Chapter 7 The physical and emotional abuse of children

1. Chapter 7The physical and emotional abuse of children

2. PHYSICAL ABUSEDefinition • The physical and emotional abuse is a worldwide phenomena. This chapter addresses the issues and describes the investigations and management within the UK as an example although principles apply worldwide. In the UK, child abuse was formally defined in the 1999 Department of Health guidelines and redefined in 2000 (Department of Health 2000)

3. Physical abuse involves hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to the child which is actual or likely. Fictitious (or factitious) illness by proxy is also included under physical abuse. From a clinical perspective, the severity of the injury, the number of injuries, the age of the child and any previous injuries and other abuses (neglect, child sexual abuse, emotional abuse) are all part of the jigsaw which leads to a diagnosis of physical abuse.

4. Setting and incidence • Much physical abuse is considered by the carer to be "reasonable chastisement", and over 90% of 4-year-old children in the UK are hit (Leach 1999). However, an increasing body of adults perceive physical punishment to be physical assault and, as such, not an acceptable part of child rearing (Newell 1989).

5. At the time of writing, in England the use of physical punishment in the form of reasonable chastisement (which in practice has become "bruising means the hit was too hard") is allowable by the child's parents and, with their consent, their child minder. Physical punishment is not permitted in nurseries, schools, foster and children's homes, but hitting does occur, and levels may be higher in foster and children's homes (Hobbs et al 1999a).

6. The belief is that the career inflicts pain on the child so he learns. Smith et al (1995) also noted that a majority of children are hit (over 90% of those aged 4 to 7 years). Considerable pain may be inflicted: 14% of the punishment was assessed as severe by the researchers. Cawson et al (2001), in a helpful paper in a field which is lacking a firm evidence base (Department of Health 1995), asked young adults about their own, recent experience of physical punishment:

7. ● 26% had witnessed domestic violence • ● 20% had been physically assaulted • ● 7% had been severely assaulted • ● 6% had been hit with an implement • ● 4% had been choked • ● 1% had been burned or scalded.

8. Domestic violence is common in the UK (Jewkes 2002): it occurs in a third of households, where children watch, listen to, or are part of the violence. Most of these children suffer emotional abuse; physical abuse is estimated to occur in haiti child sexual abuse (CSA) is estimated to occur in as many as a third of the children in these violent households.

9. Domestic violence is related to certain occupations: soldiers, prison officers, police and, a worldwide problem, boy soldiers. Over 90% of abuse takes place at home, with mothers hitting more than fathers, but men causing more damage. Teenage babysitters pose a risk to small babies. All ethnic groups in the UK appear to hit their children.

10. Mothers who are physically abused are more likely to hit their children, and their parenting may be impaired as they are 15 times more likely to abuse alcohol, 9 times more likely to abuse drugs, 3 times more likely to be depressed and 5 times more likely to attempt suicide than non-abused mothers (Stark & Flitcraft 1996).

11. Domestic violence may begin or escalate during pregnancy (Morgan 1998): prevalence rates of fetal abuse, 0.9-20% are given. The injuries to mother and fetus may be serious (see Box 30.1) and lead to placental separation, ruptured uterus, preterm onset of labor and fetal fractures. (See Chapter 16).

12. A study of women in a refuge (Casey 1989) found that 60% of women spoke of violence during pregnancy, 13% miscarried, and 22% threatened miscarriage or went into premature labor. Further indication of the importance of drugs and alcohol in child abuse is found in the 25% of child protection conferences that record them as a significant factor (Leeds ACPC, KWatson 1998).

13. There are many complex issues concerning maternal drug use and abuse, for example sodium valproate for maternal epilepsy is teratogenic, as well as non-prescribed drugs such as alcohol and opiates. Poor diet, cigarette smoking, and mental health problems in the mother are damaging to the fetus.

14. It is recognized that women are more physically violent than was formerly acknowledged. A trend for girls to be part of violent gangs follows a pattern seen in the US. • A further complication for careers who hit arises in adolescence, when the teenager hits back and is likely to use offensive language.

15. In households where conflict is resolved by violence, the boy (and, increasingly, gift) is at risk of developing generally aggressive behaviors and being suspended from school. Later, he or she may play truant or run away, with all the associated dangers of living on the streets.

16. Bullying affects the majority of schoolchildren at some time and, for some, becomes intolerable leading to suicide. Programs for management and prevention are available (Elliott 1991, Dawkins & Hill 1995).

17. It has been estimated that there are between 200 and 300 nonaccidental child deaths each year, and this figure has varied little. There are persisting recording differences and accurate statistics are not available in many areas (Creighton & Noyes 1989, McDonald 1995).

18. It has been estimated by the National Society for the Prevention of Cruelty to Children (NSPCC) that there are between 200-300 non-accidental child deaths each year in the UK. This is thought to be an underestimate. The Home Office figures of 29 child murders each year have changed little over 30 years (Ending child abuse deaths, 2002).

19. In this series nearly half the children were aged 0-4 years, 25% 5-9 years, and 25% 10-14 years; 12% of the sample were aged less than 12 months. Seventy per cent of serious head injuries occur in children under 12 months, and deaths due to head injury occur mainly in this abused group. The severity of injuries was summarized as: moderate injury 90%, severe injury 9%, and fatal abuse 0.6%.The ratio by gender is 55% boys to 45% girls.

20. Much abuse is associated with emotional damage to the child but the association of physical abuse and CSA of 1 in 6 (Hobbs & Wynne 1990) and the recognition of neglect with all types of abuse is more recent. • Children at particular risk of abuse are disabled children, whether in their own homes, foster homes, children's homes or boarding school.

21. Patterns of accidental bruising • Children bruise themselves in the course of their ordinary play. The numbers of bruises seen depends on age, the type of play (such as with a new skateboard or bike), and the nature of the child. Careers may claim "he always bruises easily".

22. Very few bruises should be seen in infants aged 0-6 months. Bruises over bony prominences occur in 30-40% of 9-12-monthold infants. Up to 12 bruises are seen in normal active children; the bruises are mainly distal and few are seen on the chest or abdomen. Shin bruises should not be ignored adults kick too and were assumed to be always accidental (Robertson et al 1982, Leventhal et al 1993).

23. Patterns of injury that might arouse suspicion of abuse • Bruises are rarely seen on the ear due to the protective triangle of the side of the skull and shoulder tip. A bruise on the pinnais likely to be a pinch (Figures 30.3 and 30.4), and linear marks with stippled bruising or petechiae extending from the cheek above, below and behind the ear are typical of a blow from an outstretched hand.

24. A penetrating blow to the upper face orbit is needed to cause a black eye (Figure 30.5). Bilateral black eyes are worrying and suggest intracranial damage but may follow a blow to the forehead. Petechiae over the face and neck should be investigated: they may be part of a viral illness but might also indicate strangulation or neck compression, which always has to be excluded. Bleeding from the mouth and other dental injuries may warrant referral to a forensic odontologist. Bony injury is uncommon under 12 months and should be investigated.

25. Fractures of the clavicle and parietal bone may be seen in infancy from, for example, falling out of the highchair, or rolling off the settee.Ambulant children may fall, and fractures are usually distal, e.g. radius and ulna e.g. of the limb.

26. Toddler fracture is an undisplaced spiral fracture of the lower tibia seen in toddlers who having just begun walking and try to run fall, twist the leg, and cause the fracture. • Note: fractures are painful and there is disuse. There may be swelling, but not always bruising.

27. Factors in the presentation of physical abuse Some presentations strongly suggest abuse, e.g. a badly bruised face in an infant (Figure 30.2) or a fractured tibia in a non-ambulant child. There may also be, for example, bruises that do not match the given history, being too many, too severe, in the wrong distribution (Figure 30.6) or of the wrong duration.

28. Multiple injuries following a moderate fall necessitate careful assessment, as do all head injuries in infants and young children" (Figure 30.7). Subdural hematoma, usually associated with retinal hemorrhages, must always be investigated (see later), as must burns and scalds. • In physical abuse there may be a delay in seeking medical help and non-compliance with advised treatment.

29. The injury may be discovered incidentally at nursery or school, and the parents behave unexpectedly, for example aggressively, toward staff, refusing treatment or admission to hospital. The child may be seen repeatedly with minor injuries at the general practitioner's (GP) or family physician's surgery and also the hospital; it is therefore important to check records.

30. Further indicators include: • lDiscrepancies in the history. • lThe history may change with repeated telling or according to teller. • lThe telling varies according to whom it is told. • lThe history may be vague and lack detail. • lThere may have been delay in seeking help. • There may be denial of pain or minimization of symptoms.

31. Trigger factors, such as feeding or sleeping difficulties, prolonged crying, wetting, soiling, stealing, or lying may precipitate aggression toward the child. The adult may be physically or mentally ill, drugged or drunk; overlying of young children only occurs if the adult is "unnaturally sedated". There may be social factors such as abuse in childhood, poverty, loss of job, or partnership break-up (see Box 30.2).

32. Conclusion and summary • l Accidental injury is common in childhood. • lCertain patterns of injury should cause the possibility of abuse to be considered. • l Mothers and fathers are the main abusers. • lAny bruising in infancy should be investigated. • lFractures under 12 months or in non-ambulant children require investigation. • lSevere head injury following minor falls in infancy usually results from abuse. • lPhysical abuse is associated with neglect, CSA and domestic violence.

33. FICTITIOUS ILLNESS IN CHILDHOOD • Fictitious illness (also termed "fabricated", "falsified" or "factitious illness") was initially known as Munchausen Syndrome by Proxy (Meadow 1977). Much debate continues as to the most descriptive title for this form of abuse, in which the career presents a false picture of illness to the physician. The "illness" from which the child is suffering has been fabricated by the career.

34. The syndrome has as its prerequisites the career, usually the mother, who describes the "illness", and the child who is cast in the "ill" role. The career may cause the symptoms directly, as in suffocation (or apneic attacks), exaggerate an existing disorder such as convulsions, leading to more investigations and drug therapy, or present the child with a history of an imaginary disorder such as asthma for which the child has no objective signs.

35. The symptoms most commonly seen include: • ~ Vomiting • ~ Diarrhea • ~ Bleeding • ~ Fever • ~ Convulsions

36. ~ Rashes • ~ Failure to thrive • ~ Drowsiness/coma. • Consequences of the behavior include: • ~ Attention for the mother, "such a wonderful career", on the hospital ward.

37. ~ Status for the mother amongst friends and family. • ~ Financial gain through disability allowance. • ~ Relationships with medical staff (to the extent of going on "ward outings"). • ~ The career may become the local authority on the "disorder" and run the parents' support group.

38. ~ The child who is forced into the role of illness is made part of the fabrication and deception, and is betrayed by his careers. • ~ The abuse is emotional, may be physical, and above all denies the child a childhood with ordinary peer relationships through being "ill" and needing invasive and painful investigations and drug therapy (with the associated side-effects). • Induced apnea and drug overdose might be more appropriately labeled "suffocation" and "poisoning".

39. EMOTIONAL ABUSE • The definition of emotional abuse (Department of Health 1989) is the actual or likely severe adverse effect on the emotional and behavioral development of a child caused by persistent or severe emotional in-treatment or rejection.

40. All abuse involves emotional ill-treatment to a greater or lesser degree. A wider definition includes: "acts of omission or commission by a parent or guardian that are judged by a mixture of community values and professional expertise to be inappropriate or damaging" (Gabarino & Gilliam 1980).

41. The Children Act (England and Wales, 1989) uses the term "harm" to describe the effects of ill-treatment and poor care leading to injury, impairment of the health or development of a child. "Significant harm" is a measure of the severity of ill-treatment, i.e. that it is noteworthy.

42. The incidence of abuse (number of new cases occurring during a given time period) and prevalence of abuse (the proportion of adults abused during childhood) is not known. The latest UK data for prevalence of emotional abuse (Cawson et al 2000), based on interviews, record that 30% of the adult population recalled this form of abuse. The National Commission of Enquiry into the Prevention of Child Abuse (Childhood Matters 1996) estimated the incidence of abuse to UK children as:

43. l350 000-400 000 cases of emotional abuse • l450 000 cases of children being "bullied at least once a week". • The Commission used a wider definition: "child abuse consists of anything which individuals, institutions, processes do, or fail to do, which direcdy, or indirecdy, harms children or damages their prospects of safe and healthy development into adulthood".

44. This definition includes physical and developmental growth as well as educational, medical and social neglect. Failure to thrive (nonorganic) is the failure to grow and gain weight despite the absence of physical illness. To grow and develop optimally, the child should be well fed and loved.

45. Emotional abuse is part of all the other abuses but also occurs without them. Thus, a child witnessing family violence may be physically well cared for but emotionally distraught.

46. Emotional abuse includes discouragement, ridicule, unfairness, hostility, threats and bullying, "You are bad, stupid, useless and I don't love you". Children at risk of emotional abuse include those who are: • lUnwanted • lOf the "wrong sex" • lDisabled • lIll • lDifficult (e.g. to feed) • In a family where parents have a difficult relationship, have themselves been abused in childhood, abuse substances or alcohol, or there is domestic violence.

47. That ‘s for today Thanks everyone!