence can have a lasting effect on the development and sexual adaptation of the child, especially among older children and adolescents. Counseling or psychotherapy for the child and related adults can reduce these effects.

Taking the child out of the house. Although the temporary removal of the child from home until all the circumstances have been fully clarified and the child's safety is ensured, often they are carried out, the ultimate goal of the Child Protection Service is to keep the child with his family in a safe, healthy environment. If the above measures do not ensure this, consider taking the child out of the family for a long period and, probably, depriving parents of their parental rights. This serious step requires a judicial decision submitted by the relevant officials. The procedure for the removal of parental rights varies depending on the state, but usually includes a doctor's testimony in court. If the court positively solves the issue of the child's removal from the family, he must determine the place where the child will live. A family doctor should take part in determining the place where the child will be; if not, you must obtain his consent. While the child is temporarily removed from the family, the doctor should, if possible, keep in touch with the parents to make sure that proper efforts are being made to help them. Sometimes children are subjected to violence and while in the foster family. The doctor should be prepared for such events. The opinion of the doctor plays an important role in solving the issue of family reunification. With the improvement of the conditions in the family, the child can return to the parents. At the same time, repeated episodes of domestic violence are common.

How to prevent child abuse?

Prevention of child abuse should be carried out at each visit to the doctor by providing information to parents or carers of the child, and by contacting the appropriate services in identifying families at high risk of child abuse. Parents who have been abused or neglected in their childhood are more likely to abuse their children in the future. Such parents often express concern about their propensity to violence in the family and are well amenable to correction. There is also a high risk of abuse of children from parents when raising their first child, if their parents are teenagers, and if there are several children under 5 in the family. Maternal risk factors can often be detected before the child is born, for example, the expectant mother does not comply with the prescription of the doctor, is not on reception, smokes, uses drugs, or has a history of information about domestic violence. Medical problems during pregnancy and childbirth, as well as the early neonatal period, which can affect the health of the baby, can weaken the attachment between the parents and the child. In such periods it is important to find out the feelings of the parents in relation to their own insolvency and the well-being of the baby. How well can they treat a child with a large number of needs or health problems? Do parents give each other moral and physical support? Are there any relatives or friends who can help if necessary? A doctor who is wary of these key issues and can provide support in such conditions, makes a long way to prevent tragic events.