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In the name of God. Child Maltreatment (Child Abuse). H Fanian MD. Definition of Child Maltreatment Center for Disease Control & Prevention (CDC) .

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definition of child maltreatment center for disease control prevention cdc

Definition of Child Maltreatment Center for Disease Control & Prevention (CDC)

Any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child

journal of child abuse and neglect

Journal of Child Abuse and Neglect

Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation

child abuse that occurs in medical setting munchhausen syndrome by proxy

Child Abuse that Occurs in Medical Setting(Munchhausen Syndrome by Proxy)

An adult caregiver either makes a child appearsick by fabricating symptoms, or actually causes harm to the child, in order to gain the attention of medical providers and others

Medical assessment of vague illness

Multiple diagnosis

Therapeutic procedures for unclear reasons

incidence of child abuse an international phenomenon

Incidence of Child Abuse An international phenomenon

4 million cases annually in US, including 2000 death

6000 emergency calls annually in Iran (out of 144000)

Tip of the Iceberg

Non-reported & un-diagnosis

risk factors of child abuse child abuse is a complex phenomenon with multiple causes

Risk Factors of Child AbuseChild abuse is a complex phenomenon with multiple causes

Marital separation, job loss, family death, unintended pregnancies, financial difficulties,

Substance abuse (alcohol, cocaine, heroin,….)

Nonrelated adult living in the household

Stepparents, babysitter, boyfriends, relatives

Prematurity, congenital anomalies, medical fragility …

effects of child abuse

Effects of ChildAbuse

Guilt, nightmares, insomnia

Fear of things associated with the abuse (including objects, smells, places, doctor's visits, etc.)

Sexual dysfunction

Chronic pain, addiction, somatic complaints

Self-injury, suicidal

Depression, PTSD, anxiety

after 30 years

After 30 years

Bentley and Widom (2009) found that physical abuse during childhood is a risk factor for obesity in adulthood

major categories of child abuse child abuse can take several forms

Major Categories of Child Abuse(Child abuse can take several forms)

Neglect 54%

Physical 22%

Sexual 8%

Psychological or Emotional 4%

Other forms 12%

child neglect

Child Neglect

Failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child's health, safety, and well-being are threatened with harm

Lack of attention from the people surrounding a child

observable signs in a neglected child

Observable Signs in a Neglected Child

Frequently absent from school

Begs or steals food or money

Lacks needed medical and dental care

Consistently dirty

Lacks sufficient clothing for the weather

Delays in physical and psychosocial

child sexual abuse

Child Sexual Abuse

A form of child abuse in which an adult or older adolescent abuses a child for sexual stimulation

In US, approximately 15% to 25%ofwomen & 5% to 15% of men were sexually abused during childhood

Child-on-child sexual abuse?

physical abuse child

Physical Abuse Child

Including hitting with a hand, stick, strap, or other object; punching; kicking; shaking; throwing; burning; stabbing; or choking to the extent that demonstrable harm results

Injuries vary greatly from mildredness on the buttocksthat fades over several hours, to injuries so severe, that the child dies
physical abuse in children

Physical Abuse in Children

1-3 years (34%)

4-7 years (23.4%)

8-11 years (18.7%)

12-15 years (17.3%)

16-17 years (6.2%)

Children younger than 1 year had the highest rate of victimization overall

orthopedist child abuse

Orthopedist & Child Abuse

30% to 50% of abused children visited by an orthopedist, if unrecognized, 25% risk of serious re-injury, & 5% risk of death

Prepare records as thought everything will be reviewed & read in court

Photographs taken to document skin lesions must be done before cast placement

types of physical injures in child abuse

Types of Physical Injures in Child Abuse




Head injuries

Internal injuries

burns in child abuse

Burns in Child Abuse

Hot liquid, hot object, chemical, electrical

Force to drink a cleaning fluid for punishment

central nervous systems injuries

Central Nervous Systems Injuries

Subdural hematoma (SDH)

Abusive head trauma (AHT)

Shaken baby syndrome (SBS) /shaking-impact syndrome

love me never shake me

Love Me…..Never Shake Me

Shaken Infant Syndrome

abdominal injuries in physical child abuse s econd most common reason for death1

Abdominal Injuries in Physical Child AbuseSecond most common reason for death







fractures in abused children 11 to 55 second after skin lesions

Fractures in Abused children(11% to 55%) second after skin lesions

Rib, extremity, & skull

Femoral fracture in children <1 year of age are commonly due to abuse

investigative interview

Investigative interview

What happened



Who was there

Child position before injury

How the child reacted

How caregiver promptly does


no babygram

No “babygram”

58% of fractures were seen

Fractures can be missed on digitalized images

Repeat skeletal survey in 2 weeks

mechanism of rib fractures in child abuse

Mechanism of Rib Fractures in Child Abuse

1: squeezing of the chest by a caretaker

2: hitting the child from behind

3: stepping on the chest

Nondisplaced & can be very difficult to diagnose acutely

corner fracture

Corner Fracture

First described by Caffey

Small piece of bone is avulsed due to shearing forces on the fragile growth plate

These fractures are often subtle, and the likelihood of detection is directly related to the quality of the radiologic studies

bucket handle fractures

Bucket Handle Fractures

These fractures are essentially the same as corner fractures.

The avulsed bone fragment is larger and seen 'en face' as a disc or bucket handle.

These corner and bucket handle fractures are most common in the tibia, distal femora and proximal humeri.

They are frequently bilateral.

bone healing dating of injuries

Bone Healing & Dating of Injuries

Dating of boney injuries is particularly important in the evaluation of physical abuse, because it may assist investigators in determining who had access to the child in the period the injury is estimated to have occurred.

dating fractures

Dating Fractures

Orthopedist often is asked to determine the age of fracture

Periosteal reaction appears at about 14 days

Not all classic metaphyseal lesions develop visible callous

Skull fractures generally cannot be dated

Bone scan are not useful for dating of fracture

differential diagnosis of physical child abuse skin lesion

Differential Diagnosis of Physical Child Abuse (skin lesion)

Mongolian spots





Bleeding disorders


differential diagnosis of child abuse radiographyically

Differential Diagnosis of Child Abuse (Radiographyically)


Caffey's disease (infantile cortical hyperostosis)

Metaphyseal dysplasia

Vit D deficiency



prevention of child abuse

Prevention of Child Abuse

April is national child abuse prevention month

Blue ribbon against child abuse

Child protective services team

Home visitor programs

pediatr emerg care 2012 dec 28 12 1366 8

PediatrEmerg Care. 2012 Dec;28(12):1366-8

Increased serum creatine phosphokinase in a child with bruising due to physical abuse

Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis

psychological emotional abuse

Psychological &Emotional Abuse

Production of psychological and social deficits in the growth of a child as a result of behavior such as loud yelling, coarse and rude attitude, inattention, harsh criticism, and denigration of the child's personality