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Number of confirmed CPS child abuse cases each year in US


How sure do you have to be to mandate report?

only 51% sure

How many children dies each year from abusive injuries?


Child abuse/ homicide is the _____-leading cause of death for children 1-4


In 2011, _____ confirmed cases of child abuse occurred in Iowa


Risk factors for abuse/neglect in child

1. children 0-5 most likely to be abused/neglected
2. Boys more likely to be physically abused
3. Girls 3x more likely to be sexually abused
4. Medical conditions that predispose a child to abuse: ADHD, physical/mental disability, speech & hearing problems
5. Age-specific behavior

Risk factors for abuse/neglect in parent/caregiver

1. Unrealistic expectations for child's developmental ability
2. Substance abuse/ mental health disorder
3. Environmental stress eg. job loss, marriage etc
4. Domestic violence
5. History of abuse in own childhood

First legal case of child abuse in US

- 1873
- Mary Ellen Wilson was child
- Edda Wealer was social worker
- Henry Berg was lawyer
- Got Mary out of home in 48 hr period

Three basic categories of child physical abuse

1. Skin trauma
2. Abusive head trauma
3. Fractures

Even if an injury is consistent with accidental trauma:

Consider the possibility of supervisional neglect

3 common findings of skin trauma

1. Bruises
2. Burns
3. Bites

What is important to remember about pre-mobile children?

- They don't bruise on their own
- If bruised, suspect abuse/neglect

5 important things to ask/consider when seeing a cutaneous trauma in a child

1. What was the child wearing? -diapers and clothing can provide some protection to skin
2. What happened after the injury? -especially prompt, proper care after burns
3. Who else was there? -To confirm story
4. Is there a pattern to the bruise/burn? Unusual in accidental bruises/burns
5. Consider the possibility that a medical condition may predispose a child to bleeding or bruising.

Common body areas of toddlers to have accidental, exploratory bruises

1. Forehead
2. Forearms
3. Shins

Less likely body areas for toddlers to have accidental, exploratory bruises

1. Buttocks
2. Back of leg
3. Upper back

Bruising of the _____ in absence of history of significant trauma is highly suspicious of abuse, and requires ________ evaluations and close monitoring

- Abdomen
- Emergency dept. and/or surgical

Abdominal child abuse is ____ leading cause of child death from inflicted injury, inflicted head injury is ____ leading cause of child death due to abuse


________ and _______ are critical in diagnosing child abuse

1. Pattern
2. History

An inconsistent _______ can make the diagnosis of child abuse


Child ear bruising

- Rare to be an accident
- Can be due to caretaker slapping or pulling and twisting the ear

Burns that are ____, ____, or ____ are concerning and require thorough history

Patterned, Bilateral, or Symmetrical

Bruising of the ______ is child abuse unless proven otherwise

- Ear
- extremely difficult to bruise ear accidentally

Biting in children

- Common for children to bite each other
- Bites without other children around, in combination with other injuries, or is in suspicious regions (genitals, buttocks etc.) is highly suspicious

Babies' head weight

25% of total body weight
Neck muscles not able to support head well enough-- shaken baby syndrome

Aging bruises

Very difficult
- reddish-purplish is fresher
- Greenish-yellowish is older

Shaken babies may present with what signs from severe head trauma/ shaken baby syndrome

1. Broken ribs
2. Retinal hemorrhage/ dislodging
3. Subdural hemorrhage

Subtle signs of mild head trauma/ shaken baby syndrome

1. Vomiting
2. Poor feeding
3. Fussiness

What happens to child after severe head trauma/ shaken baby syndrome

1. Becomes immediately unconscious
2. Rapid escalating, life-threatening CNS dysfunction

Long term effects of head trauma in surviving children of shaken baby syndrome

1. Physical disabilities
2. Visual disabilities/ blindness
3. Hearing impairments
4. Seizures
5. Behavior disorders
6. Learning and developmental impairments

Characteristics of water burns

- Less blistering as water runs down skin and cools
- V-appearance

Rib fractures in child abuse

- Specifically posterior and lateral fractures
- Caused by anterior-posterior compression of thorax
- Usually when adult hands wrap around and squeeze child's chest

Complicating factor in diagnosis of posterior rib fractures as abuse

- will theoretically appear the same as abusive fractures

Classic Metaphyseal lesions

- Cause by pulling or twisting force on ends of long bones
- In children, attachments to ends of growing bones are stronger than ends of the bones themselves
- Force causes pieces of bone at the metaphysis (mechanical weak spot) are pulled from bone

Classic metaphyseal lesions are often referred to as_______ or _____ fractures

- Bucket handle
- Corner

Spiral fractures

- Don't necessarily indicate abuse, but the history and radiology findings should fit

Retrospective studies show than 1 in ____ children are sexually abused before 18


Period of purple crying

- Baby's crying starts 2 weeks and peaks around 2 months, then declines
- The curve of crying corresponds almost perfectly to cases of abusive head trauma
- Guidance programs that educate parents on how to prevent this.

% of sexually abused children will have normal genital examinations when seen. Why?

- 95
1. Most child sexual abuse involves touching/viewing the child's genitals or having the child touch adult's genitals, but not vaginal/anal penetration. = no physical signs
2. Healing is rapid for vaginal/anal trauma

High specificity fractures for child abuse

1. Rib fractures, especially posteriorly
2. Classic metaphyseal lesions
3. Scapular fractures
4. Spinous process fractures
5. Sternal fractures

Main reasons children delay or never disclose sexual abuse

1. Psychological manipulation
2. Shame and guilt
3. Fear family will fall apart
4. Dissociation
5. Young children who have been manipulated may not realize it is wrong

What to do when children disclose sexual abuse

1. Stay calm
2. Write the disclosure in notes verbatim
3. Find out who? what? where? when?
4. Avoid interviewing for details- leave this up to forensic specialists
5. Report to CPS

_____ comprises majority of child maltreatment.


More children die from ______ than other form of child maltreatment


Outcomes of neglect vs other forms of child maltreatment

- Neglect is associated with worse outcomes

Most common form of child maltreatment


3 big forms of child neglect

1. Physical neglect
2. Educational neglect
3. Emotional neglect

More inclusive definition of child neglect

When children's basic needs are not adequately met

Responding to child abuse requires:

- Multidisciplinary approach
- Don't try to do it alone; collaborate with other professionals


- Process that child sexual abusers will use to gain trust and build a relationship with a child and manipulate him/her before sexually abusing him/her

______ are the 2nd most common manifestation of child abuse


Sexual abuse affects about _____ children each year in US


Characteristics of neglectful parents

1. Maternal depression/ psychoses
2. Intellectual impairment
3. Substance abuse
4. Social isolation
5. Domestic abuse

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